Diabetics In Motion - Traveling With Diabetes

Traveling with medical supplies, regardless of if they're for diabetes or not, can be a daunting prospect. We often find ourselves asking what extra steps we need to take to make sure our insulin doesn’t lose potency during road trips or long plane rides, how do you take supplies through airport security, and what the heck do you do if you run out of something? Amy and Liz talk about general tips for traveling with diabetes and then dig into extra tips for flying, driving, hiking, and generally existing on the move.

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Links:

Insulin effectiveness after sun, heat, and cold exposure https://www.bmj.com/content/338/bmj.a2218.long and https://go.gale.com/ps/i.do?id=GALE|A235631421&sid=googleScholar&v=2.1&it=r&linkaccess=abs&issn=15209156&p=AONE&sw=w&userGroupName=anon~695c9ea3

Insulin storage study https://www.sciencedirect.com/science/article/abs/pii/S1544319118301924

ISPAD Clinical Practice Consensus Guidelines 2018 https://onlinelibrary.wiley.com/doi/10.1111/pedi.12718

GLP-1 storage and life-span https://www.researchgate.net/figure/Formulations-and-storage-conditions-for-GLP-1-RA-products_tbl1_326447155

TSA recommendations https://www.tsa.gov/blog/2020/11/13/travel-tip-traveling-diabetes and

Traveling with an insulin pump and cgm https://www.diabetesadvocacy.com/traveling-with-an-insulin-pump-and-cgm/

Airplane cabin pressure and unintentional insulin delivery https://medicalxpress.com/news/2012-11-airport-x-rays-diabetes-devices.html

General insulin pump screening recs https://medicalxpress.com/news/2012-11-airport-x-rays-diabetes-devices.html

T-Slim screening recs https://www.tandemdiabetes.com/docs/default-source/general-guides/ml-1000524_a_print_info_card_tsa.pdf?sfvrsn=2

Medtronic screening recs https://www.medtronicdiabetes.com/loop-blog/tsa-screenings-update-for-people-with-diabetes/

Transcript

Amy: Living with diabetes is exhausting both for our bodies and minds. It's not surprising that many diabetics struggle with the mental health side of this disease, including burnout and diabetes distress. We at the Diacast want to remind anyone who is struggling that you deserve all the help and support in the world. If struggling, please go to Diacast.com/resources for a list of resources and links, diabetes support groups, ways to find therapists in your area who specialize in diabetes and crisis lines. Diabetes is hard, and sometimes we all need a hand.

Liz: Hello and welcome to this month's episode of the Diacast. Today we're gonna talk about traveling with diabetes since the biggest concern, regardless of your mode of transportation, is maintaining the integrity of your insulin or other temperature sensitive meds like Opic or Trulicity. The bulk of this episode will focus on insulin storage, endur travel. Before we get into that though, I am your host, Liz, and I'm here with Amy. Hello, Amy. How are you doing today? I'm

Amy: Pretty good. How are you, Liz?

Liz: Doing well, Doing really well. It's fall is here, so we're just staying alive, you know.

Amy: It is, it is fall. We have termination dust. We've got some snow on the mountains up here. It's I'm not ready.

Liz: <Laugh> <laugh> I do wish I could see it. It sounds beautiful. Fall here in, in Ohio is still well into the seventies and very muggy, so, ah we do the best we can.

Amy: Wow. Just come north. I have magnums and a spare bedroom, so you know where to find me. There

Liz: You go. There you go.

Amy: Well, before we get into this month Liz, what's your bg?

Liz: I am currently rocking a 251 M G D L, which comes out to 13.9 millimole,

Amy: And I am 1 73, which is 9.6 millimole.

Liz: I do not regret the choices that got me to this point. At least it's on its way down.

Amy: Although you, you just got some blood work done, didn't it? You, your A1C is, is down significantly, right?

Liz: Yes. I hit 7.0 on the dot down from an 8.6 or 8.7 four months ago. So what my doctor said that I had to get it down to, you know, deal with, make sure I'm not at risk for complications for all the other things I'm on. So, very excited about

Amy: That. Awesome. So what's what, what's been your plan of attack with that? I know this is off topic, but, you know,

Liz: Life often to, to our fans that don't know, I'm a big fan of dance, Dance Revolution. I recently acquired a couple of the L Tech pads from Poland. Shipping was expensive and totally worth it. So a couple hours of dance dance revolution several times per week. Making slight but healthier improve ch choices in my diet. And just in general, just being more aware of my blood sugar and, you know, being more on top of taking my insulin and everything else has, you know, just making small changes, but they've come out really well.

Amy: That's awesome. I'm very proud of you and thank you. My father would be as well,

Liz: <Laugh>.

Amy: All right. So we are here today to talk about traveling as a diabetic. Now, there are a couple rules of thumb that are going to apply for any and all medical supplies when traveling, regardless of whether or not they're for your diabetes, regardless of whether or not they're temperature sensitive. So we're gonna kind of stress those first. Number one, there's a hand gesture. I hope you heard my hand gesture. Have at least some of your meds in a container with a prescription label on it, just in case someone challenges you on, on those meds. Now, in 28 years of traveling with diabetes supplies, I have never been challenged about the massive random quantities of pills and supplies that I've carried. That said, it does happen generally when you're doing international travel. So TSA does recommend that when you travel with prescription meds, you carry them in the prescription container that has the label on it with your name. Number two, <laugh>. Make sure that you have redundancy for checking your blood glucose, be that extra continuous glucose sensors a extra transmitter for your sensor, a backup blood glucose meter, what have you. Redundancy is key because when things break, they do it when you're not at home.

