Plan ahead for travel with diabetes

When you have diabetes, travel takes a little more planning. Talk to your diabetes specialist team about your itinerary and get advice on how to adjust your insulin or other diabetes medication, and food, when crossing time zones. Ensure you have travel (medical) insurance. Carry a letter (and copies) from your doctor about your diabetes and prescriptions, that also states if you need to transport insulin, syringes and blood testing equipment. If going to remote locations it is recommended to take other medications such as antibiotics and antidiarrhoeals with you.

Getting ready

When you have Type 1 or Type 2 diabetes you can usually do everything you want to do when you travel, but it does take advance planning. How you prepare depends on where you are going and for how long. Two weeks backpacking through Europe takes different planning than a week at the beach. Will you be crossing time zones? What kind of food will you eat and when? Will you be more active or less active than usual?

Consider telling your travel agent that you have diabetes and explain some of the particular needs that entails. That way, together you can plan a suitable itinerary to meet your needs.

General travel considerations

• Carry essential supplies and insulin or diabetes medication (as applicable) on you at all times
• Have several copies of a medical letter stating you have diabetes and are carrying blood testing equipment and (if applicable) insulin and syringes or pen needles, to give to Customs agents. Don't give away the original of this letter
• Get specialist help before you leave, on adjusting insulin doses (or tablets) and food through time zones
• Check your blood glucose frequently while travelling - your whole routine, activities and food are likely to be different
• If having difficulty with blood glucose levels, follow the guidelines you worked out in advance with your team, or consult a local diabetes specialist
• If you do visit a hospital take along as much documentation as you can (your medications, test results, travel/medical insurance forms, etc) 
• Always obtain travel medical insurance before leaving home 
• Watch what you eat and drink while away. Avoid tap water overseas (including ice cubes). Ask for a list of ingredients for unfamiliar foods
• Wear comfortable shoes and never go barefoot. Check your feet every day. Look for blisters, cuts, redness, swelling, and scratches. Get medical care at the first sign of infection or inflammation on your feet.

Insulin and travel

• Don't expose your insulin to extremes of temperature. If insulin is stored in very hot or very cold temperatures it may lose its strength
• Don't store insulin in the baggage compartment of planes because it will freeze
• The glove compartments or boot of a car are not good places to store insulin as they can get very hot; as can backpacks or cycle bags exposed to direct sunlight
• Travel packs (insulated bags) are available for transporting insulin or you can use a small wide-mouthed thermos flask
• If you use an insulin pump, follow the manufacturer's guidelines for flying
• Check the strength of any insulin you get overseas (some countries market different strength insulin)
• At room temperature the insulin you have opened (and are using) retains its potency for 30 days
• Keep a daily record of insulin doses and test results (to help identify any trends, and to help any medical advisors you may need to see)  
• Avoid using local needles if not sterile.

Immunisations

Get immunisation shots (if you need them) at least one month before you leave. If the shots make you unwell, you'll have time to recover before your trip. Also see: Travel vaccinations

Travel health insurance

Health insurance for your trip is a must. Handling your diabetes while travelling is a challenge and you are more likely to have problems with unexpected low or high blood glucose levels. All travellers are prone to infectious illnesses as they travel through new countries. If you develop an infection it can result in serious problems. It's very important you can access good quality healthcare if you need it.

Diabetes related documents

Before any trip, get these papers from your doctor:

• A letter for Customs
• A letter for a doctor (should you need to see one when you are away)
• A prescription for your medication and test strips in case you need to get more supplies while away.

The letter for Customs:

• Should state that you have diabetes and are carrying blood testing equipment and (if applicable) syringes or insulin pens and needles for your diabetes
• Store the original of this letter safely with your travel documents. Have enough photocopies of the letter to give to the Customs agents at each border you are crossing. Don't give away your original!

The letter for a doctor should:

• Explain you have Type 1 or Type 2 diabetes and what insulin type (or medication type) and doses you are on. Also the times you usually take your insulin
• List the pen device or syringes you use plus the blood glucose meter and the testing strips
• Note any other medical conditions you have
• List any allergies you have or any foods or medications to which you are sensitive.

Supplies of diabetes medications

Make sure you have a full supply of all your diabetes medications before you leave. The prescription to get filled before you leave should give you:

• Ample supplies of insulin [if applicable] and test strips. Enough to get you through to the next time that you will be settled in a country where you are certain you can get supplies (never run low on insulin or test strips while you are travelling)
• A supply of individually foil-wrapped urine ketone testing strips [if applicable to you].
• Two glucagon hypokits if you are travelling with a companion [if applicable to you].

