The annual clinical meeting of the Diabetes Technology Society was help recently in Los Angeles http://diabetesmd.blogspot.co.uk/ and VoyageMD used the opportunity to also spend 2 weeks in the San Francisco Bay on vacation rather than hang out in the smog of LA.

A few notes for travellers thinking about trying San Francisco as a holiday or business destination. Firstly and most importantly the weather in the city can be variable to say the least and is usually foggy at least some part of most days and significantly cooler than the surrounding Bay Area. If you are spending the day in San Francisco then take a coat just in case – if you find yourself shivering on the Golden gate Bridge then pop over to Chinatown where fleeces and jackets are at bargain basement prices.

The other practical point is that car hire is essential for anyone spending any length of time in the US and best to book on-line before arriving as it is often much less expensive. Beware however that most companies require you to pay to have the gas tank filled up at a premium price after you return the vehicle but you can haggle with them and it is certainly not unexpected to negotiate a lower price.

Eating out in California is a daily occurrence and many American friends rarely (sometimes never) cook a meal at home. Prices are reasonable but remember that the final bill will add sales tax and that 15-20% tip is expected. Here are a few of the more memorable places that VoyageMD sampled this time:

An American breakfast is always a real treat and you would struggle to find anywhere better that Nini’s in San Mateo http://www.facebook.com/pages/Ninis/40679569194 which has been operating since 1955. The walls are covered with an array of memorabilia, service fantastic and the food wonderful – my personal choice was teriyaki steak and eggs! Check out the reviews on yelp.com. If you prefer pastries for breakfast then hop over to Speciality’s Café and Bakery http://www.specialtys.com/. The menu lists calories so you can keep a check on the waistline. Carbohydrate content would also be very helpful for visitors with diabetes.

Other notable places VoyageMD samples included Tokai in Foster City for Japanese food http://www.tokaijapanese.com/ – the sushi is fresh and delightful and most importantly the staff are extremely welcoming and helpful, authentic Mexican dishes at Reposado in Palo Alto although it is not always easy to find a table if you have not booked http://www.reposadorestaurant.com/ and great Mediterranean dishes and pizza at the Waterfront again in Foster City http://www.waterfrontpizza.com/. The Cheesecake factory near San Mateo also remains very popular with locals http://locations.thecheesecakefactory.com/ca/san-mateo-156.html with a mind-blowing menu selection.

For those keen on the American burger experience the usual suggestion in California is to visit an In-and-Out restaurant but this time we sampled 5 Guys in Burlingame http://gofiveguys.com/Order/Order.aspx?VendorId=4121. Totally unhealthy but delicious and the calorie content is on the menu. Also 139 types of soda available from the fountain.

The best new gem on the latest trip was undoubtedly the Refuge in San Carlos http://www.refugesc.com/ which offers probably the best pastrami you will ever taste, a mouth-watering scallop salad and an astonishing selection of Belgian beers (18 on draft) as well as wine. It is a favourite hang-out of the Silicon Valley set so don’t be surprised to over-hear million dollar deals being down by  incredibly youthful looking individuals dressed in tee-shirts and sneakers at the next table.

So after visiting all of these places, did VoyageMD gain weight – actually no – simply because of (a) the wonderful weather meant lots of running around, (b) the shopping requiring walking miles each day and (c) the facilities for exercise in this part of California. Unlike the rest of the US and the UK, most locals are positively sylph-like

The next trip for VoyageMD  – St Petersburg, Russia.

Not the best day to choose to travel to Spain as a general strike was due to take place and the Spanish personality can occasionally be rather “volatile”. However the purpose of the trip was to discuss improving the safety of insulin so VoyageMD has no qualms about making the trip?

The drive to LHR was surprisingly quick given that this coincided with the rush hour but it did look as if most drivers were parked outside every petrol station in the land, at least in Dorset and along the M3 motorway – obeying the (now regretted) Government advice to “top-up your tank” given the possible tanker driver strike.