Liz: Absolutely. I always, even, even when I'm wearing the Libra I, I take two blood, I take two monitors with me just because Yeah, I don't wanna, I don't wanna not be able to check it.

Amy: Yeah. So I should know better, but I don't <laugh>. So a few years back I went out to the field and I was there for like eight weeks. And I brought extra sensors and I brought extra transmitters and I forgot my meter at home on the bathroom counter. And of course, this was the season where all of my sensors got frozen and all of them read very, very off, and I couldn't calibrate them because I didn't have, Oh, no, a fingert stick. I ended up going to the medic in the camp and asking to check my blood and they were very baffled by it. And then I was like 300 and my meter thought I was like 180. Whew. So that was a bad experience. My husband, bless him overnighted me my meter Oh, wow. And a bunch of chocolate because he loves me <laugh>. It was, it was an absolute disaster. A hundred percent my fault. I,

Liz: Is this another case of do as Amy says, and not as Amy does?

Amy: I, you know, this is the first time this had ever happened to me, like ever. Yeah, I, I know better. And this is just, this is Murphy's Law, not even Murphy's Law. This is the, the minute you're not fully prepared is when you get bone. So bring your backup and bring the second independent way of checking your blood glucose, because the minute you don't is the minute you need it. <Laugh>.

Liz: Absolutely.

Amy: Leading us in too. Number three, keep your medical supplies, especially the temperature sensitive ones on your person. Insulin goes in backpack or carry on if you're on a plane. If you're driving and you have it in a cooler, keep it inside the car. Do not let your medical supplies off of your immediate person bags get lost sensors in a massive gear bag, get frozen or boiled. So on your person, because where you are, you know, you have some control over the temperature and whatever climactic conditions. Is that a word? Climactic?

Liz: I think so,

Amy: Yes. Yeah, it is Now whatever, whatever conditions it's being stored at, you have a little bit of control when they're on your person.

Liz: I think. I think it's worth mentioning too along with insulin, make sure you've got the, the delivery system, pen, needles or syringes or whatever it is, the TSA or your, your airline governing body of choice. I don't even know how to describe the other ones, but they understand. They, they know that there are diabetics in the world. They are not going to be surprised by a few needles in your bag because having just the insulin on you and no way to deliver it because you were worried about them taking your needles is also a bad time. It is. So that includes the needles. Keep the needles with you.

Amy: Yes. I have an insulin pump. I actually have multiple, I either travel with a backup insulin pump, or I travel with a set of insulin pens, backup way of take, checking your blood glucose just as important a backup me way of taking your, your insulin. Which leads us into number four <laugh> function on the assumption that your trip is going to be unexpectedly long and bring way more supplies than you actually need, including any pills. My default starting point is bring double what I need for long trips for when I know I'm gonna be gone for a month and a half, two months. I, I may bring, you know, 150 times what I need, so like one and a half times. But you have to make sure that you have enough buffer that if for some reason you are gone longer than anticipated, you have enough of a buffer to get additional supplies, either via mail or by transferring a prescription to a pharmacy. You have to be prepared to get stranded because like everything else, the minute you're not is the day you have three infusion sets fail in a row, or you drop your bottle of pills and you lose two thirds of 'em down a drain or into a

Liz: Toilet. Oh yes. Done, done, done that one.

Amy: Oh god. Yeah.

Liz: This is one of the few, few, few cases that I could make for one of the national pharmacies here in the States, like a Walgreens or cvs, cuz it's honestly not that difficult. So I don't, like when I travel within the country, you know, I travel to big cities. It's not, you know, at a couple extra days worth just in case. But knowing that I can get to a pharmacy is, is a god's end. But you travel to the middle of the middle of nowhere and I I I would have a whole bag of just supplies and I think that's what you end up doing.

Amy: <Laugh>. Yes. I, I have taken photos in the past of my, my packing. My default, because I travel with so many supplies is I take every, all of my like pump supplies and stuff out of the box and dump them into multiple one gallon ziplocs because it's a little more space efficient. Mm-Hmm. <affirmative> yeah. I, I've never had any issues with, with pump supplies or asinine quantities of insulin. And I, and I have traveled internationally with 30 vials of insulin.

Liz: Oh,

Amy: Wow. Not a word, <laugh>. That was when we moved to Europe when I went back to school. So just no, there, nobody's gonna challenge that. It, it really is the pills in bottles that are the problem that people talk about. Yeah. Insulin is really not what you think. Glucose sensors similar, similarly, not, not really an issue, but yeah, yeah, just bring, bring extra, which means we are, and we're now at number five. So number five, <laugh>, do not under any circumstance assume that you will be able to pick up hypo treatment, hypo treatments on the fly. You need to carry enough low food that you can treat your hypos in the moment. And just as importantly, that low food needs to be accessible. Inevitably when you have a severe hypo, you a get kind of dumb because hypos make you dumb and you're usually somewhere super inconvenient. Like, I don't know, Mida or over the Pacific Ocean <laugh>, just that this is, this is all you're noticing a trend here. It's all about you need to be self-sufficient. Well, in transit.

