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REVIEW ARTICLES Dietarv Advice for Airline Travel J Peter Leggat and Madeleine Nowak of the chemicals in the food, which may include preservatives, coloring agents, or other chemicals.’ Food intolerance is not an allergy; for example, lactose intolerance is due to a lack of or reduction in the enzyme lactase.2 Dairy products which are safe for those who are lactose intolerant include (1) yogurt in which the lactose has been fermented; and (2) cheese in which the lactose remains in the whey. New milk products which are low in lactose are also on the market, and these may be made available on request to the airlines. Travelers should inform the airlines of any food allergy, sensitivity or intolerance. Prospective passengers should be as specific as they can, since a number of ingredients tend to be used in producing gourmet foods served on aircraft nowadays,which may dsguise a potential allergen or chemical. Gluten-free meal options are usually given. Common food allergies include seafood, a variety of which is often served on board. In addition to their regular meal service, most of the major domestic and international airlines offer special meals. I t should be noted that regular meal services on international flights often give a choice of meals, even in economy class, and often include a salad and or fruit dish, which could be consumed by most people. More airlines also seem to be moving towards having at least one more culturally appropriate meal on the menu, particularly for relevant flight sectors. However, these meals may be inappropriate for some passengers, and there is a need for this special meals service. Meals services on airlines have improved greatly in recent years, particularly with the employment of consultant dietitians to the catering staff of airlines and advances in chef training. Special meal services are designed to cater to the most common variations of meals required by most passengers for medical, religious, or other reasons.The special requirements for these meals are described elsewhere.’ It is important to realize that the meals are designed and the ingredients interpreted by that airline, and may not necessarily reflect what the traveler might eat at home. So it is important to advise travelers not to have high expectations of this special meal service.This paper aims to provide some basic practical advice for selection of special diets for airline travelers. Special Meals Vegetarian Meals There are two main types of vegetarian meals: vegan and ovo-lacto vegetarian.Vegan meals contain no animal products. In ovo-lacto vegetarian meals, eggs and dairy products are the only animal products included.Table 1 gives possible user groups for each of these two main types of vegetarian meals. Special vegetarian meals such as Asiatic (Indian) vegetarian meals may also be available. Food Allergies, Sensitivities, and Intolerances True food allergies are immune reactions and can be severe and life threatening.These reactions are to the protein in the food.’ Food sensitivities are the direct effect Kosher Meals Kosher meals follow Jewish dietary 1aws.There is no pork and no seafood without fins or scales. Meat and dairy products are not served together, and meat requires ritual slaughter.These meals are appropriate for those who normally eat kosher food, those who do not eat pork, and those who do not eat shellfish due to allergy. For 8 days over Passover (usually March o r April), foods which ferment or rise are not permitted. This includes any flour-based food except specially prepared unleavened bread (matzos).During t h s time, utensils must be ritually cleaned or special Passover utensils must be used. Food acceptable for Passover will be marked “Kosher for Passover.” Peter Leggat, DipCINutr, FAFPHM: Senior Lecturer, Department of Public Health and Tropical Medicine, James Cook University of North Queensland, Townsville, Queensland, Australia; Madeleine Nowak, DipNutrDiet: Course Co-ordinator and Dietitian, Department of Public Health and Tropical Medicine, James Cook University of North Queensland, Townsville, Queensland, Australia. Reprint requests: Peter Leggat, Department of Public Health and Tropical Medicine, James Cook University of North Queensland, Townsville, Queensland, 4811 Australia. J Travel Med 1997; 4:14-16. 14 Leggat and N o w a k , D i e t a r y Advice for Airline Travel Table 1 Potential Applications of Main Vegetarian Meal Options Vegetarian Meal Options Dietary Characteristics Vegan (no animal pro ducts) Vegans Ovo-lacto vegetarians Those on low-fat diets Those on cholesterolreducing diets Diabetics, since desserts X X X X X X are usually fruit Those who do not eat red meat (or who eat only fish) Those with religious dietary laws (e.g.,Hindu, Moslem,Jews) Those who wish to avoid bloating And enjoy spicy food Athletes who are carbohydrate loading (extra carbohydrate should be packed on board) Ovo-Lacto Vegetarian (egqs and dairy products) X X x X X X X 15 delayed. In addition, airlines usually carry artificial sweeteners and a limited range of low calorie soft drinks on both domestic and international flights. Caffeine-free diet colas may also be offered. If in any doubt, the traveler can take on board convenient small dispenser packs of artificial sweeteners. In addition to being advised about diet, diabetics should be advised about the amount of insulin required for the trip, as well as appropriate storage methods. Protocols for insulin dosage can be found in a number of travel medicine publications (e.g., Benson and Metz3). Diabetics should also be advised to monitor blood sugar levels (BSLs) more closely. Short-acting insulin may be used if additional doses are required, or more frequent snacks may be necessary. Diabetics should be counselled regarding long periods of inactivity on board aircraft and the effect this may have on their BSLs.Those travelers taking oral hypoglycemics may not require any changes to their dosage schedule; however, they should also be advised to monitor their BSLs more closely. Diabetic travelers should be given a doctor’s letter or a travel health card with details of insulin or oral hypoglycemic dosages and syringes being carried. low-Cholesterol Meals Moslem Meals These meals follow Moslem dietary laws. There is no