By Carol L. Hernandez, RN, CNOR
Having diabetes should never hold you back from doing the things you love or from embarking on new adventures. However, when it comes to traveling, especially to destinations far off the beaten path, managing all the details of your diabetes care in addition to the details of travel – tickets, itineraries, connections, and reservations, to name a few – may seem overwhelming. You may be concerned about simply getting your supplies onto the airplane, not to mention time zone changes, new climates, or counting carbohydrates in the jungle or desert. Even a simple pleasure like sightseeing can feel difficult to manage with diabetes. However, with a little forethought and planning, many obstacles can be overcome. Here are some tips to help make your travels as stress-free as possible.
If you’re traveling by plane, you may encounter a few hassles at the airport, where upgraded security measures and baggage restrictions have become the norm, and flight changes or delays are always a possibility. Wearing a medical ID bracelet or necklace and showing it to security personnel is a good first step toward explaining why you are carrying medicines and diabetes supplies and is sometimes sufficient since more people are becoming knowledgeable about diabetes. A letter from your doctor that includes the date, your name, your diagnosis of diabetes, and a list of all the supplies (blood glucose meter, strips, lancets, etc.) and medicines you use can also smooth your way through security. If you use insulin, make sure that the type of insulin and dosage or pump, as well as the supplies you need for administering it, are listed as well. (This list might include an insulin pen and needles, syringes, or pump infusion sets.) Personally, I made such a list, had my doctor sign it, then made several copies of it to carry with me when I travel. Whenever I have presented this letter to the security personnel, they have been exceptionally courteous and considerate.
The Transportation Security Administration (TSA), a division of the US Department of Homeland Security, also offers the following guidelines for people with diabetes regarding air travel:
Further directives from the TSA and Federal Aviation Administration (FAA) state that syringes and insulin delivery systems (pens, jet injectors, pumps, etc.) can be carried onto a plane only when accompanied by insulin, and that glucagon kits should be kept intact in their original, preprinted pharmaceutically labeled containers.
When I have called international carriers before trips abroad, they have suggested carrying a doctor’s letter and list of supplies and medicines. It is perhaps because I have always had the letter ready with my passport at the security station that I have never been asked to produce insulin boxes or actual pharmacy labels. But being prepared to show all of the above forms of medicine identification is the best way to ensure a trouble-free security check.
When flying, I carry all of my diabetes supplies in my carry-on luggage. They all fit well inside a wheeled backpack, which is easy to carry or pull along. It is also convenient for security officers to examine if they choose to do so, and it stays with me in case of delays or cancellations. When going through security, I have also learned to mention beforehand that I wear an insulin pump so that the personnel do not attempt to pull on it when they feel the pump in my pocket.
Insulin should never be placed in checked baggage since the baggage compartments of airplanes, buses, and other forms of transportation can get very hot or cold, and either extreme will degrade the insulin. Likewise, you should never leave insulin in the trunk or glove compartment of a car or leave a bag containing insulin out in direct sunlight. Be careful at hotels without a refrigerator; don’t, for example, set your diabetes supply case on a sunny window sill. If you put your insulin in the ice bucket overnight, you may want to remove it in the morning (mine was tossed out by housekeeping on one trip).
Many frequent travelers invest in an insulated insulin carrying case to keep their insulin cool. For a list of such cases, see “Carrying Cases.” Homemade insulin carriers using thermoses and ice, for example, will also work to keep insulin cool but are not much less expensive than a modest commercial case and may be bulkier and less convenient. (Be sure to avoid freezing the insulin, and do not use insulin that has been frozen.)
Some travel guides recommend taking twice the amount of supplies that you would normally need for the time span of the trip to allow for unexpected problems and delays. I have found that taking what I would normally use plus enough for a few more days (and enough pump supplies to allow for two extra infusion set changes) suffices for most trips, and usually I have surplus to bring home. When carrying oral medicines, it is often easiest to carry the original prescription bottle rather than count out pills just for your trip. You may also want to bring extra batteries for your blood glucose meter, particularly if you are traveling to a remote area.