Liz: Yeah. Yeah. I just, I just did this one too recently was under prepared for a hypo, and I was out working a fencing tournament and had exercised way more than I had been which meant that the insulin that I was taking was way more than I needed. And woke up at one in the morning in a dark hotel room with not nearly enough glucose tabs and ended up eating all of the sugar I could find from the coffee maker in the room and stabilized. But I didn't know what my next move was going to be at that point. And the front desk was closed. So don't be Liz, do better

Amy: <Laugh>, but Liz, you were adhering to number six, which is if you are traveling alone, have somebody who you can te just touch base with to hold you accountable. Just make sure you're alive. Liz was texting us while she was super hypo in a hotel room, so we knew what was going on and that she treated, but that also meant we were there to be on alert if she like, I don't know, stopped responding all of a sudden. Mm-Hmm. <affirmative>. So we've, we've talked in the past about the importance of having a safety net. Having somebody have access to your CGM data, whether that's, you know, Dexcom share or Libra Link or a Night Scout url. Just having somebody who can check in on you and making sure that they know if you are concerned. I just, that safety net, and this is just incredibly critical if you're traveling alone if you've got, you know, a friend, even if you're in different hotel rooms, you know mm-hmm. <Affirmative>, shoot 'em a text, be like, Hey, the blood sugar's low. Just fyi.

Liz: Yeah.

Amy: So Liz, you get mad props for, you may have failed rule five, but you crushed rule six.

Liz: Hey, I, I'll take it, I'll take it. It's it's kind of nice to have a, you know, maybe they weren't local, but at least it was a support system. One of the things I love about the people I've met on the internet via the support servers we're in they actually understand and they're in different time zones, so I don't feel bad for waking them up <laugh>.

But yeah. So that's, that's kind of the, the rules of thumb. You know, that's how you do it. But, you know, now we should dig into something. We should dig into insulin storage. You know, the biggest concern we hear from people who will be traveling and diabetes, How do I deal with my insulin? We answer this question basically every day on on the discord, the, our diabetes discord. The question comes up all the time in the r diabetes subreddit, and it's, it's very important you know, the tsa I, you speaking from an American, American-centric point of view, of course the TSA has made it extraordinarily complicated and confusing to understand what it is you are even allowed to bring on a plane. And so it's just, it's, it's a mess. It's a disaster. You know, the most important thing to remember about insulin storage at home and while traveling is to keep it out of the sun and try to keep it at a room temperature. It's okay for insulin to be out of the fridge for a prolonged period months, even as long as you keep it from getting too hot or cold. Exposure to direct sunlight can degrade insulin. So keeping out of the sun is probably the most important thing.

Amy: The one of the really challenging things is actually preventing your insulin from getting too hot or too cold. You, you hear about optimum recommended storage temperatures of insulin. And, and that is because letting your insulin get too hot or from experience freezing, it will mess it up chemically and it'll just dramatically degrade the effectiveness of the insulin. So according to the manufacturers the, the big concern with freezing is that it actually compromises the vials, whatever it's stored in your vial, your pen cartridge. And, and that compromises the hygiene of the insulin. From experience, if you actually freeze your insulin and it gets crystally, it's boned. It is basically slightly weird smelling water. Now on the other hand high temperatures has been pretty extensively studied for as far as insulin effectiveness, because this is a much more common concern.

Most people do not do the stupid shit that I do, where you go outside with exposed tubing at negative 40. Yeah. So exposure to high temperatures and direct sunlight accelerates the breakdown of the peptide hormones in the insulin. There are documented cases of diabetic ketoacidosis in insulin pump users whose insulin has stopped working due to exposure to hot or freezing temperatures. And you run into that, especially with direct sunlight, even if your insulin is being stored at what many of us would consider kind of a high room temperature which we'll get into in just a minute being warm is less detrimental to the insulin than sun exposure.

So as far as storage insulin manufacturers claim that insulin can be stored, opened, or unopened at room temperature for up to 30 days. And at a temperature of up to 86 Fahrenheit or 30 Celsius, depending on the type of insulin storage temperatures of 25 cells Yes. For two to four weeks may apply. It, it is a insulin specific storage criteria. Some insulins do better at room temperature for longer than others. The most common fact fast acting insulins used for bowls and correction doses or basal rate if you're on an insulin pump are insulin lira and insulin aspar both have a recommended storage criteria of 28 days at 30 Celsius as the in shelf life, sorry, as the in-use shelf life and storage temperature. That means if you have an open vial of insulin list spro or insulin asper humalog re novalog, you can store that open vial at 25 Celsius, two to four weeks, no concerns about degradation of the insulin for long acting or basal insulins. Lantis and Edgar b

Liz: I thought it was basal glar.

Amy: Basal glar. That sounds much better. Basil,

Liz: I have to, we have to go look it up and put it in the show notes. Yeah.

