Month: April 2023

What To Pack When Travelling (Day Pack)

leontribe1 Comment

I have written before about taking insulin through customs but, with a trip to the US happening tomorrow and a trip to Germany completed two months ago, I thought I would pass some thoughts on about travelling as a pumping and CGMing type 1. This is part one (Day Pack) with part two (interstate and overseas travel) coming after my trip and with the wisdom gained.

The Spreadsheet

This spreadsheet removes a lot of the thinking when it comes to packing. The Day Pack list is in the top right.

Day Pack

My Diabetes Bag

My Day Pack is the conference bag from the Berlin trip. I also use this as a bag for all my carry on medical supplies when travelling interstate or overseas. Why a bag just for medical supplies? Because most airlines these days do not count medical supplies towards carry on quotas so it is easier to show them what is being excluded if it is all together. For the local Jetstar airline, who weigh carry-on luggage, this makes the process slightly less excruciating. The bag is also easy to locate when I need to do a set change mid-flight. This also means less bag swaps whenever I travel for the day/interstate/overseas as the core set of stuff in this bag never change.

Here are the contents of the bag:

Going from the top we have:

  • Diabetes kit with finger pricker, glucose tabs, lip balm, Splenda tabs, lancets, batteries, prescriptions, business cards of my health care team, and blood/organ donor cards
  • A USB fridge (a new addition yet to be tested in the wild)
  • Spare prescription glasses
  • N95 mask
  • Tissues
  • Sharps container (for those mid-flight set changes etc.)
  • Hayfever/cold nasal spray
  • BreezyPack with MedAngel inside (NB: I could not find a reliable link for buying MedAngels but it is a great Bluetooth temperature monitor)
  • Glucagon pen
  • Needles for emergency
  • COVID testing kit (just in case)
  • Hypo snacks
  • Power banks and cables (when you rely on technology to keep you alive 24-7, you want backup power sources and the ability to charge devices)
  • A spare pump
  • A transparent packing cube for needles and insulin so it can be easily pulled out at security

FlexPen(s)

I use Novorapid FlexPens cartridges to refill my pump and this also means I have the FlexPens on hand if the pump has a catastrophic failure so, for day trips, I carry 1-2 NovoRapid pens in the BreezyPack in case I need a refill or if I need to fall back to multiple daily injections.

Diabetes-Compatible Watch

My watch is a cheap TicWatch but, with xDrip+ as a companion app to CamAPS FX, I get access to my CGM data and have it appear on my watch. Very useful when you want to quickly check your BGLs but you are in a tiny economy class seat and your phone is in your pocket or when you are in a business meeting and it might be considered a step too far to pull out the phone and start swiping.

Medi/Emergency bracelet

A medi/emergency bracelet is a must for me, especially if I am travelling solo.

Mobile Phone

Being the brain of my CamAPS looping application, my phone comes with me everywhere.

Pump Consumables

In terms of pump consumables, for day trips, I generally carry a spare infusion set and cartridge set in case I am caught unawares while out and about. In a pinch, I can make a full set change without drama.

While I could also carry a spare CGM sensor, the applicator for the Dexcom G6 is so large, I generally do not bother as, at worse, it will mean a few hours with looping off and no CGM data (for the pump the default basal settings will take over and, for me, they are well tuned so it will keep me going until I get home.) I also have the finger pricker in the diabetes kit if I want to double-check.

Snacks and Water

While my bag has snacks inside for hypos, this entry is a good reminder to put in a water bottle and check expiry dates.

Masks

Not strictly needed for diabetes management but good to carry in case you go to crowded places with people coughing or if you are travelling and mask wearing is required. I generally carry N95 or equivalents and, as mentioned above, normally have a spare in the bag.

Diabetes Book

This contains a wealth of information including, as can be seen above, step-by-step instructions for essential tasks like set changes and cartridge swaps. Some of the veteran type 1 folk laugh at the fact I rely on a book for, what is to them, second nature but, frankly, if I am jetlagged, half-asleep, half-drunk, and/or in some other compromised state, I would much prefer to trust the book than my foggy head.

Other information it contains are my profile settings, an on-going list of foods I discover I can snack on without spikes, support numbers for equipment, and miscellaneous diabetes thoughts or ideas jotted down on the run.