Yes business parking at Heathrow terminal 5 is grossly overpriced but I challenge anyone not to be impressed by the automatic Pod system that takes you from the car park to the terminal with the world’s most soothing and relaxing voice explaining the process on the gentle 5 minute trip.

The flight was full and www.BA.com coped admirably with the rather unusual number of travellers using wheelchairs as well as families with young children. It took of late but arrived only 5 minutes behind schedule.

No taxi this time as VoyageMD had a lift already organised but plenty of taxis, and little traffic because of the strike. The hotel http://www.novotel.com/gb/hotel-5560-novotel-barcelona-city/index.shtml was outside of the city centre but adjacent to the Glioria metro station and a tram so easy access (on a non-strike day) to the city centre. Service at the front desk was exemplary, the hotel had good facilities including a roof-top pool, the room was large and you could open the window.

This trip and hotel evoked memories of travel to Spain in the 1970’s and 80’s as the smell of sewage was pretty strong and although the fittings in the bathroom were ultramodern, nothing quite fitted or worked – the shower doors left just enough space to turn the bathroom into a swamp and slippery open at that and the water temperature ranged from scalding to arctic and back again every few minutes – plus ca change! Breakfast was unremarkable but despite years of travelling  VoyageMD remains astonished at (a) how much some people can eat first thing in the morning and (b) how certain nationalities seem to enjoy mixing everything the hotel breakfast has to offer together on one plate!

Outside the hotel there is the astonishing Segrada Familia church (desgined by Gaudi) within walking distance – still being rebuilt but still fabulous although the number of dodgy looking characters (AKA pickpockets) hanging around seems to have multiplied in recent years. Otherwise not a lot except for a few bars ,restaurants and “ladies of the night” hanging around the roundabout next to the hotel.

Great meeting with healthcare professionals from 27 countries and the trip back was uneventful and again congratulations to BA on being on time.

Barcelona has everything – weather, history, culture, architecture, food, shopping and nightlife and this time even a general strike was tolerable!

VoyageMD is likely to be biased given his Scottish Roots but even so a trip to the capital is always an exciting prospect. The perennial problem however is what to pack in order to cope with unpredictable Edinburgh weather but at the same time avoid the excess costs of checking luggage in on Flybe (www.Flybe.com).  VoyageMD travelled light. Whenever possible use the electronic check in machines for travelling with hand luggage – use the traditional counter method and you will be asked to squeeze your carry-on bag into a ridiculously small box to avoid the penalty of checking in luggage. Most fail and are £36 lighter.

Hats off to Flybe though – arrived in Edinburgh ahead of schedule and a very smooth and pleasant trip it was.  On arrival it is easy to get to Edinburgh City Centre by bus and will only set you back £3.50 for a single ticket.

VoyageMD was staying the George Hotel – a perfect location to enjoy the city (http://www.edinburghgeorgehotel.co.uk). Thumbs up to the hotel (it has recently changed management so many of the reviews are out-of-date) on all aspects – service, room and especially breakfast (you might have to queue though). Good value provided you avoid the “rack-rate”.  Across the road is the must-see Edinburgh bar – the Dome. (http://www.thedomeedinburgh.com).

Lunch was at the Grain Store in Edinburgh’s Grassmarket area. (http://www.grainstore-restaurant.co.uk/about).   The food is a tribute to the best of Scottish fare without a deep-fried Mars Bar anywhere to be seen. Good, value with great service and you can also have a before lunch/dinner drink across the road at the Bow Bar – this traditional pub offers more than 200 whiskies and 8 real ales on draft.

In between VoyageMD had a very successful meeting focusing on “disruptive” technologies and approaches to blood glucose monitoring for people living with diabetes (more to report soon!!) so the evening meal was booked at Oloroso on Castle street (http://www.oloroso.co.uk/) to celebrate.  Compared to the lunch, this was a big disappointment – mostly because of the price. A £55 “burger” actually turned out to be a huge meat feast with enough protein to induce temporary kidney failure but the steak and chips was simply not good value. The view is OK but not spectacular and the balcony option is unlikely to be popular given the traditional Edinburgh weather. Puddings were unremarkable so all-in all VoyageMD will probably not be back given the huge choice of eating places elsewhere in the City.