Amy: Oh Lord. Yeah. So Atlantis and Basil Gar are both 28 days at 30 CELs for opened vials, storage containers. TBA is eight weeks at 30 Celsius. That's that 86 Fahrenheit and Lair is six weeks at 30 Celsius.

Liz: Yep. And of course, the most common recommendation is to discard this open insulin at is being stored out of the fridge for 28 days. Although, and many diabetics question this, although the validity of this recommendation has been questioned in the us approximately 81% of diabetics use insulin beyond the manufacturer suggested discard date, an average of 43 days rather than 28 days. All that said, the impact really is unknown, but there's a lot of anecdotal evidence that kinda supports the fact that it'll be okay a little bit longer than the 28 recommended days.

Amy: Yeah. So some of the just scientific rationale behind these recommendations is that the insulin in pharmaceutical formulations undergoes chemical and physical degradation pathways over time leading to reduced potency. This degradation is accelerated by exposure to high temperatures, direct sunlight, sheer stress through agitation, and by an increased air liquid surface, which occurs as the volume in a vial decreases. And when we talk about sheer stress through agitation, that's if you take your bottle and you shake it that can damage the effectiveness of your, of your insulin. Diabetics take insulin injections several times a day or carry an insulin pump close to the body. So insulin is regularly exposed to all of these stress factors. Hmm. temperature changes can be more damaging to the insulin effectiveness than simply being stored at one temperature. So for people who use insulin pumps, storing the open insulin vial in the fridge between refilling your insulin pump is totally fine.

Since the stored insulin is only at room temperature for a short period for insulin pen users who are taking multiple injections a day, it may be preferable to keep the open insulin pens at room temperature because of that more frequent usage. As kind of a side note, when used in an insulin pump, insulin manufacturers propose a maximum in use temperature of 37 Celsius, or 98.6 Fahrenheit, and insulin should be discarded after one week and can only be stored unre refrigerated for two weeks prior to use. So there are some recommendations that are designed to account for the higher temperature during use in an insulin pump because that pump is typically stored right next to your body.

Liz: Right. Right. Yeah. So we've, we've established at this point heat is hard on insulin. According to the pediatric and adolescent diabetes clinical practice consensus guidelines 2018, and I quote at room temperature 25 C 77 Fahrenheit, insulin will lose less than 1% of its potency over 30 days. In contrast, insulin stored in a refrigerator will lose less than 0.1% of its potency over 30 days. So recommendations are more often based on regulatory requirements regarding sterility than loss of potency. And of course, the average level of awareness of consequences as a result of exposure to heat seems to be higher than for exposure to low temperatures. As many diabetics who live in or travel to warmer climates use cooling bags. And a survey conducted in the southwest of the United States, 64% of diabetics reported to carry items in a cooler slash ice chest or carry items in a commercially produced case with ice gel packs, ice or gel packs to protect the medications and supplies from heat.

And this is where we get into the fun part because there are several products on the market for protecting insulin, pens and vials from heat, notably, the frio, which cools using water evaporation and whose effectiveness slash cooling temperature is dependent on the ambient humidity. And of course, the tempera med, which cools using phased charging material and vacuum insulation. That just sounds awesome, by the way. Other common and cheaper forms of regulating insulin temperature include coolers and thermos. It's important to remember that if soaring insulin in a cooler with a freezer pack or ice, make sure the insulin isn't resting directly on the ice to keep it from freezing. Also, keep in mind that because coolers and theists are insulated, you can use them to help keep insulin from freezing in addition to keeping it cool. They work both ways.

Amy: Okay. So our, our takeaway as far as insulin storage while traveling, is basically your insulin is fine at room temperature. Keep it from getting super hot, so that's above 30 Celsius or 86 Fahrenheit and keep it at a direct sunlight. You're not going to see any significant reductions in effectiveness or potency, even if you are storing your unopened vials at room temperature for multiple months. It's also worth noting that all of this discussion about insulin storage and inject it applies for injectable diabetes medications. Notably the GLP one s like Trulicity, Victoza, and Ozempic, these meds are all fine at room temperature after being opened for between two weeks for Victoza and Trulicity, and 56 days for Ozempic. As kind of an aside, Ozempic is good unopened in the refrigerator for up to three years. Years.

Wow. And Victoza and Trulicity are good for up to two years in the fridge unopened, and 14 days at room temperature after being opened. And again, all of the storage recommendations, throw it in a cooler, you know, a frio or whatever, these all apply to any kind of drug, not just diabetes meds that are temperature sensitive. If you are super cheap like me I have a lot of travel mugs for coffee. I will get a damp washcloth, stick it in the freezer, and basically chill my washcloth, throw it in the bottom of my coffee mug and put my insulin in it, close it up.

Liz: That

Amy: Works Tiny portable cooler. Yeah. Works super well. And, and again, this is the, you want you, if you can keep your insulin cool, that's awesome. Really, you wanna keep it outta the sun and you wanna keep it from being hot.

Liz: Yeah.

Amy: So it doesn't have to be cold. It's okay if you're cooler and the ice or whatever melts because it's outta the sun and it's still gonna be less than whatever the god awful ambient temperature is wherever you're at.