Set Change Ziplock

This is a bag of “stuff” I need to do set changes (cartridges and infusion sets). This does not sit permanently in the diabetes bag as I use it all the time.

We have:

  • Emergency antiseptic gel (in case I run out of wipes)
  • Ypso cartridge box (which I also use to store the Ypso coin, batteries, and other Ypso-related set change stuff)
  • Ypso cannula inserter
  • Safety razor (for shaving a spot for the cannula to go)
  • Jar grips for pulling FlexPens apart to get to the insulin

Conclusions

That is my current kit. It does evolve over time but is relatively stable at the moment. If you have other items you carry with you on day trips, feel free to add a comment.

Applying Motivation Theory to Diabetes Management

leontribe1 Comment

Just after we got married, my wife and I embarked on an MBA (Masters of Business Administration). Along with teaching how the organs of business work, there were some interesting electives to choose from. One of the ones I chose was “Leadership and Motivation”. It provided guidance of how to lead people (as opposed to managing them), and how to motivate people. Obviously, in the context of an MBA, it was to help employees stay motivated to work on tasks deemed important to their employer, but I see parallels in the management of diabetes as well i.e. working on tasks deemed important for survival. For those not interested in the details, you can skip ahead to the tl;dr.

The 3C Model

The course was taught by Professor H.M. Kehr, formerly of UC Berkeley who created what is now called the “3C Model“; the Three Components Model.

I find it easier to remember it as the “Head, Hearts, and Hands” model. While relatively simple, the model brought together various motivational models of the time e.g. Csikszentmihalyi and Rheinberg. In this case the head, heart and hands are:

  • Head: Our logical thoughts regarding the task at hand
  • Heart: How we feel about the task at hand
  • Hands: Our ability to perform the task at hand

Other key concepts with the model are “volition” which, for the rest of us, is willpower and “flow”, a state of “effortless achievement”, which is sport is sometimes referred to as being “in the zone”. In short, when the head, heart, and hands are aligned, achievement is effortless.

Another key aspect of the model is the understanding that willpower is a finite resource which cannot be called upon indefinitely and, if pushed to its limit, leads to burnout. Burnout, of course, is a term familiar to many of us who manage diabetes meaning a complete abandonment of diabetes management.

Misalignment and Intervention

While alignment of the head, heart, and hands leads to a “flow state”, misalignment means willpower will be needed to achieve the task. For a task, such as diabetes management which is relentless, it is clear, without intervention, burnout is inevitable. Ideally, the intervention will either give the person a break from the task, allowing willpower to recharge, or make the amount of necessary willpower so small as to prolong burnout practically indefinitely.

Depending on which component is not aligned to the task, this dictates the kind of intervention to use.

When the head is the problem i.e. the person is emotionally aligned and has the skills, but there is a logical conflict, the person may need further convincing, have additional incentives put in place, or have the goals adjusted.

When the heart is the problem i.e. the task makes logical sense and they have the skills but it does not feel right, or they fear the task, emotional support, redesigning the approach, or focussing on the eventual outcome may help.

When the hands are the problem i.e. the person does not have the skills or knowledge to achieve the task, the answer may be education/training, coaching, or having others provide assistance.

Again, we start to see how this model could be overlay onto diabetes management and ensuring a specific approach is a good fit to the individual.

An Example of the Application of the Model

A classic example is the case of someone wanting to give up smoking. They know logically is makes sense (head), and may well have the skills to do it e.g. employing patches (hands), but their heart may not be in it or they fear failure. In this case we see suggested interventions which are often applied to help people give up smoking e.g. in New South Wales we have the ICanQuit web site and Quitline where people looking to give up smoking can call and get support and encouragement to help them on the path.

Application to Diabetes Management

The model provides insight into why intensive lifestyle interventions fail so often. While radical changes to diet or exercise in the management of diabetes frequently address the head and hands, the heart is almost always ignored and is the key point of failure. Very few of us deny the health benefits of exercise and most of us are capable of walking/running yet, like smoking, many of us fail to incorporate it into our lives. Simply put, our heart is not in it. Options to make exercise more palatable could be engaging a physical trainer to provide motivation (support), entering a charity fun run and then training towards the goal for the greater good (new motivators), or changing the type of exercise to something more enjoyable or aligned to the person’s lifestyle (redesigning the work).

