Speaker A: It. Have you ever wanted to go on an international trip with type one diabetes but have been worried or scared to do so? Or maybe you're a parent of a child who wants to travel internationally. If that's the case, that can be terrifying. I remember when I was first diagnosed, I was traveling a lot, and I'm sure my parents were very, very nervous, even if they didn't say anything. Welcome to live free with 1D podcast brought to you by the diabetes psychologist. This is the only podcast where we teach you to build your stress management plan with type one diabetes. Like a sailboat, you are the captain. Your diabetes management is the whole. Your mindset is the sails. Your behavior is the rudder, and your support team is the crew.
Speaker B: When you build your sailboat correctly, you.
Speaker A: Will have smooth sailing in your life with type of diabetes. I'm your host, Dr. Mark Heyman. In this episode of the podcast, we're talking to Melissa. Melissa's son is headed off to Europe for the summer, and Melissa is worried about him, and she's also worried about herself and how she'll deal with life without him for those ten days. Will she be checking a CGM?
Speaker B: Will she be worried?
Speaker A: Will she be in communication with him? Will she know what's going on? In this episode of the podcast, we talk about the sails or Melissa's mindset around letting her son go to Europe. We also talk about the hull of the boat and how to make sure that her son diabetes management is solid before he goes and that he has a solid plan to follow if things go awry while he's traveling.
Speaker B: If you're a parent of a child with type one diabetes or if you're.
Speaker A: Someone with diabetes who wants to travel.
Speaker B: Internationally, this episode is for you.
Speaker A: Melissa. So glad that you're here with us today. Why don't you introduce yourself and tell us a little bit about you and your situation?
Speaker C: Great. Thank you so much for having me today. My name is Melissa. I'm a mother of a 15, almost 16 year old type one diabetic son. He's diagnosed just a little over two years ago in the midst of the pandemic. So not only is it a challenge to parent a teenage boy, then you add in the diabetes on top of it, and it's extra complicated.
Speaker A: Yeah. And so I hear that he is going on a trip this summer that you have agreed to let him go on. Tell us a little bit about that trip and what you're thinking and what your concerns are.
Speaker C: Sure. Yeah. So he has been lured by a favorite high school English teacher to travel to Prague, Budapest, Vienna, and Munich for ten days this summer without mom or dad. So as the parent feeling a lot of anxiety and stress of the idea of him being 4500 miles away without us there to help in an emergency or just sort of monitor the everyday ins and outs of traveling with diabetes.
Speaker A: So tell me about his management right now. How is he doing with this management? And how is he doing with his independence around monitoring his blood sugar, taking insulin, cutting carbs, all that stuff?
Speaker C: Sure. So if it was up to Andrew, he would be 100% independent as a 15 year old and only two years into this illness. We feel like he needs a little bit more support. He wears a Dexcom more often than not. He occasionally goes on like a one week strike from wearing it, and then he does multiple daily injections for his meals at home. We provide him with the carb counts, and I'm very organized and type A about that down to 1 gram. I know how many carbs he's going to be fed when he's out on his own with friends or at work. He spins the dial on his quick pen and injects and hopes for the best.
Speaker A: And how has that been going for him so far over the past two years? Any challenges or any major highs or lows that have been concerning?
Speaker C: I would say for the most part, he does an excellent job. Probably his biggest weakness is remembering that long acting injection at 930 at night. And then as the parent, it's the struggle. Do I remind him that he hasn't taken it, or do I let him try to navigate that himself? His a one C is excellent. So our endocrinologist loves us. We're the model patient family. So overall, I would say he does a good job in terms of counting carbs. He'll look at something and make a wild guess, whereas I would choose to use an app or a website and make a more informed guess.
Speaker A: Okay, and what about at night? Is he waking up during the night with his alarms and alerts for lows or highs, or is that something that you're taking on?
Speaker C: No, I can hear his alarm. His room is next to ours, but there's a bathroom in between them with a fan on in the bathroom and a noise machine in my room. I can hear his alarm from his room, and we'll have to wake him to treat a low.
Speaker A: Okay. It's a little aside here that's a common thing is I hear a lot for parents of teens who don't wake up for their low alarms at night, but then when they're away from their house, whether they're at a friend's house or at camp or wherever, they are magically, that changes. And I'm just curious, do you think that's the case for Andrew, or do you think that he is not waking up and then because he knows that you'll be there for him, but when he's away that he could?
Speaker C: I would say he's had very few opportunities to test that skill.