Next day back to Southampton on the using the propeller version from Flybe and arrived slightly early so well done again to the airline.

Edinburgh is a great place to visit for the history, culture, locals, food, entertainment etc but this is probably the only time where global warming is an attractive option.

Airline: http://www.flybe.com/

Hotel: http://www.rheinhotel-meerbusch.de/

Feeling unhappy, depressed or verging on suicide then a couple of nights at this hotel will surely finish you off! Situated on the banks of the Rheine, early March is probably not the best time to visit but VoyageMD was left wondering if there ever is a best time to visit this particular place?

Airline: The good thing about recent flights with Flybe is that they are punctual, sometimes even arriving before the scheduled time. On board, the flight attendants are invariably helpful and appear genuinely pleased to see you. The in-flight magazine was the usual fare although it did contain short descriptions of Flybe destinations – they even managed to make Doncaster sound a must visit destination!
On a negative side, the food on board for purchase was fairly dreadful unless you have a particular fondness for high sugar, high fat, waist-busting junk. No mention of carbs or calories but assume high values for both.  Anyway arrived slightly early and in the pouring rain.

Taxis: The hotel was 15 minutes from the airport and cost 40 euro although the return journey somehow seemed a better bargain at 30 euro! The fare for the much longer ride into the centre of Dusseldorf was again 40 euros!

Hotel: OK, if you like peace and quiet it is probably quite a pleasant place to stay, perhaps also in the spring or summer but on this occasion a few more human beings beyond the receptionist and waitress would have dissuaded VoyageMD feeling like Charlton Heston in the Omega man!

The room was small but comfortable and for once it was possible to open the window for fresh air (US hotels please note). For those travellers who are “nutritionally challenged”, they might struggle manoeuvring around the bathroom and using the facilities. Clearly our German hosts anticipated that guest should limit themselves to one shower (no bath) per day as they only provided one modest sized towel which appeared to be made out of sandpaper – use once and it remains wonderfully damp until replaced the following morning. The bed was firm but pleasant enough however to go beyond one thin pillow meant rummaging through the cupboards for the spare one. No such luck in supplementing the almost see-through duvet – the Hotel owners presume verging on hypothermia throughout the night is invigorating and good for well-being.

Nearby to the hotel there is almost nothing to do and human life disappears completely after dark. There are two bar-restaurants within walking distance but if you go there you would probably double the takings for the night. If you need to visit (escape!) downtown Dusseldorf, there is a ferry outside the hotel which takes you across the Rhine and after a 10 minute walk there is a tram directly into the City.

Overall, this hotel is functional, clean and suitable for the agoraphobic! VoyageMD will probably not be returning soon…

A UK based technology company (Patients Pending Ltd) just announced the launch of Timesulin, a novel replacement cap that fits on all major insulin pens.

A really simple and neat idea –  the “smart” cap for the insulin pen shows how long it’s been since the last injection. Timesulin apparently works with all major insulin pens, straight out of the package without any programming required.

A UK based technology company (Patients Pending Ltd) just announced the launch of Timesulin, a novel replacement cap that fits on all major insulin pens.

A really simple and neat idea –  the “smart” cap for the insulin pen shows how long it’s been since the last injection. Timesulin apparently works with all major insulin pens, straight out of the package without any programming required.

Often simple ideas are the most helpful for people living with diabetes. Remembering to take insulin with every meal, every day, for years and years is not always easy. Surveys have shown that, on average, an insulin injection is missed about three times every month. If the injection is missed there is a risk of high blood glucose levels. Also if a person cannot remember if a recent injection was taken and they decide to take another one then there is a risk of hypos – this is called insulin “stacking” in medical terms where two or more injections of fast-acting insulin are taken too close to one another.