In the case of Weight Watchers, the success rate is quoted at 11%. Even with intense coaching on top of lifestyle changes, one study showed remission for Type 2 was only achieved in 3.5% of participants. In the case of the Dr. Bernstein diet where the logic of the benefits of lowering dietary carbohydrates is sound (head), and there is no doubt, once the book is read, someone with Type 1 is equipped to undertake the program (hands), the majority of the strongest adherents, who literally commit to following the program to be part of the “international social group”, failed to meet the basic premise of sticking to 30g of carbohydrates per day. This is not the fault of any one program; the fact is changing habits and maintaining that change is hard and we need to consider the whole person to be successful. We must align the head, hearts, and hands for each person and provide the support that person needs. There is no “one size fits all”.

We also see this with diabetes technology. While the clinical studies speak at the benefits of, for instance, looping systems at improving outcomes (head), there may be a fear of using the technology due to a lack of skills/knowledge (hands) or the person simply does not like the idea of permanently wearing something on the body (heart). Professor Katharine Barnard-Kelly presents on this often at conferences and passionately believes “heart interventions” are effective at improving outcomes.

Professor Barnard-Kelly has also developed the Spotlight-AQ system which facilitates pre-clinic assessments to ascertain where interventions may be required e.g. the need for structured education (head/hands).

Putting the spotlight on my “Practical Diabetic Solution”, I think, if someone commits to replacing all meals, as I did, this would usually not be sustainable because the conflict with the heart e.g. no longer sharing food with family/friends would be simply too great. However, replacing non-social meals would not require the same level of willpower and the use of looping technology would greatly reduce the mental burden of daily management, assuming the person has the skills to use the loop (hands) and understand the benefits (head). To put it simply, the level of commitment and tool emphasis would be different for each individual, but a sustained improvement is better than one which fails to be maintained, however successful in the beginning.

How Can We Use This Model?

My vision is this could be used for self-assessment but also as a framework for the discussion between the health care team and the person with diabetes. For example, by considering why exercise may not work in the context of the three areas, a plan to address the disconnect can be intelligently devised. In the case of technology and medication, if one tool is not aligned, other tools can be considered instead with a closer fit, or other appropriate interventions considered.

tl;dr

The 3C Model of motivation, primarily used in the context of motivating employees, can also be applied to the management of diabetes and to frame conversations between health care professionals and their clients (people with diabetes).

The model focuses on three aspects of the individual, their:

  • Head: logical thoughts on a diabetes management approach
  • Heart: their emotional response to a diabetes management approach
  • Hands: their skills and knowledge regarding a diabetes management approach

When all three are aligned with the approach, its use as part of the diabetes management plan is effortless. When one or more are not aligned, interventions are required to reduce the excessive need of willpower to use the approach which could lead to burnout. Interventions may include:

  • Head: Education, adjustment to goals
  • Heart: Support, redesigning of the approach
  • Hands: Training, assistance

With a framework in place, it will be easier to identify appropriate interventions and optimise outcomes.

The Practical Diabetic’s Ten Levels of Medical “Facts”

leontribe1 Comment

Not all medical information is equal, even if it comes from a reliable source. To help me filter the wheat from the chaff, I created these ten levels ranging from Idle Speculation up to verified Medical Fact. Let us get into it and, as is often the case, we have the tl;dr at the end.

Level 1: Idle Speculation

The least reliable medical fact, this is conjecture with literally nothing to back it up. An example might be “I reckon lies cause head colds”.

Level 2: Secondary Source Anecdote

Something someone has heard from somewhere else. The evidence is a “friend of a friend” who had success with the approach. An example might be “Yoga cured my aunt’s diabetes”. Perhaps she was cured, perhaps her management improved. Perhaps she was pre-diabetic or, perhaps, it was gestational diabetes which went away after pregnancy.

Level 3: Primary Source Anecdote

It worked for the person telling you. A good example of this is my “Practical Diabetic Solution”. While, since publishing the article, many people have said things along the lines of “I have a similar approach which works for me”, the fact is, at the time of writing this article, the only person to try the Practical Diabetic Solution is me because I literally wrote about it seven days before writing this article.

Level 4: Multiple, Corroborating Anecdotes

Many people have tried a similar approach and claim to have success. The quotes you see on dodgy supplement sites or on the back of books fall under this category. While the quote may be genuine, sample selection is often biased (when was the last time you saw a bad review on the back of a book?).