pork. Other meat requires ritual (Halal) slaughter. No wine or alcohol is permitted, even for cooking. These meals are appropriate for Moslems who choose to eat traditionally,and for other passengers who do not eat pork. Hindu Meals Hindu meals follow Hindu dietary 1aws.There is no beef, no pork, and no wine or alcohol, even in cooking. These meals are usually curries. Hindus may or may not be vegetarians.These meals are appropriate for Hindus, and for other passengers who do not eat pork. Diabetic Meals These meals are normally low-sugar, low-fat meals. They are appropriate for those with non-insulin-dependent diabetes, those with insulin-dependent diabetes, those with impaired glucose tolerance, and those on weight reduction diets.This type of diet may also be considered for travelers with chronic obstructive pulmonary disease (COPD), who should avoid high carbohydrate meals which may increase oxygen demand. Diabetics should also be advised to carry a carbohydrate source in case of hypoglycemia, as well as appropriate diabetic identification.Travelers should be advised to pack on board any snacks that they may routinely take, particularly in the event that an inflight meal service is These meals are low in saturated fat and low in cholesterol. They are appropriate for those on low-fat diets, those trying to lower blood lipids, and those on weight loss diets. Athletes will need to add more high carbohydrate foods or drinks. Gluten-Free Meals Gluten-fiee meals contain only gluten-fiee products. They are appropriate for those with celiac disease, those who have allergic reactions to gluten, and those who may have allergic reactions to gluten. low-Sodium Meals In low-sodium meals, there is no added salt or sodium. No foods with sodium are added in processing (e.g., corned beef, ham, cheese), and meals include lowsodium bread and unsalted butter.These meals are appropriate for those currently on a low-sodium diet for hypertension, those currently on a low-sodium diet for chronic renal failure, those currently on a low-sodium diet for congestive cardiac failure, and those who do not like salt. High-Protein Meals The requirements for these meals need to be specified.Almost all cases can be dealt with by carrying on board convenient packs of high-protein drinks. They are unlikely to be needed during a 24-hour flight for a walk-on traveler. 16 low-Protein Meals These meals are appropriate for those in chronic renal failure, and those with diabetes who are on a low-protein diet at home to reduce the risk of future renal failure. Other Meal Options Each airline usually has its own menu of special meals. Other meal options which may be available include high-fiber meals, raw fruit vegetable meals, bland meals, seafood meals, a special menu for children, and baby food. Ordering Special Meals Special meal requests should be made at the time of booking and be reconfirmed at check-in. Note that if travelers have a late check-in, it may be difficult to obtain a special meal.Trave1 agents may be able to assist travelers with establishing the range of special meals available and these can be discussed with their travel health advisor or physician. Many “frequent flyer” programs and airline lounge clubs offer to put these special meal requests onto travelers’computer profiles, so that they are “automatically” requested at the time of booking. It is still wise to double-check at check-in to avoid disappointment. Special meals often cannot be guaranteed if last-minute flight reservation changes are made. Role of Dietary Supplements Most travelers will eat more food than they do at home and include more variety in their diet, therefore they do not usually require supplements.Those who take supplements at home, and feel uncomfortable if they do not continue to take them, should take their own supply of supplements and should not attempt to buy something sirmlar in another country.They may find problems in communicating their needs, and the quality and composition of the supplements may vary. Stanton’ and Burke and McCoy4 give information on possible nutritional requirements for athletes. Reducing Jet lag Most airlines use meals as a means of circadian retraining. Meals are too frequent, taking into account J o u r n a l o f T r a v e l M e d i c i n e , V o l u m e 4, N u m b e r 1 circadian rhythm adjustments and colonic needs. To avoid over-eating and its consequences (e.g., poor digestion, bloating, and nausea) only half the food offered should be consumed. Alcohol is freely available and hangovers form an important part of the jet lag suffered by many over-indulgent passengers,discussed el~ewhere.~ Coffee, tea, cola soft drinks, and other beverages often contain caffeine and, in addition to alcohol, may aggravate the dehydrating effects of the aircraft environment. Passengers also need to be encouraged to drink su5cient water. This is particularly important for travelers with COPD, since alcohol can reduce respiratory drive, and dehydration may lead to thickening of secretions. Conclusion I t is important that travelers be made aware of the availability of special meals appropriate to travelers with particular medical conditions. It is vital that travelers understand the significance of food allergies and sensitivities, and that airlines are informed of these, since triggers may not be readily identifiable in airline meals. This information could also be incorporated into travelers’ handbooks and guides produced by the travel industry and by travel health advisors, so that travelers can make an informed choice regarding their selection ofspecia1 meals. If passengers order special meals, control excessive consumption of food and of alcoholic and caffeinated beverages, and keep well hydrated, the stress of travel can be reduced and control maintained over the traveler’s lifestyle. References 1. Stanton R. Different diets in Food for Health. 3rd Ed. London:WB Saunders/Bailliere Tindall, 1990:157-166. 2. Loblay RH, Swain AR. Food intolerance. Recent Adv Clin Nutr 1986;1:169-177. 3. Benson 6 ,Metz R. Management of diabetes during intercontinental travel. Bull Mason Clinic 1984;38:145-151. 4. Burke L, McCoy M.The complete guide to food for sports performance. Sydney:Allen and Unwin, 1992. 5. Leggat PA.“Jet lag”: surviving air travel. Safety Austral 1995; 18(1):10-12.