For travelers with diabetes who need to take insulin injections, the combination of travel fatigue and jet lag can play temporary havoc with remembering when the last injection was taken. At VoyageMD we think that the Timesulin device could be helpful – so much so that we have asked the company to let us do a road-trip with their new device. We will let you know how we get on perhaps with some photographs of travelers and the Timesulin device in exotic and interesting places?

You can check out their website for additional information: www.timesulin.com ,join them on Facebook (www.facebook.com/timesulin) or email them at: info@timesulin.com 

This program has been designed for people that are about to go on a skiing holiday. The exercises shown here target the specific muscle groups that are used when you ski – the idea is to train them so that your holiday will be pain free!!!

The program should be completed at least 3 times a week to get the most benefit, more than 3 times a week will increase the benefits further.

*Reps – repetitions

Squating oblique twists:

• Stand with your legs shoulder width apart and bend your knees to about a 90 degree angle
• Keep your chest and glutes pushed out
• Hold your arms out in front of you about chest height
• Twist your body to the left, as you do this straighten your left leg so that all the pressure is going through the right leg muscles
• After completing this, twist to the right and do exactly the same
• Repeat this movement for 15 reps each side

Jump squats:

• Stand so that your legs are shoulder width apart and knees are slightly bent
• Place your arms out straight in front of you, about chest height
• Keeping your chest and glutes pushed out start to bend your knees until your knee joint is at a 90 degree angle
• Make sure that when you are bending your knees your knees never go over your toes
• When you get to a 90 degree bend jump up in the air raising your arms above your head
• As you land make sure you bend your knees
• Repeat this action for 30 seconds

Lunging with oblique twists:

• Stand with one leg in front of you and the other leg behind you
• Make sure that both your feet are facing forwards
• Start to bend your knees, both legs should bend to about 90 degrees
• The back legs knee should be about an inch away from touching the floor
• When your in this position put your hands on each side of your head and twist your body to one side and then the other.
• Repeat this movement for 15 reps each l

Bent over rows:

• Stand so your legs are hip width apart keeping your knees slightly bent
• Slightly lean forward and keep your chest and your glutes pushed out
• Keep your arms shoulder width apart and place them in front of you keeping your elbows slightly bent
• Your hands should be positioned so that your palms are facing the side of your body
• Bring your arms back so that your hands are about an inch away from your stomach, keeping your arms by your side
• Slowly straighten your arms so that they are in front of you again to the starting position.
• Repeat for 15 reps

Upper body twists:

• Stand with your legs hip width apart with your knees slightly bent
• Hold your arms out in front of you about chest height
• Turn your upper body to the right then to the left, keeping your hips facing forward at all times
• Make sure that when you twist your upper body you face the way that you twist
• Repeat this movement for 30 seconds

Deadlifts:

• Stand with your legs hip width apart and knees slightly bent
• Grip the dumbbells with your hands and place them hip height in front of you
• Keep your chest and your glutes pushed out and bend your knees so that your dumbbells are touching the floor
• Keeping your back straight and your head facing forward, straighten your legs, as you do so you want the dumbbells to brush your shins
• As you stand up push your hips forward so that your back is extended
• Repeat this movement for 15 reps

Tricep kickbacks:

• Place your left leg in front of you bending your knee just below a 90 degree angle
• Your right leg should be behind you with your knee slightly bent
• Both your feet should be positioned so that your toes are facing forward
• With your right arm bend your elbow so that your hand is just above chest height, keeping your elbow as close to the side of your body as possible
• Your palms should be clenched facing the side of your body
• From this position slowly straighten your arm completely until your elbow is completely straight (if the elbow isn’t completely straight you wont target all three tricep muscles), keep your arm as close to the side of your body as possible
• Once this movement is completed for 15 reps swap arms and do exactly the same

Impact of High Altitudes on Glucose Control

Article published in the November 2011 issue of the Journal of Diabetes Science and Technology.