Speaker A: Okay.
Speaker C: Yeah, we haven't gone out of town without him in the past two years, and he's just sort of in this post pandemic time, he's only had a few sleepovers and his blood sugars were fine those nights.
Speaker A: Okay. Yeah. And I mean, I don't know if that's the case, but I've seen that as a theme in people that I've talked to. Is that magically when they're away from their parents, they're able to wake up from low and high alarm. So let's hope that's the case.
Speaker C: I can hope.
Speaker A: Yeah. So, Melissa, tell me a little bit about your thinking in letting Andrew go on this trip. I think it's awesome that you're letting him go and that he's able to do what you told me before we got on that how are you going to pay for it? And he got a job right away and he saved up all the money that he needs. But from your point of view, it sounds like you're a little torn about this situation. You want him to go and experience life in Europe for a couple of days of summer, but also you're a little worried that he's going to be on his own without your oversight.
Speaker C: Yeah, so my husband and I really went back and forth on this. Parents were invited if they wanted to join, but what 16 year old wants their parents tagging around Europe with them? And the bottom line for us was if he was any other child who didn't happen to have a diabetes diagnosis, we would let them go and not think twice about that decision. So we didn't think that it was fair for his diabetes to hold back the life experience. And it's also probably good preparation for when he leaves the nest to go to college. All of that being said, I feel like I am not going to sleep for those ten days with worry of is he remembering to do things properly, is he dosing properly? What if there's an emergency and he needs medical care in a foreign country and I'm so far away?
Speaker A: Yeah. And all those Roy's, I think, are really normal for a parent to think of all of the worst case scenarios and really go there. So before we get dive into the coaching part, I'm curious. Have you thought about and discussed with Andrew a plan around how he's going to manage his blood sugars? If and how you're going to communicate with him over the time he has gone? How and if you're going to monitor his blood sugars from afar? What's your thinking around that right now?
Speaker C: So we did have some discussions when we agreed for him to go and made sure that we purchased Travelers Insurance. That also allowed us to cancel up until the last minute, contingent upon his personal management of his diabetes leading up to the trip. So that is to say, if he totally threw out management out the window that we would have the authority to revoke the trip at cost to him. We felt like that was fair his chaperone agreed to download the Dexcom app. So that way there will be an adult with him who will have access to those blood sugar numbers, especially the overnight alarms. We've been trying some of the foods that we feel like he might try when he's abroad pretzels and Spencel and things like that, to kind of see how it goes. But again, being a teenager, it's a one time trial for him. I had the pretzel, I took some insulin. It worked out fine, and move on. Whereas me, I would be trying a pretzel each day and trying different doses. My goal would be to not be checking his Dexcom while he's gone and leave that to him and his chaperone. That's my goal.
Speaker A: Okay, so you'd like to just be completely shut off or cut off from that information?
Speaker C: I feel like having that information, even when he's in the same as I am, is sometimes too much information, if that makes sense. So then you add in 4500 miles and the ability to get to him. I feel like having access to that update every three minutes would just be overwhelming and unhealthy for me.
Speaker A: Okay. Yeah. And I'm glad that you recognize that for yourself, is that having that data, while helpful in some ways, can be put an extra burden on you. I think back to the time when we didn't have CGM and or the ability to share share data, and we did okay. And I think it's important to remember that there's a long time where CGM data wasn't available at all, and even when CGM data was available, we didn't have the ability to look at it. So I think approaching it from that perspective is a good thing for you. So I want you to imagine for a minute that Andrew goes on this trip, and I'm confident that he will, and he comes back safe and sound. What would you consider to be a success, both from your point of view and those ten days where he's away from you as well as for him in terms of his blood sugars, in terms of your and his anxiety? What could you say is a successful trip for him?
Speaker C: A successful trip for Andrew would be not ending up in the hospital in Czechoslovakia. And for me, it would be the ability to sleep while he's gone and not feel consumed with worry, to not be checking those numbers over which I can do nothing. I don't expect him to stay in range. I mean, we all know when we're on vacation, even when it's the next state over from us, that's when blood sugars tend to get a little wonky. So I expect he'll have some highs, I expect he'll have some lows. So I don't think it's fair to set those parameters. Yeah, but really, that he wouldn't end up in a hospital and that he would address those highs and lows to the best of his ability and then for me that I would find sleep and peace.
Speaker A: Okay, so over the past two years, has he found himself in a hospital other than a diagnosis? If he was in a hospital a diagnosis?