Liz: I honestly, when I travel, I air travel quite a bit. And when I was a Vic Victoza, you mentioned Victoza, I took Victoza years ago and then now on insulin pens, and I just don't bother anymore. I try the first several times I flew spent the time, spent the effort, like, Okay, how do I keep this cool? How do I do this and that? But as it turns out, airports don't get that hot. You know, they're air conditioned airplanes. If you bring it with you on the plane, they stay relatively the same temperature. And of course, it's in my backpack out of the sun. So at this point, you really can just throw a couple pens in your bag and be fine. And well, that's what I tend to do.

Amy: The, the big con, the difficulty that I, I see people have most often is with road trips, honestly. Mm-Hmm. <affirmative> and, and even, you know, backpacking or hiking because all of a sudden you lose that that ambient temperature control that you have if you're in, you know, a train or on an airplane. As an aside on airplanes, I think we maybe said this already, but do not put your insulin in your checked luggage. Do you know how cold it is at 5,000 feet real cold, Like negative 60 Fahrenheit? Do not. Yes. Do not. For the love of all that is holy, do not put your insulin in checked baggage. If it's going in the belly of an airplane, you're making a bad choice. <Laugh>.

Liz: <Laugh>. Love it.

Amy: Okay, moving on.

Liz: <Laugh>. Yes. We've made our, we've made our plea to to the listeners now. Let's move on.

Amy: Yeah. So different modes of travel, right? So we kind of already started talking about flying because that's super calm. So we're also gonna go into a little bit more detail for road trips and then little more detail on doing stuff outside camping and hiking. So for flying there are some official recommendations for a lot of the airport security. We're gonna do a quick rundown on the TSA recommendations. Now, big, just big disclaimer here, here, I've been going through TSA with medical supplies since TSA was created, <laugh>. And I don't do 99% of these. So, you know, do what you're comfortable with and if somebody challenges you, there's, you know, there are official things you're supposed to do, but I would bet it's only an issue if you bring it up. Yep. All right. Running down the list, notify the TSA agent of any medical devices attached to your body.

Be that an insulin pump or a cgm. This I actually do. Medical devices are subject to additional screening that, that hand wipe and the pat down of the area. And, and again, this is the only thing that I've ever actually had happen consistently in, you know, 20 plus years of flying with an insulin pump. As far as taking insulin pumps or CGMs through metal detectors Medtronic pumps and Omnipod do not set off metal detectors. The tlim sets off metal detectors. <Laugh> pumps and insulin seem to be fine. If you go through a full body scanner, insulin is totally fine going through an x-ray scanner. Insulin pumps, generally speaking, should not go through an x-ray scanner. And that is because those x-ray scanners use what's known as a direct current motor technology which can be compromised by x-ray exposures. So insulin pump manufacturers recommend against putting your pump through an x-ray or a scanner. Medtronic pumps can go through metal detectors, not x-rays. Medtronic also recommends removing your CGM transmitter rather than taking it through a scanner. The Dexcom CGMs, the G five and the G six and the freestyle Libra are cleared to go through metal detectors.

Omnipod is approved or is the Omnipod party line is, it's fine to go through a full body scanner, scanner. It's fine to go through a metal detector, and it's fine to go through an x-ray. So Omnipod is pretty much fine to do anything Tandem Tlim is fine to take through a metal detector and a full body scanner. The tlim is not okay to put take through x-rays. Now, tandem recommends disconnecting at the infusion site and having an alternative screening done on the pump. Whatever the Tlim has set off every metal detector I have ever walked through. So I take off my TLA and pass it around for a hand screening because it saves me time. This is a choice. You don't have to do that. It's fine through a metal detector. It is not fine through an x-ray and aside for the tlim. And this is only for the tli.

Well, this is actually all insulin pumps. You ready? Air bubbles conform due to pressure changes while flying. People have reported unintentional ins insulin delivery during air travel on, on insulin pumps like the Medtronic, or you know, the Dana insulin pumps that have a cart or a a reservoir. The pumping mechanism used in the, the tandem insulin pumps isolates the insulin reservoir. That which is a bag in the cartridge from the user line, so that if air bubbles are formed in the cartridge due to pressure changes, the internal bag will expand, but no insulin will be delivered to the user from the reservoir. So a little more on that. On an airplane, the increased cabin pressure can cause some insulin pumps to deliver slightly more insulin. Generally speaking, this is not a significant concern for teens or adults because the potential amount of extra insulin isn't large enough to make a big difference in your blood sugar levels. In young children or people who are extremely insulin sensitive, the extra insulin can cause a drop in your sh blood sugar levels. And that can be very problematic, obviously. So parents who are aware of this potential can monitor their children more carefully while flying to avoid unexpectedly low BG levels. And in addition, the sensitivity of CGMs may be affected by changes in air pressure with potential for lower readings on the CGM due to extra pressure.

Liz: But I would love to see somebody actually study that. Like I, I, I fully agree that that's a possibility, but I would love to see somebody actually study something like that. Yeah, there's, and imagine, imagine how helpful it'd be to, to, to have that study and then help us understand like compression love and things like that.