Other medicine supplies

It is often sensible to get a prescription from your doctor for anti-nausea and vomiting medication, anti-diarrhoea medication, and some basic anti-fungal and antibiotic medication. Get the prescription filled before you leave and you will then have the medications on hand should you become sick overseas and are unable to get medical help quickly.

Discuss your needs with your doctor and remember to get instructions on when and how to use the medication.

Diabetes identification

No matter where you go, wear a medical ID bracelet or necklace that states you have diabetes and if you take insulin. It is also wise to carry a card in your wallet or among your travelling papers that states you have diabetes and are on insulin (or diabetes medication). Visit the MedicAlert Foundation of New Zealand website for more information about obtaining a medical ID bracelet.

Language barrier: If you're going overseas learn how to say, "I have diabetes" and "sugar or orange juice, please" in the language(s) of the countries you'll visit.

Managing low blood glucose levels

If you take sulphonylurea tablets or insulin, always carry a source of simple carbohydrate on you, eg. orange juice, glucose tablets, jelly beans. It also pays to carry a small complex carbohydrate snack on you (eg. muesli bar).

People on holiday often drink more alcohol than usual. Try to drink only moderately, and be aware of the safety guidelines for drinking alcohol when on sulphonylurea tablets or insulin.
Also see: Low blood glucose type 1 diabetes and Low blood glucose type 2 diabetes

Managing sickness and high blood glucose levels

If you get sick overseas you may not have access to the same level of health care that you have in most parts of New Zealand. You may get sick on a camel trip across the Sahara!

It is important for you to be clear about how you go about managing sickness and high blood glucose levels.

Type 1 diabetes:
You also need to have the tools for avoiding ketoacidosis on you at all times. These are:

• In-date, individual foil-wrapped urine ketone testing strips (with the colour matching chart)
• A good supply of short-acting insulin that has been stored properly.

Type 1 and Type 2 diabetes:
Carry with you:

• A good supply of unsweetened fluids. The best is a supply of bottled water
• Anti-nausea and vomiting medicine
• Anti-diarrhoea medicine
• If you are away from medical help, a supply of basic broad-spectrum antibiotic tablets
• Anti-fungal cream
• Your own knowledge about managing your diabetes during illness
• Basic guidelines written down (for yourself and others) on managing your type of diabetes in illness.

Also see: High blood glucose type 2 diabetes

Packing

Pack more medication and blood-testing supplies than you think you will need. Pack all of these in your personal carry bag so your medication and testing supplies are always with you. This way you are less likely to get separated from your essential supplies if your luggage goes astray.

Also the temperature in the baggage compartments of some planes can be very low. This can damage your testing strips, meter or insulin.

Your carry bag should contain:

• Your insulin [or diabetes medication] and your insulin delivery device (syringes or pen) 
• Blood testing supplies (include extra batteries for your glucose meter)
• Ketone testing sticks (if applicable)
• Any tablets you take
• Your other medications such as glucagon, anti-diarrhoea medication, antibiotics, and anti-nausea drugs
• A diabetes identity card stating your name and the fact you have diabetes [and if you are on insulin]
• A supply of simple carbohydrate, eg. glucose tablets, small juice pack, jelly beans [if you are on sulphonylurea tablets or insulin]
• A well-wrapped snack pack of something containing complex carbohydrate eg. muesli bar, crackers and cheese
• A clear, written guide sheet for managing your type of diabetes through illness.

If you don't need to use insulin for your diabetes, click here to go to the next section.

Insulin doses when travelling

Managing your insulin doses while travelling is complex, especially if you are crossing time zones rapidly (by air). Crossing time zones makes your day either longer or shorter, so you'll need to adjust your insulin doses (and food) to compensate for this.

The safest way to plan your insulin management when travelling is to work it through with your specialist diabetes team before you leave. Give yourself plenty of time to plan by making this appointment well in advance of your departure date.

Take your full travel itinerary when you see the team. Make sure you come away with a written plan you are happy with and that you understand.

Insulin and flights

The security scanners used at check-in will not damage your insulin or blood glucose meter. Insulin is affected by extreme temperatures and should never be stored in the baggage hold of the aircraft. Carry your insulin with you at all times. Wait until you see your food coming down the aisle before you take your injection. Otherwise, a delay in the meal could lead to you having a low blood glucose level.