Speaker C: No, he has not.
Speaker A: Okay. Yeah. And I think that that's an important thing for you to remember as you're thinking about your anxiety is that, yes, him being far away is definitely an anxiety provoking thing for you. But what we know is that the best predictor of future behavior, future incidence of diabetes, is the past. And if he is able to manage his diabetes to a degree that's going to keep him safe, there's no reason why that can happen and won't happen while he's on his European adventure. I think that's an important thing for you to remember in this process. And also remember, I don't mean to minimize decay or severe lows by any means, but they're fairly hard to come by as long as you're doing the very basics. So, for example, especially if he is on MDI, the research shows that as long as he's taking his long acting insulin every day and that's I mean, that's I know, I know that for you that is a wild card. But as long as taking his long acting insulin every day, the chances of him going into DK and being in trouble anywhere, Europe or the US. Is very low because he has that background insulin in his body, no matter how high his blood sugar goes, having that basal insulin in his body will almost always keep him safe. I don't want to say completely always, but that is the one thing that is critically important. If he doesn't take his insulin every day, then that's where the trouble can get in. If he's using an insulin pump, making sure that the insulin pump is obviously on but also working correctly, and if it's not, changing the site is an important thing as well. And then of course, treating lows. And I'm curious, does he feel his lows when he has them?
Speaker C: He does if he's awake.
Speaker A: Okay.
Speaker C: He's definitely in tune. And to say he feels his lows, I mean, he feels it for that alarm goes off. So he is in touch with the physical reaction, the physiological reaction that he has. I've heard some diabetics, it will actually wake them from sleep and that has not been his experience.
Speaker A: Okay, and how low has he gone? Do you have any idea what his lowest number has been?
Speaker C: Maybe in the upper forty s. Okay, so fairly low. And I mean, as a mom, as soon as that first tone goes off and I'm up and in there with the straw and the juice box, my husband still is mid snore. He hasn't heard anything.
Speaker A: Yes, it's the mom reflex. Yes, I totally understand and I'm sure that he appreciates that. I don't want you stopping doing that. But I also want to mention, as I had talked about before, that one of the reasons why and this is all anecdotal I don't have any data to back this up, but when I see teenagers who don't wake up for their lows a lot of times. My hypothesis is that it's because their mom is so caring and you want to care for him and make sure that he's safe. He knows that if he goes low in the middle of the night, that mom will be there.
Speaker C: Right.
Speaker A: I wonder if there might maybe be a way for you to not stop that at all, but come to an agreement with him that you will not be there right away. And that's also why I think that we find that when kids are away from home, whether on a trip or whether at a friend's house, that that doesn't happen that they they tend to wake up because they know that mom is not or dad for that matter, is not going to be there. And they know intrinsically that it is something they need to take care of.
Speaker C: Okay.
Speaker A: I wonder if, leading up to the trip, you can find some middle ground. I think a conversation with Andrew would be really helpful in that case, to be able to find that middle ground.
Speaker C: That's a great suggestion, because my instinct is to treat immediately, because I'm running the risk of it going even lower.
Speaker A: Yeah.
Speaker C: So I'm very willing to give that a try.
Speaker A: Yeah. I think that it's important to remember that certainly low blood sugar is something that you want to pay attention to, that you want to treat. But I think two or three minutes, especially if he's dropping fast very quickly and he's very low, then of course that needs treatment. But if he's hovering around 65 and not dropping, kind of giving him that time, monitoring him could be helpful and really making him aware that the responsibility is on him. You're there as a backup, but the responsibility is on him. And that will likely get him to a point where he is actually taking action on his own and taking more responsibility for it. I mean, teenage boys, I was one once, they like to sleep. They don't like to be woken up. Right. Any excuse or any way that they can find to not do that, especially if Mama's going to be there to shove a juice box in their face, they'll take it. But given the other option, my guess is, without knowing Andrew, that he will sum up to the plate, but he has to be given that opportunity.
Speaker C: Right. That's a great point.
