Diabetes may not be the ideal travel companion, but with adequate prepa type I diabetes should carry glucagon, and every traveler should pack glucose gels …
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The thought of traveling with diabetes can discourage the most confident of travelers Diabetes may not be the ideal travel companion, but with adequate preparation and common sense, the two are very compatible Anticipating and avoiding common health problems in both tropical and temperate climates, and being able to manage them on your own, will ensure a more pleasurable, healthier journey Being cavalier and leaving home without the necessary preparation can be fraught with danger, whereas excess caution might lead you to avoid adventurous travel altogether; the appropriate balance is somewhere inbetween
Preparing for departure
Visit your diabetes physician at least 46 weeks before the trip Ask for a signed and dated letter on official letterhead outlining your diabetes care, any other medical conditions, and the need for you to carry medications and equipment such as syringes/needles This letter will reduce hassles from overly suspicious customs officials either looking for a bribe, or thinking that your equipment is being used for the administration of recreational drugs Obtain a summary of your medical history, including allergies and prescriptions You should carry
double the amount of needed medication and monitoring supplies for your planned length of stay the latter to allow for increased testing Carrying rapid- or short-acting insulin eg, Humalog–see below to deal with emergencies is advisable even if it isnt part of your usual routine Those with type I diabetes should carry glucagon, and every traveler should pack glucose gels or tablets since they travel so well It is always nice to have a travel companion for a variety of nonmedical reasons but also for helping administer an injectable medication, such as glucagon, should the need arise Finding a travel clinic–The other obvious reason to see your physician is to obtain an assessment of your fitness to travel Remember, you want an opinion, not permission; the decision to travel is yours, after carefully weighing the risks and benefits Unless your personal physician has experience in travel medicine, it is wise to visit a travel medicine specialist 68 weeks before departure You can find one on the Web sites of Travel Medicine, Inc wwwtravmedcom, the International Society of Travel Medicine wwwistmorg/disclinicshtml, and the American Society of Tropical Medicine and Hygiene
wwwastmhorg/clinics/ clinindexhtml
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Travel medicine advisors usually focus on five main areas: 1 pretravel immunization; 2 prevention of malaria; 3 prevention and self-treatment of travelers diarrhea; 4 prevention of injuries, accidents, and infections including sexually transmitted diseases, which are almost always accidental; and 5 the first aid travel kit Immunizations–Travel immunizations are classified as routine those childhood or adulthood vaccinations that may require updating, such as tetanus/ diphtheria and polio, required such as yellow fever, which is needed to cross certain international borders, and recommended those recommended according to risk of infection, such as hepatitis A B, typhoid, meningococcal, Japanese encephalitis, etc For the most part, having diabetes will not worsen vaccine-preventable infections, but it may predispose you to some eg, pneumococcal disease Almost all travelers should be protected against hepatitis A Since you may require an injection in an emergency situation with a potentially unsterile needle, you should be protected against hepatitis B as well A new combined hepatitis A/B vaccine TwinRix is now available For full
protection, travel vaccines may need to be administered several months in advance–the most important reason to seek advice early Medications–Depending on your itinerary, the travel medicine clinic advisor may wish to prescribe antimalarial medication, antifungals to treat yeast infections, which worsen in the heat and humidity of the tropics, antiemetics for nausea and vomiting, and an all-purpose broad-spectrum antibiotic such as levofloxacin Levaquin or azithromycin Zithromax, which are useful for the self-treatment of travelers diarrhea and other infections No traveler with diabetes should leave home without an antibiotic for self-treatment of travelers diarrhea since its consequences may lead to loss of blood sugar control and/or salt and water imbalance A first aid kit is another travel necessity, especially when traveling to an exotic destination Packing: All medications and glucose-monitoring equipment should be placed only in your carry-on luggage Checked bags may be exposed to extremes of temperature, and, most importantly and likely, your bags may end up elsewhere, without you Insulin, however, travels well except above Consider carrying all of your diabetic 86F and
below 32F Where temsupplies in a specially designed case, peratures might be an issue, consider such as the DIA-PAK carrying a designated insulin travel case or widemouthed thermos Never keep insulin in direct sunlight or on ice Although insulin can be stored for 30 days at room temperature, in warm climates you may wish to request a room