Authors: Johan Jendle, M.D., Ph.D.,1,2  and Peter Adolfsson, M.D.3

Airplane flight results in exposure to hypobaric conditions. At cruising altitude, usually 10,000 to 13,000 meters (30,000 to 42,000 feet), the pressure in the cabin is 0.75 atm, which is 75% of the pressure measured at sea level.

The difference in pressure between 1.0 and 0.75 atm is what passengers experience as temporary ear discomfort at take-off and landing.

What does elevation have to do with diabetes then? It would be anticipated that people with diabetes travel as frequently as everybody else. It has been described in the literature1  that some glucose meters are affected with changes in altitude. The  glucometers  studied  underestimated  glucose  levels  by  approximately  1–2%  for  each  300  meters/1000  feet  of elevation after correlation for changes in temperature and humidity. The lower the oxygen partial pressure, the lower the glucose value. Most glucometers use glucose-oxygenase methods, which are dependent on oxygen in the surrounding environment.2  The partial pressure of oxygen in the airplane cabin is 16 kPa compared to 21 kPa at sea level, thus there is a risk that a glucometer can show a false hypo- or normoglycemia while in the air, when the true value in fact could be higher.

These effects of high altitudes do not apply only to flying conditions. There are many cities around the world situated at high altitudes: Colorado Springs, United States, 1840 meters (~6040  feet); Mexico City, Mexico, 2200 meters (~7220 feet), and La Paz, Bolivia, 3640 meters (~11,940 feet). It might be that people with diabetes living in these cities are taking much lower insulin doses than necessary because of false, low self-monitoring of blood glucose readings and therefore have a higher HbA1c level compared to a similar population living close to sea level. For instance a comparison between residents of Colorado Springs and Boston would be interesting to see.

Hypoglycemia has been reported, in connection to flying, in people with insulin-treated diabetes using continuous subcutaneous  insulin  infusion.3   This  may  be  due  to  trapped  air  within  the  ampule/infusion  set  or  related  to  a  direct effect on the pump’s insulin delivery system, but this has not been completely investigated. With the increasing use of continuous glucose monitoring (CGM), especially in sensor-augmented pumps,4   it is of importance that sensor systems as well as insulin pumps be evaluated in various pressure conditions.5 The glucose oxygenase method is used by CGM systems and by most glucometers. However, the accuracy and performance of one CGM system was minimally affected when  challenged  under  hypobaric  conditions  at  0.5  and  0.75  atm.6   The  Food  and  Drug  Administration  has  advocated that all sensors being used for glucose sensing be evaluated under relevant pressure conditions.

Author Affiliations: 1Endocrine and Diabetes Center, Karlstad Hospital, Karlstad Sweden; 2Department of Medicine and Health, Örebro University Hospital,  Örebro  Sweden;  3Pediatric  Growth  Research  Center,  Department  of  Pediatrics,  Institute  for  the  Health  of  Women  and  Children, The Sahlgrenska Academy at Gothenburg University, Göteborg, Sweden

Abbreviations: (CGM) continuous glucose monitoring

Corresponding Author: Johan Jendle, M.D., Ph.D., Endocrine and Diabetes Center, Karlstad Hospital, SE-65185 Karlstad, Sweden; email address

johan.jendle@liv.se

What then are the implications for our patients with diabetes?

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With the seasons about to change we need to be aware of the potential impact that environmental temperature can have on the self-measurement of blood glucose levels. If you try to measure your blood glucose levels outside of the range recommended by the manufacturers this could cause serious problems.

Just think if your glucose was just in the hypo range but the meter reported wrongly that the level was in the normal range or even above normal there would be a serious risk of you suffering a severe hypoglycaemic event! Imagine that happening half way up a mountain on a skiing or snowboarding holiday? Likewise if the meter tells you that your blood glucose level is fine but in reality it is vey high then you could end up with uncontrolled diabetes and be very ill. If this happened when you were in a foreign country out in the wilderness this could be disastrous!