Amy: Yeah. There, there has been a little bit of research on it, not a ton. And we will throw every, every study that we kind of even tangentially reference in this episode, we're gonna put into the show notes. So if you're looking for specific data on the Medtronic recommendations or this conversation about extra insulin delivery potential during air travel links will be in the show notes for you on this. So enjoy that.

Liz: Absolutely. So, a couple other final notes about flying TSA cards slash doctor notes are not required. A TSA notification card is kind of a discrete way for notifying agents about medical conditions prior to screening, but it is not a requirement for carrying medical supplies or devices or hypo treatments, including liquids greater than three milliliters through security. And finally, insulin vials and all medication should have the pharmaceutical label that clearly identifies the medi medication and in big, bold letters that I wish I could put on a screen for you. You do not put insulin in checked luggage if, and really when it freezes in the cargo hold, you wrecked it. We spent a lot of time earlier talking about that at length plus bags get lost and you really don't wanna be somewhere without your medical supplies. It happens. Yeah, it happens to all of us.

Amy: Funny story about that. Oh no. So <laugh>, I was diagnosed when I was four. My younger sister was diagnosed when she was four. My older sister made it till she was 19 Aw. Without diabetes. But she basically grew up in a family of diabetics, right? So she knew shit, Sorry, I'm a little sweary this episode.

Liz: That's the first one. <Laugh>.

Amy: It was a third <laugh>. So my sister got diagnosed, went back to college, came back for Christmas, got caught up in this god awful, like flight cancellation winter storm coming outta Seattle, which happens like every other year. Well, she checked all of her supplies, all of her supplies. She had no insulin on her. She had no insulin pens, no pump supplies. Yeah. She ran out of insulin in the airport on like a three day delay.

Liz: Oh man.

Amy: It was a whole thing. She, I mean, we, we had some family friends in the area. We were able to get a, we, like I had anything to do with this. You know, my, my dad was able to help facilitate getting some prescriptions called. And she was able to get some like emergency supplies, <laugh>, big fat reminder <laugh> to like carry your supplies. Yeah, don't check 'em. Make sure you have enough to lose your bag and not be boned because it happens. And even those of us who have been doing this, you know, our entire lives forget. We make mistakes, we get complacent and we know better and we forget. So just internal checklist. And even though it's tempting to save space in your carry on, don't do it. It's, it's always gonna be the time you check your insulin stuff that you wind up ripping out sight or breaking an insulin pen or whatever. Mm-Hmm. <affirmative>.

Liz: It's not worth it.

Amy: Not worth

Liz: It. So, so we've talked a lot about, a lot about flying now. What about road trips? I'm actually set to take one of these very shortly and took one earlier this year. So the whole, the whole keep it out of the sun and keep it from getting too hot or freezing. Logic applies here as well. Storing insulin in an opaque water bottle wrapped in a cold wet towel will work depending on the length of the trip. For long trips, a cooler frio like device may preferable since you get longer protection from heating or freezing as a result of the insulated container. Side note, I bought for long trips, a little miniature refrigerator that runs off the car. It's not a, it's not a cigarette lighter anymore cause those haven't really been a thing for 15 years. But runs off the, the thing in the car doesn't get super cold, but stays cold enough for exactly that purpose. And when I made my trip across the country with two years of insulin and supplies that's how I got it from Washington to Ohio without it. I, melting is the wrong word, but you know what I'm going for

Amy: <Laugh>. You didn't get it hot.

Liz: Exactly. I kept it, kept it cool.

Amy: Climate control. It's all about that. Climate control. <Laugh> doesn't have to be cold, just has to not be hot.

Liz: Yep. And I'm still using some of that insulin. So as it turns out, my, my lantis supply is ridiculously big anyway. Keeping your insulin storage container under a seat and out of the sun also helps reduce the heat flow through the storage container. That's true of any cooler really. If you wanna keep the hot dogs cold, you keep 'em out of the sun. Glucose meters also don't like being too cold or too hot and should be kept outta direct sun to make sure they work when you want them to. The effectiveness accuracy of a meter isn't going to change if you bro it on the car dash, but they, ty typically have temperature cutoffs and won't work until they've cooled down. Similarly, if your meter gets super cold, just shove it inside your jacket, under your arm, or between your legs until it's warmed up enough to work. I've done both of those by the way. I've both frozen and cooked my meters. Yeah. Me and they work fine.

Amy: Me too. It's just, you just, they don't like electronics oddly enough. Yeah. You don't like extreme temperatures.

Liz: <Laugh>. and we've said it before and we will continue to say it, but keep your low snacks handy and monitor your blood glucose, especially if you're the one driving. That's a big one for me cuz I do a lot of solo road trips. Yeah. 

Amy: I, I have a stupid amount of fruit snacks and transcend glucose gels in my glove compartment or not in my glove compartment, in my center console on my car. It's right there if I get worried about a pending low or just whatever with an arms reach, Don't put your hypos snacks in the back of the car. Don't put it in the backseat. Mm-Hmm. <affirmative> within arms reach.

