The Special Traveller: Diabetes
Cruising the Nile...trekking in Nepal...elephant rides in Thailand...the Taj Mahal. The places to go are endless, as are the reasons for going. But regardless of where and why you go, travel should be relaxing, stimulating and fulfilling. Diabetes should not be a barrier to travelling. However the diabetic traveller's planning needs to go well beyond the usual itinerary and clothing list. If you use Murphy's Law (i.e. "whatever can go wrong will go wrong") as your guide, you will realize what I mean.
Imagine the following scenario. Your early morning flight to Greece sits on the runway for three hours in a snowstorm. The lovely breakfast you anticipate never materializes. You forgot to pack the granola bars 'just in case'. The flight attendant seems to ignore your requests for orange juice. What about the time zones? When should I take my next dose of insulin? How much? Where is my insulin? Great! It's in my suitcase in the hold! It'll freeze. Finally you land in Athens. Your baggage lands in Tokyo! The lovely customs agent takes away your syringes. What do you mean there's no Diet Coke in Greece! A lovely cruise through the Greek Islands. Motion sickness! I wonder what my blood sugar is now... Get the picture?
Close control of blood glucose is paramount in the treatment of diabetes. However while travelling, particularly during long flights, the goal should be to avoid any extremes that might result in symptomatic hypo- or hyperglycemia. Once you have arrived at your destination, you may then get back to a pattern of tighter control. But in order to achieve this, you must plan ahead.
Skimp on your underwear and socks, but not on your supplies. You never know when something might get damaged, lost or stolen. It is probably prudent to carry double the supplies that you will actually require. That goes for your insulin, syringes, batteries for your blood glucose monitor and alcohol swabs. It may not always be possible to purchase the same supplies abroad. For example the U-100 strength insulin you use here may not be available in certain countries. The same goes for your syringes or the insulin cartridges for your "pen". It is worthwhile, however, to check with the manufacturer of your insulin regarding the availability at your destination. Premixed combinations of insulin are available, and might be appropriate for someone with stable insulin requirements.
Insulin "pens" are perhaps ideal for travel. There is less risk of damage or theft Many patients with diabetes find them a lot easier and quicker to use, which can be particularly important for the traveller who may require more frequent injections and adjustments than usual. Finally, there is no need to carry syringes and vials.
Carry your supplies in your hand baggage. Insulin that travels in the baggage compartment may freeze and lose its potency. Or it may end up in Tokyo! Consider giving a bottle of insulin to your travelling companion, just in case you become separated from your hand luggage.
It is important to carry some identification such as a Medic Alert bracelet or a wallet card' and a letter from your doctor explaining that you have diabetes. A written prescription for your insulin, needles and other supplies will smooth your passage through customs, as well as help you out should you require more supplies abroad. A list of English-speaking doctors around the world, which is available through IAMAT (International Association for Medical Assistance to Travellers) might also prove useful.
Remember that mealtime while travelling may be anytime. Flight delays, flat tires, power failures, long-winded tour guides and coup d'etats are only a few of the factors that will conspire against you and your ideal schedule. So always be prepared. Pack some cheese, crackers or dried fruit at all times, as well as some hard candy should you require a fast-acting source of sugar. A Glucagon Kit, for treatment of severe hypoglycemia, might be a good idea for someone with "brittle" diabetes, or for someone going a bit farther off the beaten path. Check this one out with your doctor. If you do take one along, be sure to instruct a travelling companion on its use.
Don't neglect other precautions which might be worthwhile before you travel. Certain inoculations may be required or recommended. Antimalarials may be needed. And go prepared for motion sickness, cuts and bruises, Montezuma's Revenge, and all of those other inevitable joys of travel!
The insulin you are using should be comfortable going wherever you go. It does not need to be refrigerated. However, it must be protected from temperature extremes and direct sunlight, or it may lose its potency. Crossing the Sahara in a Land Rover while your insulin swelters in the glove compartment is not ideal! And remember, unpressurized airline baggage compartments may lead to your insulin freezing. Unopened bottles of insulin should be refrigerated as soon as possible.