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with a refrigerator or air conditioning Before using insulin, check vials for signs of damage crystals, clumps, discoloration, etc and discard frozen or damaged vials In the event of unanticipated delays or a sudden change in plans, your carryon luggage should contain food ample amounts of carbohydrates and water to prevent dehydration on long flights Medical care abroad–Other pretravel to-dos include the issue of travel insurance for overseas medical care and emergency medical evacuation coverage, and diabetes identification Identification cards and useful phrases in foreign languages such as sugar, please are available from the American Diabetes Association wwwdiabetescom Information on health-care providers abroad can be obtained from the International Diabetes Federation wwwidforg and from the following commercial
organizations, which charge a fee or request a donation: The International Association for the Medical Assistance of Travelers IAMAT wwwsentexnet/ iamat/, International SOS/AEA wwwintsoscom/, The Travel Emergency Network wwwtenwebcom, and Medex wwwmedexassistcom It is advisable to have some knowledge of your destination before leaving home so that you can identify potential risks and customs The Internet is a useful source of information
Enroute
For security reasons, keep your carry-on bags within sight and easy reach Show your travel companion, or tour group leader, where your glucose meter and medications for the treatment of hypoglycemia are located When traveling at altitude 8,000 ft, or by plane, pressure in insulin vials needs to be equalized; be sure to re-equalize the pressures once you are back at sea level Insert the syringe without the plunger into the vial Then, withdraw the syringe, replace the plunger, and withdraw insulin as usual Also, it isnt necessary to inject air into the vial at high altitude Rapid-acting insulin–Since you as a passenger cant predict air turbulence or other reasons for delays in meal delivery, administer premeal insulin only when food is in
sight and reach This is where Humalog insulin lispro can play a role see below Since airline diabetic meals are often low in carbohydrates, fats, and flavor, most travelers with diabetes find it easier and more palatable to request a regular meal and eat the foods that best match their usual meal plan Adjusting insulin dose across time zones–One of the most confusing and worrisome aspects of diabetes management is the problem of travel across several time zones No matter whether you adjust your insulin dose or snack times, the key to success is frequent monitoring of blood glucose It is best to consult with your diabetes caregiver to work out a plan before departure As a general rule, traveling east shortens the day and thus decr 
eases insulin need Traveling west, on the other hand, lengthens the day and the need for more insulin and the snacks with it If
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the time difference is three or fewer hours, no insulin adjustment is necessary It is best to keep your watch on home time during travel to determine when your meal/ insulin doses should be taken Set your watch on local time the morning after arrival to get in step with meal activities of the destination country
North-south travel does not require insulin dosing adjustment If you take pills to manage your diabetes, use your usual dosing and meal schedules Some oral medications eg, sulfonylureas can cause hypoglycemia, so extra snacks may be necessary Tables such as Table 1 that summarize insulin dose adjustments across time zones can be helpful, but there is no magic formula for insulin dosing; common sense and more frequent monitoring are the mainstays in maintaining adequate blood glucose control The goal of control during travel is to avoid extremes–tight control is not the objective Better to let your glucose level run a bit higher than usual than to suffer a bout of hypoglycemia in a strange land with strange people speakInsulin lispro–Most travelers receiving regular insulin do not follow in-
structions to inject their insulin 3045 minutes before eating a meal Because insulin lispro Humalog has a much faster onset of action, it can be injected immediately before a meal, increasing compliance and more closely matching insulin action to postprandial glucose levels Traveling diabetics benefit from both the convenience and the short action profile of insulin lispro Regular human
insulin is absorbed slowly since it consists of hexamers of insulin that are crystallized around zinc molecules To be absorbed from its subcutaneous injection site, it must first dissociate into monomers and dimers Insulin lispro derives its name from the switching of two amino acids, proline and lysine, within the beta chain of insulin After subcutaneous injection, this insulin dissociates more rapidly into dimers and monomers The peak serum concentrations of insulin lispro occur 3090 minutes following The Humulin Pen administration, and regardless of the site of administration, there is a better match between carbohydrate absorption and insulin availability with less chance for late-peaking regular insulin to cause postprandial hypoglycemia Humalog can be mixed, if required, immediately prior to injection, with Humulin NPH, Lente, or Ultralente