Level 5: Observed Under Controlled Conditions

Social experiments often fall under this category; the rules are set and then let to play out to see what happens. The movie “Super Size Me” is a good example of this where the movie’s maker followed a set of rules for engaging with the fast food restaurant, McDonald’s, and monitored his health to see the effects.

Level 6: Observed and Confirmed Independently Under Identical, Controlled Conditions

By Level 6, we are starting to see some rigour in the analysis. An example might be Alcoholics Anonymous (AA) if they released their statistics. As an aside, a Stanford researcher did confirm in 2020 that AA is more effective at keeping people sober than therapy.

Level 7: Published in a Peer-Reviewed Journal

Even when a study is peer-reviewed and published, it can be wrong or misleading. A great example is the Wakefield Vaccine-Autism study published in The Lancet in 1998. With evidence of fraud, the paper was retracted in 2010. Dr. Bernstein’s Diabetes Solution meets this level because of its publication of results in Pediatrics.

Level 8: Published in a Peer-Reviewed Journal, Conducted in a Double-Blind Study and/or with a Control Group (When Ethical/Appropriate)

Let us explain some of these terms by pretending we are testing a new drug. A control group is a group of people, similar in characteristics to the active group who do not receive the drug (or a placebo, explained below). The control group allows us to compare the fates of the control group to the group receiving the drug.

A double-blind study is when the subjects of the study AND the people conducting the study do not know if the subjects are receiving the drug or a fake version (sometimes called a placebo). Why such extreme measures? To remove bias from the experiment and, in the case of a triple-blind study, from the analysis of the data afterwards. The “placebo effect” is probably the most famous form of bias being addressed in this kind of setup.

Generally, if a paper is published following this level of protocol, it likely has medical findings worth further investigation.

Level 9: The Same as Level 8 Plus the Results are Statistically Significant

Claims are often made in science but they do not always have a necessary level of statistical significance to back them up. Understanding p-values and confidence intervals are key in seeing what data are valid and which are not. Often journalists are not well versed in such things and will publish “breakthroughs” where there are none.

Level 10: The Same as Level 9 Plus Verified By Independent Third Parties

Anything meeting this standard can be considered, in my opinion, medicine. One study is compelling but multiple independent studies, being conducted under the strictest of conditions is more compelling. In most developed countries, all vaccines and medications have achieved this level of scrutiny, as a minimum, before being released onto the population.

Using the Levels

Pharmacies (chemists) sell pretty much anything from Level 2 or above e.g. ear candles. Alternative medicine generally gets up to Level 6 or 7 because, beyond that, it starts becoming actual medicine.

This is not to say alternative medicine or diets are bad or wrong, they are just not scientifically proven to the level of other potential treatments. In the absence of other verified treatments or as an adjunct to other therapies, they may be worth considering.

Journalists/mainstream media generally publish “breakthroughs” down to Level 7 but, I would argue it is only in the public interest at Level 9 or 10. Wakefield’s autism claims are the poster child for why this is the case.

Medical research can get to Level 9 and then hit a dead end because it cannot be easily replicated. The famous Rat Park experiments of the late 70s is a good example. While linking environmental conditions to addictive behaviours, the results proved difficult to replicate elsewhere.

In terms of general science, the same ten levels apply although the need for control groups and double blind studies are less important in other science areas. A good example of a Level 9 physics error was the 1989 cold fusion hoax highlighting that science is indeed fallible, at all levels, and before embracing something you read on the internet, ensure it meets the highest possible standard.

tl;dr

Here I present ten levels for assessing medical information. The ten levels are:

  • Level 1: Idle Speculation
  • Level 2: Secondary Source Anecdote
  • Level 3: Primary Source Anecdote
  • Level 4: Multiple, Corroborating Anecdotes
  • Level 5: Observed Under Controlled Conditions
  • Level 6: Observed and Confirmed Independently Under Identical, Controlled Conditions
  • Level 7: Published in a Peer-Reviewed Journal
  • Level 8: Published in a Peer-Reviewed Journal, Conducted in a Double-Blind Study and/or with a Control Group (When Ethical/Appropriate)
  • Level 9: The Same as Level 8 Plus the Results are Statistically Significant
  • Level 10: The Same as Level 9 Plus Verified By Independent Third Parties

Using these levels as a guide we can assess the medical information we receive and how reliable it may be.