Speaker B: I talk to people with type one diabetes every day, and every day is clear to me that people at T 1D need a plan. They need a plan to follow to manage the emotional burden of living with diabetes without a plan to manage the stress. Life with diabetes is overwhelming. You feel like you're drinking out of a fire hose and you have no idea how to feel steady on your feet and find the peace of mind you're looking for. You feel like diabetes takes away your freedom to live a normal life. A plan to manage the emotional burden of T 1D is very simple. There are five frameworks you need to know, and if you know these five frameworks, you have a plan for how to deal with any stress diabetes throws your way. With this plan, you'll be clear about what you're doing right now and what you need to do next. That's exactly what you get when you join LiveFree With T. Live Free With T coach you to manage the stress of type one diabetes like a sailboat. You are the captain. The whole of the boat is your diabetes knowledge and management. The sales are your mindset. The rudder is your behavior, and your crew is your support system. If you build the five parts of your subtle correctly, you'll be sailing smoothly with type one diabetes. All of that is part of the plan that's available to you when you join Live Free with T 1D. Plus, as part of Live Free With T, host a live coaching event every month where you get access to me and have the opportunity to ask me questions and even get personalized coaching. To join LiveFree With T 1D, go to www.thediabetesychologist.com LiveFree with Q 1D. Join other people with type one diabetes, just like you, who have a plan to find peace of mind and freedom in their lives with type one diabetes.
Speaker A: What is their plan for communication with the chaperone? With his roommate? I assume he's going to have people in his room both in terms of education but also in terms of support for him to make sure that he is taken care of and that he has the physical but also the emotional support that he needs to take care of himself.
Speaker C: Sure. So luckily the chaperone is a high school teacher, so he's already had Andrew in class, has had sort of the school based education on what type one diabetes is. I plan on giving him a lot of oral and written communication. That way he doesn't have to necessarily remember everything. Again. He'll have the dexcom. He has agreed to download the Dexcom app and to carry a second set of supplies should Andrews get lost or stolen or misplaced or what have you. Okay, andrew's best friend is going on the trip, so I assume they'll be rooming together. And the friend is already aware of Andrew's diabetes, so he has that safeguard. Andrew is fiercely independent though, and I can't imagine him having a conversation with Mason and saying, hey, if my alarm goes off, wake me up. So that would probably be something worthwhile to discuss with Andrew as well, to alert who's ever going to be sharing the room with him of what it could look like at night.
Speaker A: Well, my guess is that if Andrew's alarm goes off at night, and even if Mason hasn't heard about it, mason will hear about it, and then Andrew will hear about it because Mason will be mad, because Angie's alarm will.
Speaker C: Be a new alarm.
Speaker A: Of course. Right. Knowing what the alarm sounds like is going to be important. But I have a feeling that if I was a teenage boy hearing my friend's alarm going off, I would be there trying to turn it off and get him up to take care of it.
Speaker C: Right.
Speaker A: Hopefully that sort of peer pressure or call it peer support, can be helpful.
Speaker C: And then in terms of I was going to say in terms of Andrew communicating with us back here, we haven't discussed that. I haven't sort of navigated that yet. Whether he should be texting daily yes, I took my long acting, or whether it just needs to be, send me a text that you're having a good time. I don't need to hear about diabetes while you're on vacation. I honestly don't know the answer to that.
Speaker A: Okay. And I think that thinking stuff for yourself and seeing what is most comfortable for you as well as for Andrew, to make sure that he feels supportive, but also that you feel safe is important. I don't think it's necessary for you to completely be hands off in that case. I'm just thinking out louder here. I'm thinking out loud right now, but I would not think it would be horrible for you, as a safety check and as a safeguard, to not look at Dexcom all the time, by any means. But maybe just once a day, maybe when you wake up in the morning, look at Dexcom and see what's been happening, because you can tell if his blood sugars have been high all day. Really high. It's possible that you've got to take as long acting insulin, and that would be a good check for you, as long as you know yourself well enough to know that that's not going to cause you to keep on checking, checking, checking. Right. But if you want to kind of see that with that one day snapshot to make sure that he did that, I think that would be appropriate for a 15 year old situation. So I think that's something that I would encourage you to think about. I do want to say I'm really happy that you said that you don't expect him to be in range all the time, especially in Europe. I mean, there's all kinds of new foods, adventures. He's going to be walking a lot, I'm sure, eating new things. And so giving him that flexibility and setting yourself up for success in thinking about the expectations, even if he's out of range in the 200s all the time for those ten days, I think that would not be an awful outcome. Remember that high blood sugar is not something we want to have, but what we call intermittent high blood sugar. So, like little spikes or even a couple of days or even a week of high blood sugars, especially if there's a good reason for them, they're not going to cause any kind of long term complications. The complications really come from high blood sugars over a long period of time. And long period of time meaning months and years, not one week of highs. I tell people all the time, I go on vacation a couple times a year, and on those vacations, I don't really pay attention to my blood sugars. I mean, I monitor them, make sure that I'm safe, but I'm more interested in having a good time and eating good food than I am with having blood sugars in range, because I know that when I come home, I will ratchet them down and they'll be back where they need to be. But giving him that flexibility, also, setting yourself up for that expectation of flexibility, I think will be really helpful.
