Travelling with Diabetes

I had meant to write about traveling with diabetes a while ago. For our honeymoon my wife and I traveled around Vietnam and Cambodia. It was long before I started this blog, so I will focus this post on something more recent and save that for another time.

I am writing this having spent a long weekend in and around Philadelphia and from there traveling to DC then Montreal and finally New York before flying home to Tel Aviv (with a short stop off in Madrid). We have been here for a family wedding so my brother and I have both been training and managing our diabetes together.It's not been easy. The heat has been punishing, hot and extremely humid. Aside from waking up early for some morning training we are wandering around the city so being far more active than normal. Add to all this the food is wildly different from what either of us are used to.

The "Rocky Steps" leading up to the Philadelphia art museum

The hotel had a gym so we were on the exercise bikes in the morning before going for a run to the art museum and some interval training up and down the famous rocky steps. My brother is tapering off for his preparation for the London triathlon next weekend while I am continuing to build up to the mHealth Grand Tour.

Rocky and Me

The problem throughout the weekend has been the food. Portion sizes and sugar content being the biggest difficulty. In the US as anywhere there are novelties with the food that is different from what we are used to. Whether its a fatty Philly cheese steak or a giant kosher style salt beef sandwich. We just don't have quite the same food back home.I have blown throughout 60 test strips in 5 days. And the swings have been up through the roof after going back for seconds at the wedding and middle of the night lows after a long day starting with training and ending with a meal at the fantastic Marimoto Japanese restaurant.It has been as constant battle between correcting for highs and stuffing my face full of gummy bears when I am low. As the trip continues and we start visiting more friends and eating more home cooked food I am hoping that will help keep my sugars more balanced.

This is not my first time traveling and every trip no matter how exotic the location poses its challenges. My advice for travelers with diabetes is that it's important to test more frequently, changes in routine, particularly volume of activity; the stress and sedentary nature of long haul flights; different climate; and new foods all have an effect your insulin sensitivity and sugar requirements. Check packaging of food to get the nutritional information and ask waiters in restaurants about your food to make it easier to estimate how much insulin to take. As I sit on a four hour intercity bus ride I will add that it is always a good idea to stock up on water and emergency sugar, like coke and gummy bears, on a journey like this one. I like to bring some fruit too, I prefer to keep my sugars up with that rather than let them drop to hypo and then eat junk. On flights this is less of a problem as there is almost always something available. I usually travel with my wife and if not I am rarely on my own. I always take far more supplies than I need: extra testing strips; double the insulin/spare pens; and loads of needles. I then split them up across our suitcases and hand luggage. In the case that a bag gets stolen or lost I will still have enough to last, if not to the end of my trip, until I can organize getting hold of more.

I always buy travel insurance. My health care provider, Maccabi, does travel insurance which covers me for any diabetic emergencies at no extra cost.Try to keep everything in balance with some exercise especially on a less active holiday. Most of all try to have fun. Whilst we can never take a holiday from our diabetes we can still have a really good time away from home and away from our familiar and easier to control lifestyle.

Live long and stay healthy

mHealth Tour Infographic

During September I will be riding in the mHealth Grand Tour as part of TeamBloodGlucose.  Here is a great infographic detailing the research goals of the tour.

My last Diabetes check up

Last meeting with my Diabetes team I had a really good result of 6.6%. I went to the meeting and got in trouble because my meter had too many hypos on it from the previous 2 weeks.

The annoying thing was that they didn't really pay attention.  There was probably less than half the actual hypos as I often double check or check 10-15 minutes later when I am still coming up, but the meter still registers me as low.

The second problem is a lack of understanding of statistics. They claimed that my good result was not any good because a I had too many lows, therefore balancing out the highs.  A wild extrapolation at best, the readings on my meter were for 2 weeks, the HbA1c test is and average for 3 months. Additionally the amount of time I am high for, when I am high, is usually significantly longer then the amount of time I am low for.  I treat lows very quickly with lots of sugar, and I treat highs very slowly with small amounts of insulin so that I do not end up low. So pretty simple statistics tells us that I would need an extreme amount of lows to balance out a few long highs.  Therefore my control must have on average been better than they were suggesting.