Liz: My, my last trip to Minneapolis and probably the trip I'm gonna take later or next month I actually busted out the, the Libra reader, like the, the reader that you never use instead of my phone cuz I didn't wanna be playing with my phone while I was driving. But the Libra, you push one button, you can get a reading. So I was using that to monitor my, my blood glucose. And then of course in the center console, yeah, I had a whole tub of whole tub of tabs plus I always love road trip candy, so I got some, some Skittles and some sour candies and, you know, things that I wouldn't normally eat anyway, but, you know, ran a little low, had some extra sugar and had a really good road trip. Yeah.

Amy: <Laugh>. My, I tend to, if I'm gonna get low on a road trip, Sorry, that was a weird ramble. <Laugh> <laugh>, if I'm gonna get low on a road trip, it's always gonna be a stupid persistent hypo and it's gonna be like 60 just level refusing to go up. I know I'm a Snickers shell, but straight up having that little bit of protein in there to help keep you up. A Snickers bar is the right follow up for the hypo treatment, that fast sugar and then that extra to keep you up there because yeah, God I never stayed. That

Liz: Is, that is going on my list. I forgot my Snickers last time, but, so I end up with I end up with basically what are they called? Sweet tarts cuz I love Sweet Tarts and gas station jerky sticks Mm. For the protein. But a Snickers does sound pretty good right now,

Amy: Right?

Liz: <Laugh>.

Amy: All right, so we've hit on flying, we've hit on driving. What about that body powered stuff. What about hiking and camping? <Laugh> as Liz laughs at me and shakes your head,

Liz: <Laugh>, you know, you're, you're the healthy one in this relationship. I'm just gonna go ahead and say it out loud. <Laugh>,

Amy: I'll take it. Although I'm staring at your fancy DDR setup back there and I I'm getting there. You're getting there. You're totally, you're crushing it. Lifestyle changes, man. It's a small measurable changes and it's just a habit. All right. So hiking and camping. So prolonged outdoor stuff can be very hard on insulin and ozempic and any temperature controlled med because you aren't able to control your variables the way you can if you're doing motorized travel. So if you are hiking outside in winter, if you're doing mountaineering or ice climbing or whatever, it is absolutely critical to keep your insulin from freezing. Similarly, if you want your glucose meter to work, you need to keep it from freezing. So store any insulin you are traveling with for winter, hiking, whatever winter outdoor activities inside pocket of a jacket. If you've got multiple layers on, because you're gonna shed layers inside layer of your inner most jacket because you want that to stay on next to your body.

You're not gonna overheat your insulin when it's cold outside by storing it right next to your body. For, for hot summertime adventures that thermos with a cold, wet towel wrapped around the insulin goes a really long way. You know, I'm, you know, I mentioned taking that wet towel, sticking it in the freezer overnight, and then wrapping the insulin in a second cold wet towel in the same container. I clearly have a thing for thermos because they're a great insulator mm-hmm. <Affirmative>. and then you can take that coffee mug, thermos, whatever, shove it in your backpack and just keep it outta the sun and the bottom of your backpack. Keeps it outta the sun. And then you, and then you're, you're pretty good to go. You've, you've got something that at the very least is going to not be hot. You can, if you stop and like can't buy like a glacial stream or something, you can take that that container, that thermo and just set it in a cold stream and that'll chill it back down. Lots of weird tricks, but don't

Liz: Let it float

Amy: Away. Don't let it float away. That would be a bummer.

Liz: It

Amy: Would be. Yeah. for, for any outside prolonged activity, any kind of camping, hiking, expeditions, whatever road trips, this is how this applies to everything. Make sure that you have extra infusion sites, insulin, pens, needles, and a backup way to check your blood glucose. Shit happens in the woods, usually at super inopportune times. Generally when you pee and pull your pants up and rip your infusion site out having redundancy is absolutely critical. Just bring the extras, bring that backup way of delivering insulin. And, and, and backup way of checking your blood and extra meds because, you know, I'm not, I'm not taking my pills after I dropped them in the dirt. I mean, like, I've done it and I have regrets. I've done things would

Liz: Not Yeah. Would not recommend.

Amy: Yeah. Yeah. Zero outta 10 <laugh>. So anytime, just broadly speaking, anytime you do something active, especially if you're off in nature somewhere far away, you need to also make sure you have adequate hypo treatments. That mix of fast acting carbs to treat the immediate hypo followed pretty much immediately by complex carbs and protein to help keep you up, goes a really long way. I have found that glucose gels like transcend are really great because you can eat them at very cold temps and very hot temps. And they are glucose, so they actually raise your blood sugar really fast. And then, you know, as I said, supplementing with a Snickers bar although anything like chocolate based is kind of temperature dependent because a molten snickers is not tasty and a super frozen Snickers will break your jaw. Mm-Hmm. <affirmative>, but you know, something with complex carbs and protein trail mix nuts do very well at a variety of temperatures at granola bars, meat sticks like Liz recommended.