Speaker C: And I feel like running high is a lot better than running low.
Speaker A: Yeah. And I think the expectation of running high for him in Europe is actually a good thing, because what we find is that when people are traveling, especially when they're in Europe, and they're probably walking a lot or walking more than they're used to walking at home, their blood sugars will tend to run lower because they're walking. And so their body is not used to that sort of activity. And so even if he's under bolusing for food, not necessarily on purpose, or he's eating things that are sending his blood sugar high, that walking, generally speaking, will even it out. And you don't want him being probably too tightly managed while he's walking a lot, because that could actually risk him going low. Yeah. Last thing I want to ask you about is what is your plan or thoughts about just contingency for if he does lose his insulin or if he does need to go to the doctor? I think it's important for you to have a plan for you to discuss the plan for him about what to do in those situations.
Speaker C: I would say the first stage of that plan is that the chaperone would have a second set of supplies. So the extra insulin, both the long and the short acting glucometer, test strips, needles, an extra glucagon, and those items would always be separate from Andrew.
Speaker A: Okay.
Speaker C: And then again, that's why we paid extra to have the insurance, so that way he would have access to being taken to a hospital and then for us to travel over there if needed.
Speaker A: Great. Yeah.
Speaker C: Kind of the two extremes. I don't seem to have much of a middle ground plan.
Speaker A: My sense is that you don't really need a middle ground plan. Luckily, in Europe, insulin is easily accessible and very inexpensive compared to what it is here in the US.
Speaker C: Okay.
Speaker A: So in most countries I'm not familiar with, I'm not certain about the ones he's going to. Germany, I think, is for sure. You can walk into any pharmacy and buy a vial of insulin for about $20. It's very inexpensive and does not require a prescription. I think that sending him with a letter either from his doctor or that you write just outlining his management plan that he takes X number of X units of tracebo or whatever insulin he's taking per day would be helpful just in case he needs it for a doctor. Oh, that's a great idea. And then lastly, I would recommend doing a little bit of research before he goes and knowing the names of the insulins that he takes, that the equivalent that's sold in the countries is going to be. Because, for example, if he's taking Novalog here, in most countries, that's called something like Novo Rapid or something. It's not exactly Novalog. And so you want to be able to know what the equivalent of that insulin is in the country is going to in case you need to get it. That's really no confusion as to what is happening.
Speaker C: Okay. Thank you.
Speaker A: I think that really the focus here is on making a plan and having the education that he needs to be able to manage diabetes well, as well as your mindset to be able to take a step back and to just say, okay, he's going to have a good time. The chances of something bad happening or something negative happening are relatively low, that he'll be in good shape.
Speaker C: Yeah, I hope so. And I think talking and planning always makes me feel better.
Speaker A: Yeah. All right. Well, great. Well, Melissa, thank you so much for joining me today, and I hope this was a helpful conversation.
Speaker C: It was very helpful. Thank you so much for your time. I appreciate it.
Speaker A: You're welcome. Each week, I give you a plan of action from today's episode you can use in your life type of diabetes starting today. And your plan of action from today's episode is stop and think. As I mentioned to Melissa, one of the biggest predictors of future behavior and future diabetes management is the past. And so Melissa was concerned that her son would have trouble in Europe. But the reality is, over the past two years, he's been managing his diabetes fairly well. He hasn't had any severe highs or severe lows and has not ended up in the hospital.
Speaker B: And so what I encourage most of.
Speaker A: You to do is to think back on those times of his good management and see that as a prediction of how he's going to manage his diabetes while he's in Europe. So I want to encourage you to do the same thing next time you'll worry about the future with diabetes, think back to the past and ask yourself, is there evidence from the past that should make me worry about the future? And if there is, take action. But if there isn't, recognize that you're worried. But also recognize that in the past, things have been just fine. And most likely in the future, with the same care management you've had from the past, and most likely in the future with the same care management that you've had in the past, you're going to be just fine.
Speaker B: Thanks so much for joining me on the Live Free with T 1D podcast, where I teach you how to build your diabetes management plan like a sailboat so you could have smooth sailing in your life with type one diabetes. And I'll see you back here next week, same time, same place. Bye for now.