Travel alarm clock: Be aware of time zone changes and schedule your meals and medication accordingly. If you choose to sleep while on board, use a travel alarm clock or ask the flight attendant to wake you at meal or medication time.

Two watches: Having two watches often helps you keep track of time zone changes. Keep one watch on the time of the country you have just left. This will enable you to remain very clear on when your next dose of insulin would have been due. You can also accurately judge how much time has passed since you had your last insulin if you record your doses against this time.

Insulin pump: If you are on an insulin pump, make doubly sure that the safety plug (for waterproofing the pump when swimming) is NOT in your pump. If you leave this plug in your pump when flying, your pump can deliver wrong doses due to pressure changes in the atmosphere. Otherwise, a pump is an ideal way to deliver your insulin across time zones as you can pump and dose for meals in the normal way with no real change to your dosages.

Air travel: Food

Some people have found that if they request special diabetes meals on airlines, they get served meals that are very low in carbohydrate. It is often best to order standard meals and to make healthy choices within that. Always have some appropriate snacks with you also in case your flight or in-flight meal is delayed or the meal doesn't have enough carbohydrate.

Air travel: Safety

If you are on insulin or sulphonylurea tablets the cabin staff need to know that you have diabetes (in case you get unwell during the trip).

Air travel: Avoid risks of blood clots in your legs

Keep up a good level of activity during your journey. Walk around in the terminal before boarding. When you are booking your seat try to get an aisle seat. Because you have diabetes you are more likely to develop blood clots in your legs.

To prevent this happening it is essential to get up and walk around in flight for a few minutes every hour while you are awake. Doing simple stretching exercises when seated also helps. Move your ankles in circles and point and release your toes often. This encourages good blood flow in your legs.

Air travel: Blood glucose testing

Test your blood glucose levels frequently when travelling through time zones. The timing of your eating and insulin administration will be changed. It is also easy to mix up the effects of jet lag with either high or low blood glucose levels, so it pays to know what your glucose levels are doing.

Remember, when you are tired it is easy to neglect your diabetes. But it is at these times that you need to know more about what is happening.

Once you've arrived

After a long flight, take it easy for a few days. Test your blood glucose often. If you take insulin, plan your activities so you can work in your insulin and meals. If you are more active than usual, your blood glucose could go too low. Take along snacks when hiking or sightseeing. Don't assume you will be able to find food wherever you are.

Tips for travelling by sea

With the wide array of mouth-watering foods available on cruise holidays, it's easy for your diabetes management to get out of kilter. Talk to your diabetes educator or dietitian before you leave about how you plan to deal with the food aspect. It's often helpful to get a sample menu from the cruise line so you can get an idea of the foods that will be served.

Physical activities: Cruise ships offer some great activities to help you stay active. These range from aerobics classes, swimming, gym workouts, dancing, or strolling the deck.

It's a good idea to make the cruise staff aware of your diabetes in case any problems arise. Keep a card or ID on you that states you have diabetes and that you are on insulin or diabetes medication.

Slow time change: Because you are crossing time zones slowly the changes in your insulin dosing times will happen gradually and usually without the need for planned changes.

Tips for walking, camping, hiking, cycling, kayaking

Some tips for physical activity holidays:

• Avoid going camping or hiking alone
• Tell someone where you will be and when you expect to return, so you can be found if there is an emergency
• If on insulin, carry all your insulin supplies (as outlined above). Make sure you carry an in-date glucagon kit and teach your travel companion when and how to use glucagon.

The key to enjoying a trip of this kind is to try to avoid things that may severely alter your blood glucose levels. Be aware of safety and try to avoid sunburn, injuries, blisters, insect bites and contaminated food or water. Make sure your footwear is sturdy and fits you well. Don't use brand new shoes to hike in, try them out before the trip.

Eat and drink enough to meet your needs
Take extra food, water, medication and supplies of simple carbohydrate (eg. glucose, sugar). Hiking, cycling or kayaking nearly always means you are a lot more physically active than usual, so you may need to significantly reduce all your insulin doses or sulphonylurea tablets. You will also need to increase your carbohydrate food intake.

Have a good understanding of how to reduce your insulin or tablets to compensate for increased activity. Your specialist diabetes team can help you with this before you go.

Original material provided by Diabetes New Zealand, 2008. Edited by everybody, August 2011.