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ing a strange language At the risk of being redundant, monitor, monitor, monitor This is the only way to determine how travel is affecting you and what adjustments you need to make in diet or insulin dosing Be aware that glucose meters may be affected by high altitude Check the manual or contact the customer
service toll-free hot line before departure, and be sure to carry an extra battery Two additional health tips to consider during flight: Prevent dehydration by drinking fluids liberally, and exercise regularly to improve lower limb circulation and glucose control Take a walk for at least 10 minutes every two hours, and do isometric exercises such as pressing your toes against the seat in front of you to tighten calf muscles
After Arrival
Your blood glucose meter is your best travel guide to continued good health, and it is a must because your eating pattern and activity level are likely to be different during travel You must test your blood glucose level more often in order to make appropriate adjustments and give you peace of mind Insulin abroad–Insulin produced in other countries may have reduced purity, and hence reduced activity Outside of North America, insulin is often dispensed as U80 or U40 concentration, instead of the standard U100 Syringes corresponding to these concentrations may be the only ones available Read labels carefully to avoid dosing disasters It is not recommended using a u100 syringe to draw up u40 or u80 insulin, since a very serious dosing error could
occur Also, cartridges and/or pen needles may not be available worldwide The best safeguard is to bring extra medication and supplies from home When going on an outing, always take vital supplies with you regardless of the proposed duration and type of outing Dont forget bottled water Try to eat as close to your usual meal plan as possible Counting carbohydrates and the plate method of meal planning can be especially useful Travelers diarrhea–Although the standard food rules for the prevention of travelers diarrhea are often impractical, for the record, here they are: avoid raw, undercooked foods eg, salads; roadside stands; unpurified water and ice cubes; buffets; and unpasteurized milk products This is why every traveler with diabetes should carry an antibiotic preferably a quinolone for self-treatment of travelers diarrhea Sun exposure–Travel to hot climates brings the risk of sunburn, a particular concern for those with diabetes, because healing is slower and secondary infection is more likely to occur Wear light colored, cotton clothing and a hat, and use sunscreen minimum 15 SPF All travelers need time to acclimatize to tropical heat; postpone strenuous activity soon after
arrival and drink enough sugar-free fluids to promote urination, whether or not you are thirsty Moderate intake of alcohol and caffeine is acceptable Altitude sickness–At high altitudes, hypothermia may be mistaken for hypoglycemia, and vice versa At about 16,000 feet, retinal hemorrhages may occur,
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a particular concern for those with preexisting diabetic retinopathy Altitude sickness, characterized by headache and fatigue, can usually be prevented by slow ascent and acetazolamide Diamox Foot care–Foot problems can ruin your trip Never travel with a new pair of shoes that has not been broken in Take one or more pairs of worn-in walking shoes, slippers for your hotel room, and beach shoes Avoid pressure points by changing socks and shoes frequently Inspect feet daily for blisters, redness, and skin breakdown Never delay treatment of injuries Never walk barefoot, even on a beach Dont forget to review potential risks of travel medications with your pharmacist or health-care provider: glyburide and doxycycline increase sun sensitivity; chloroquine, quinine, and Pepto-Bismol may increase hypoglycemia; acetazolamide Diamox may aggravate hyperglycemia; and antibiotics
predispose to vaginal yeast infections Keep in mind that not taking medication, such as antimalarial medication, may increase your risk of illness, which in turn can cause loss of blood sugar control In this regard, protection with DEET repellents eg, Ultrathon, permethrin fabric spray, and protective clothing and often a mosquito net is crucial to the prevention of malaria transmitted by night-biting mosquitoes and dengue fever, transmitted by day-biting mosquitoes Accidents–Finally, it is worthwhile to keep in mind that the major cause of preventable death during travel is not an infectious disease such as malaria, cholera, or Ebola virus A motor vehicle accident is much more likely cause Your risk of an accident is increased overseas especially in lesser-developed countries because of poor road conditions, badly maintained vehicles often without seat belts, inexperienced and/or reckless drivers, and a general disregard for rules of the road Here are three important safety tips to remember: dont ride on motorcycles, dont travel in overcrowded public vehicles, and never travel by road at night in rural areas The vast majority of diabetic travelers return safe and sound from their
trip Remember that healthy, comfortable travel is enhanced by adherence to common sense precautions with respect to food, water, insect bites, safe sex, and road travel, as well as close attention to diabetic control
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