Their final comment on this was that its bad to have too many lows, as you can lose sensitivity to them.  OK fair point, but considering I don't normally have that many lows I think I will be OK.  Then came the knock out punch.  I was told it can lead to problems with the brain if I have too many hypos.  What the hell.  That was new to me.  I am aware what can happen if I don't treat my hypo, then its quite possible that I could cause damage to many of my organs.  But when I refer to a hypo I am just low, nothing too serious.  Still able to treat myself.

Everyone knows about the long term complications of high blood sugar. But now I am learning about the long term problems with low blood sugar too!  According to this article research done states that there are no problems associated with too my low blood sugar incidents and in fact it is preferable, and expected,  if that is the consequence of keeping blood sugar low.  Phew!

to quote the relevant part:
"Researchers also found that intensive management, which often resulted in more frequent low blood sugars, had no negative effects on the minds of patients. You can rest more peacefully knowing that low blood sugars do not seem to have any connection to cognitive impairment."

One year on

It was around this time last year, my brother was racing in his first triathlon, the Tour de France was starting and my addiction to cycling at an all time high.  Bradley Wiggins, who I had been following since he was a track champion in 2004, was going into the tour as the big favourite.  So I pumped up my tires and started doing some cycling.  Some days when my wife needed the car I got a lift to work with my bike and rode home.  By August I was ready for a bigger challenge.  I got up early one Saturday morning and rode.  I rode until I couldn't any more.  I made it to Tal Shachar, my cousins moshav, after riding 60Km.  I was really happy with that.  The following week I was back at it.  In September I bought a new bike, Merckx EMX 1, and started riding more and faster each week.  I rode in the Tel Aviv bike ride and then the Sovev Galil Maarav.

By November last year I was a little unsure about how I was managing with my diabetes, especially as I had an HbA1c of 7.4%.  So when I met with my dietitian she recommended that I meet with the sports consultant at the diabetes center.  The consultant, Yaara, advised me to join a cycling club and recommend Carmi and X-team.  I have been training with them since the beginning of December.

Since then I have met some great people in the team, done some fantastic rides, and some not so fantastic rides.  I have raced in the national championships and now I am preparing for a 3 day tour over the Pyrenees.

I have a had a great time riding my bike and I am getting stronger and fitter than I ever was before I was diagnosed with Diabetes.  My weight has come down, my control over my blood sugar has improved and my HbA1c result was 6.6% last time it was tested.  I am thankful to Carmi and X-Team as well as my health care team, Dana, Yosi, Yaara and Dr Hazanov, for helping me achieve my goals.

Israel National Masters Championships 2013

The weekend was the open championships for masters level cyclists.  I had set my sights on this event since March and I was really looking forward to competing on this level.  The winner in each category would receive a national masters jersey and entry to the upcoming Maccabi games.  I knew I wasn't going to be getting a podium.  I had raced exactly once, fortunately on exactly the same course.  The difference in the championship race was it was an extra 2 laps (30Km) more than 100Km in all.  I have ridden this distance before but perhaps not enough and not under race conditions. My goal was just do better than last time.  Last time I was only able to stay with the peloton for 1 lap, this time if not for the whole race at least for more than before.

more pictures here

My wife left me a message to see in the morning before the race.

sunrise at the start

The evening before Alon and I had our pasta dinner together.  This time he cooked and I brought desert.  Techina cup cakes with chocolate ganache and smoked salt, made by my wife.  We talked about the race and about what I am up to with TeamBG, ate plenty of pasta and drank lots of water.  I went home and got my stuff ready for the next day.  Water bottles filled, sandwiches made, chain oiled, bag packed with shoes, helmet, energy gels and everything else that I needed.

Alon brought coffee for the team

Making his coffee run so every can start the day right

The following morning my alarm goes off at around 415am.  I jump out of bed and start to get read.  I check my blood sugar.  It was a little high (not surprising after all that pasta the night before), see below for specific details.  I took some insulin and started eating my sandwiches.  I ate two on the drive as I wanted to store as much energy as possible for the long race.We arrived nice and early at the car park, got ready and went to meet the rest of the team at the water tent.  Alon Yotam and I started our warm up.  We had a few runs at the finishing hill and made our way back to the tent.  Carmi wished us all good luck and we all made our way to our respective start lines.  Alon, Yotam, Omer and I lined up together close to the front as the four representatives of X-Team in the 30-40 category.  I check my blood sugar a final time, at 312 mg/dl it was a lot higher than I would have liked but I had no choice.