Insulin may be protected from temperature extremes by carrying it in an insulated container such as a thermos. Cool down the thermos, put the bottle in a plastic bag, and line the thermos with a wet washcloth. This will ensure that your insulin remains effective and unbroken.
Specially designed kits for carrying diabetic supplies and for protecting insulin are available and may simplify your life while travelling.
When we travel, we are looking for a change from our everyday routine. Whether this involves reading spy novels on the beach all day or climbing pyramids is up to you. Regardless, your diet and your activity will change. Throw in a 14-hour flight across eight time zones, and it becomes evident that blood sugar control will take some extra planning.
Firstly, let's cross the ocean. Schedules for insulin dosage are based on a 24 hour day. But when we fly eastward, to Europe, for example, we cross 5 time zones, and our day in fact becomes shorter. Conversely, on a westward flight, say to Hawaii, the day is lengthened by several hours. Flights to destinations north and south do not present the same problem. In addition to the time changes, the nature and timing of your meals is often a bit unpredictable, and your level of physical activity dwindles to nothing as you recline in your crowded airline seat for what seems like an eternity. Obviously, adjustments need to be made to your customary insulin schedule.
The keys to avoiding significant hypo- or hyperglycemia during travel are frequent self-monitoring of blood glucose, and flexibility. There are several ways to calculate insulin requirements, and it is best that you discuss this with your doctor or staff of a diabetes education unit. What you choose to do will depend upon the duration and direction of your flight, your time of departure, as well as your usual regime, i.e. single daily vs. twice daily injections and the type or types of insulin you use. People on oral hypoglycemics do not usually have to make any adjustments in their dosage, though they should be aware of all of the potential problems that can arise.
Eastward travel results in a shorter day and hence lower insulin requirements. You may choose to give yourself a smaller dose of your intermediate-acting insulin in the morning, and then supplement it later in the day with short-acting insulin, according to your glucose readings. You may simplify things a bit by calculating your usual "hourly" insulin dose. For westward travel with a longer day, your requirement will increase depending upon how many time zones you are crossing. This may be achieved simply by the addition of some short-acting insulin late in your day to cover the extra hours. Some people find a split dosage, i.e. twice daily, easier for travel and may switch to this prior to their departure if they are not already on such a regime. Never take your insulin unless your next meal is in sight, and don't forget to carry your own sources of carbohydrate and sugar. Again, insulin dosages and schedules need to be individualized. Discuss your plans with your doctor or diabetes educator.
With all of the newer insulins and monitors available, control of diabetes during travel should be much easier than it used to be.
A word about your diet while travelling. Certainly you will not have your usual control over what, where and when you eat. But do your best to keep to your customary meal plan. Foods that can substitute for your usual choices should not be hard to find.
It is also possible to alter slightly the timing of your meals, when possible. For example, if you take off for France at 0800 hours, it may be best to eat breakfast and take your insulin at 0600, rather than risk that breakfast will be delayed on the plane. If at times your sugar tests on the low side, than grab a quick snack. If you're running high, maybe it's because you need to get off of your sun cot (butt) and get some exercise. While some travellers prefer to stick to their "home time" for their insulin injections, it is probably best to switch over to "local time" as soon as you arrive. Once you are in the swing of things at your destination, remember that adjustments still may need to be made according to your differing activities and food intake. If you are in a very hot climate, you may find that your insulin gets absorbed more quickly and can result in hypoglycemia.
Once again, there are countless ways of managing your blood sugar during a prolonged flight and on vacation. But there is no 'right way'. It is probably best to sit down with your diabetes educator and organize a chart of your insulin and meal plans for your trip. It really needs to be individualized to each traveller. With a bit of experience, you will discover which methods work best for you, and you can learn to do your own planning.
There are many sources of information for the diabetic traveller. They include your diabetic education unit, your pharmacist, and the manufacturer of your insulin. The Canadian Diabetes Association site should be of help. With a little bit of advice, lots of planning, frequent blood sugar testing and flexibility, the traveller with diabetes should be able to choose where, when and how to travel. So good luck, enjoy, and stay healthy!