All of these things will help replenish your glycogen stores and will provide some slow burning carbs that can help prevent that reoccurring hypo. So, and, and again, you know, this, this bit really does apply for, I mean out very much so your outdoor activities, you know, and run high, run a little bit elevated when you're out doing stuff because it's, it's safer to be a little high. And also if you're out, if you're hiking, if you're camping, if you're being really physical, that can increase your insulin sensitivity. And it is a pain in the butt to be combating a hypo, especially if you're on pens and you can't just like turn off your basil mm-hmm. <Affirmative>. and, and just, you never really know what your insulin sensitivity changes are going to be without a lot of trial and error. So run a little bit high over, treat a little bit, use a little bit less insulin and at the end of the day when you're done, yeah, okay, make some adjustments. Knock yourself back down if you need to. But running low when you're out and being physical is extra problematic because you're out and being physical and you're not gonna be able to replenish those glycogen stores. A persistent hypo while you're hiking is one hell of a persistent hypo

Liz: And believe it. I've done, I've dealt with I think one since I was diagnosed and went on insulin. And it was just a miserable experience and I was heavily under prepared for such a thing. And it changed how I packed every time I went out in the woods from then on. Cuz having to hike back and it was only a mile or two from the car, but having to hike back a couple miles while basically hypo was, was a miserable experience for sure. Do not recommend.

Amy: Yeah. So that's kind of our quick and dirty rundown on traveling with diabetes. We've hit on flying, we've hit on road trips and we've hit on the God, there is a word for it that's not manually powered. Hmm. But I, I don't, yeah, I don't know. It annoys me that this is escaping me. <Laugh>.

Liz: We'll look it up and put it in the show notes. How about that <laugh>? Huh?

Amy: We don't need to document my my lapses that much, do

Liz: We? But, and, and even to be fair, even even these are kind of the, of the big three that we could come up with, but all of these tips easily apply across any mode of travel. It's, it's just a venue change at that point. So Amy is always, thank you again for another wonderful podcast episode. It's always a pleasure talking to you.

Amy: Oh, you too girl. But before we

Liz: Go, Yes, please, before

Amy: We go. All right. Diacast listeners listen up. <Laugh>. Liz and I are planning to do a quote unquote live question and answer episode. What this means is we are working on setting up a maybe something on the discord or possibly something through squad cast. Regardless, we'll be accessed via our Patreon. So we can have an episode where you are darling. Listeners can ask us questions and we will real time attempts to answer them so they can be questions about us, about the Diacast, about our motivations, about random medical stuff. And we will do our best to answer or provide some resources to do that. And we figure this will be kind of a fun way to round out, I don't know, the year-ish. So we are pretending that we are gonna do this live q and a episode in November of 2022. So plug into our social media. We've got Twitter, we've got Instagram, we have Facebook we also have a Patreon, which is how you're gonna be able to access this live QA stuff. Mm-Hmm. <affirmative>. And, and just keep us in mind, we're gonna do some, a little bit of social media blitz and it attempts to get people involved in this, but we're excited. It'll be good.

Liz: We're very excited. Very excited. And we will definitely have links to all of our socials in, in the show notes. And I need to update a couple places as well to make sure that everyone knows that we are social,

Amy: We are well, we're something,

Liz: We're something, Yeah. Something approximating social. How about that? Yeah.

Amy: And then I'm gonna do a, we're only gonna do this plug once because I don't wanna do it repeatedly, but we, Liz and I did relaunch the Diacast Patreon in this half-hearted attempt to stop losing money on this podcast, <laugh>. So we have five letters, Le letters, Jesus

Liz: Levels.

Amy: We have five levels. We have Diacast supporter for $1 a month. And that just means you love, love us, and we love you. And thank you very much. You get a warm and fuzzy. We have Y dmv your Diacast may vary supporters at this level for $3 a month will get early episode access. That's a week early. In addition to the warm and fuzzy for $10 a month you have access to our dia bloopers, which is all of the ridiculous stuff and misspeaking and bonus content that gets cut out of the episode during our editing. But you as a $10 a month Patreon subscriber, get access to that.

Liz: I've, I've started trolling through our last year of archives to start pulling things out for this level. I am looking forward to some supporters at that level.

Amy: Oh my lord, we've said things

Liz: <Laugh>. Yeah.

Amy: For $20 a month you get d cast uncensored, which means you get all of the stuff from the lower tiers in addition to the raw episode audio. So if you can hear all of our mistakes and all of the random aside that get spliced into different sections, and you also get the bloopers and early access, it's a sweet tear.

Liz: Yeah.

Amy: But if you're really bold for $50 a month or die a badass tear, you get all of the other stuff. Plus as an extra special. Thank you for making me not lose a bunch of money. You get to sit in on live recordings. You don't get a talk. We're gonna like put you in the backstage so you can like, type, but you don't get a talk. But you can listen to this whole beautiful chaos that is a recording. So that's the Patreon plug. You will never hear it again. Patreon is linked in the show notes. Facebook, Instagram, Twitter, linked in the show notes. Thank you for supporting us. Follow us on social media because the more listens we get, the higher up we go on all of the like streaming platforms. And that's, you know, good for us. I guess

Liz: It's wonderful for us. <Laugh> living with diabetes is exhausting both for our bodies and minds. It's not surprising that many diabetics struggle with the mental health sides of this disease, including burnout and diabetes distress. We at the Diacast wanna remind anyone who is struggling that you deserve all the help and support in the world. If you're struggling, please go to Diacast.com/resources for a list of resources and links, diabetes support groups, ways to find therapists in your area who specialize in diabetes and crisis lines. Diabetes is hard and sometimes we all need a hand.