Last minute tactics

getting the water tent ready

The starting beeps came and we were off.  The pace was around 35kmph and after the nervousness of the peloton died down a bit I started to relax.  My heart rate was higher than I would have liked but not sky high like the last time I raced.  As the race went on I felt comfortable moving around peloton, its not so easy and you have to fight for position.  Thankfully everyone was alert and there were no incidents, though one or two close calls, another reason to stay up near the front.  After a lap and half I was feeling really happy with myself, I had not been dropped from the group.  Time for some food, I reached for my preopened cliff bar.  First mistake of the race.  I took a big bite and I realised there was only a bit more left.  So I stuffed it in my mouth.  Ooops too much.  My mouth was really full.  I was finding it hard to breathe and I had so much in there I that I couldn't chew or swallow.  It took me me far to long to get down and sent my heart rate sky high, right gels from now on.

lining up on the start

Carmi setting off

Alon saw that I was doing ok and asked me to keep and eye on one of the danger men, Ariel.  He was easy to watch, the only one in an FC Barcelona cycling jersey.  I stuck to his wheel and watched for his moves as best I could.  I was able to take water on the go without getting dropped from the peloton.  Everything was great until it wasn't.  At the end of the 4 or 7 laps some guys made a break for it and the group sped up going up the steepest part of the towards the finish line.  I just couldn't hold on, after 60Km at race speed I was done.  I just couldn't hold the pace.  Yotam, one of my team mates, was having the same difficulty.  We rode together for a lap and a half unable to catch the peloton until I made my second mistake.  I had picked up Yotam's bottle the last time round the water tent.  I hit a bump and the bottle fell out.  I felt guilty as I was riding with the guy at the time and turned round to get it.  As I turned round I saw the Masters Pro peloton baring down on my like a freight train.  I decided to forget about the bottle and get moving again.  By this time Yotam was well ahead of me and by the end of the penultimate lap I was almost spent.  I finished up the race coming in 24th out of 30 around 20 minutes behind the leaders.

And we're off.

finishing a lap in the peloton

Yotam and I distanced from the pack

Alon in the break

Alon coming across the finish line

Finishing strong

Alon came second from a break.  Vered came second in the 30+ women, Avi came second in the 60+ men, and Orit came second in the 50+ women.  Ilan made the top ten in the 40+.  Most inspiring of all was Henry who at 80 years old was able to represent our team.  At the presentation he was presented with the winners Jersey for the 80+ category.  Carmi helped him up to the podium and he spoke a few words, thanking us all for being his extended family.

30 - 40 winners podium

All in all I had a good race.  I held the peloton for longer than last time, I collected water without getting dropped, and for the first half of the race I was riding really comfortably in with the front runners.  Next year I will be racing the the full season and hopefully after a busy off season I hope to smash it.

Post race festivities

Blood sugars and food as best as I can remember it.
2222 - 230
0428 - 215 4u insulin 80g sandwiches coffee
0615 - 257 2u insulin
0650 - 306
0703 - 312
cliff bar after 1.5 laps
gel at 2.5 laps
gel at 4 laps
gel at 5.5 laps
1028 - 43  this was a bad test, my hands were a little wet with sweat so messed up the reading
1028 - 198
1044 - 202 bowl of pasta and half a bottle of beer. no insulin
1122 - 252
1235 - 215
1331 - 204
1604 - 190 various food 7u insulin
1704 - 207
2102 - 266 schnitzel and mash potato 6u insulin
2348 - 191
0034 - 259
0747 - 142

Over all not a major success blood sugar wise.  I am conservative though because for such a long race where I have no opportunity to test along the way I do not want risk going low or running out of energy.  Should have had more insulin the night before with the pasta and more first thing in the morning, maybe 7u.  That way the insulin is mostly gone from my system midway through the race which will allow my body to break down glycogen and fat better.  When I first started and I was not getting feeding and insulin correct at all after a long ride I could be as high as 400, here finishing at around 200 wasn't so bad.  I was hesitant to give myself too much insulin in the afternoon as I was worried that the after burn would send me very low.