Therefore we have asked the manufacturers of blood glucose strips to let us have details of the ideal “operating temperature range” for their equipment.

We are still waiting for some replies but meanwhile check which system you plan to use on holiday and keep to the recommended temperature. The alternative is to switch systems to one that is more appropriate for your trip – ask your diabetes team for help.

+  FAD GDH test strip with no user calibration.   Use with FreeStyle Lite, FreeStyle Freedom Lite or FreeStyle InsuLinx

*  GDH-PQQ test strip requiring user calibration.  Used with FreeStyle, FreeStyle, FreeStyle Freedom or Freestyle Mini meters

^  Control solution tests are specified to be accurate only when used between 15 to 40 °C

At VoyageMD our main aim is to make travelling with diabetes easier and safer. We are very aware that changes in temperature and exposure to sunlight can affect treatments such as insulin and the new Glucagon-Like-Peptide-1 therapies such as Byetta and Victoza that also have to be given by injection.

Travellers therefore need to be mindful that storing these in the aircraft hold can cause these medicines to be less effective because of the cold.  However warm temperatures and sunlight can also affect medicines that have to be given by injection.

In Lisbon, Portugal this week more than 17,000 scientists and healthcare professionals are gathering to discuss the latest research breakthroughs in diabetes and we will be highlighting some as they appear. Also in Lisbon are the main diabetes industries including the manufacturers of insulin and the GLP-1 drugs so we have asked them to provide us with the ideal range of temperature that their products need to be kept at and also if there are issues with sunlight. The companies (and Twitter names) are:

      @Novonordisktbl

   @Lillypad

@Diabetes_Sanofi

Once they respond we will post the information on VoyageMD.com.

Responses

Novo Nordisk

In order for insulin to stay active it needs to be kept cool. The optimal temperature to keep insulin is between 2°C and 8°C. Insulin may be kept at room temperature for a short period of time but If insulin exceeds room temperature of 25°C, 77°F  then it will start to de-activate and will no longer be suitable to be injected.

The information varies from manufacturer but an insulin cartridge in may be stored at room temperature for up to one month.

What is known about insulin is that it should never be frozen and never exposed to direct sunlight or heat.

For example, visit Victoza’s website for information on how to take proper care of their insulin pens.

Before you use a Victoza pen

• It is advised to store an unused pens at 36°F to 46°F (2°C to 8°C) within a refrigerator.
• If any pens are not kept in the refrigerator before they are first used, then they should be used or thrown away within 30 days.
• Although the pens need to be kept in a refrigerator, they should not be kept close to the refrigerator cooling element. This can lead to the pens freezing or become frozen. If this happens then you are unable to use the pens.

When using a Victoza Pen

• It is advised to store a Victoza pen at 59°F to 86°F (15°C to 30°C), or in a refrigerator at 36°F to 46°F (2°C to 8°C) for a period of 30 days.
• If you are using the pen anywhere but your home then you need to store the pen at a temperature between 59°F and 86°F (15°C and 30°C).
• In the case where a Victoza pen has been exposed to temperatures above 86°F (30°C), it should be disposed of.
• The pen should be protected from all forms of heat including sunlight.
• When the pen is not in use, the cap should be kept on.
• The longest period that any pen can be used is 30 days. After this time, it needs to be disposed of.

Researchers in Australia have checked what happens to the amount of insulin delivered by an insulin pump on an aircraft during take off and landing.

• Make sure the pump cartridge only contains 1.5 ml of insulin
• Disconnect the insulin pump before take off
• At cruising altitude, take the cartridge out of the pump and remove any airubbles before reconnecting
• After the airplane lands, disconnect the pump and prime the line with 2 units of insulin then reconnect the pump
• During flight emergencies involving cabin decompression, disconnect the pump

Responses