One thing that I do routinely is set aside two days’ worth of medicines and supplies in a separate place (such as in my checked luggage or in my purse) just in case my carry-on luggage is lost or stolen. That way, I know that I will have enough to last until I can get to a pharmacy and get my prescriptions refilled. When I travel to a developing country where pharmacies may not be easily accessible, I tend to split my emergency stores among a couple of different locations, including my travel partner’s carry-on, and to pack a bit more than my usual extra amounts. The same practice would work well for a boat trip or cruise, especially if your itinerary calls for days at a time at sea between ports of call.
Now we’re on our way! The excitement of travel alone can affect your blood glucose control, and so can time zone differences and variations in activity level. Evaluating how each of these affects your blood glucose levels requires frequent monitoring and accurate record keeping. A walk that would seem easy and relaxed at home often seems more intense when it is combined with sightseeing and the joyful stress of being someplace new and different. Checking blood glucose levels before and after walking tours and other physical activities can help you notice changes and patterns you might not see at home. Always carry a source of glucose such as hard candy, glucose tablets, regular soda, or fruit juice in case of an unexpected drop in blood glucose levels. Small cans of juice are available at just about any supermarket.
For some people, insulin requirements increase during travel, and for others, they decrease. Time zone changes seem to make the biggest difference for me. A couple of hours may not matter much, but international travel resulting in eight hours time difference or more tends to upset my insulin clock as well as my internal sleep clock. If you use insulin, more frequent and careful monitoring is, once again, the key to good control when traveling through different time zones. If you are traveling east, your day will be shorter and you may need less insulin; if you’re traveling west, your day will be longer, so you may need more. It’s a good idea to consult your doctor about insulin adjustments before your trip, preferably with your travel itinerary in hand. (For more about planning for international travel, click here.)
Disposing of sharps responsibly is as important on the road as it is at home. Some airport and airplane restrooms have sharps containers, and some hotels offer a complimentary sharps container for guests who use them, but most do not. Whether you use sharps at a gas station, on a cruise, in a public restroom, or at your seat on a plane, train, or bus, never leave them in a wastebasket or seat pocket; someone could get stuck later. When taking a plane, I often pack a larger sharps container in my checked luggage to use after arrival and, in the meantime, use a bottled water container with a screw cap as a quick fix. A bottle is easily attainable, is made of clear plastic so that sharps can be identified by anyone who handles it after your departure, and can be closed tightly to maintain safety. Syringes, needles, lancets, and monitoring strips fit inside easily but are difficult to remove because of the narrow opening.
It is important to try to maintain your normal diet and to continue monitoring carbohydrate intake while traveling, but many people allow themselves a bit more freedom when on vacation. Sometimes the amount of control you have over food choices is limited during travel by your accommodations, restaurants, family environment, or other factors. While some restaurants and hotels can easily accommodate low-fat, vegetarian, or other specific diet requirements, having such choices available is never a guarantee, especially outside of the United States. In the course of trips to some remote developing countries, I have literally been at the mercy of those responsible for meal preparation, and my options have been very limited. In those cases, I made the best choices possible, estimated the carbohydrate count (and then added 1/3 to 1/2 the total if I didn’t have a good idea of the ingredients), and checked my blood glucose level after meals. Again, careful and frequent blood glucose monitoring will help determine the effect of different foods on your blood glucose level.
That said, in hotels, restaurants, or cruise ship dining rooms, do not ever be afraid to ask for choices from your personal meal plan, even if what you want is not shown on the menu. (The worst the waiter can say is “no.”) Airlines can usually accommodate special meal requirements, although requests should be made at least two days in advance of the flight. Buffets, parties, and group meals are often more difficult to manage, so I either plan what I will eat at the buffet or party before the meal, bring something with me that fits my plan, eat early by myself and enjoy the company without eating, or do a combination of these things.
You should always have snacks on hand that can be used to supplement or replace a meal if necessary. Cracker and cheese packets, trail mix, granola bars, and fruit cups all travel well, pack easily, and will hold the appetite until other choices are available. I usually pack enough snacks or emergency rations to replace or supplement several meals and then replenish my stores when possible. For example, one small box of cheese and crackers has six or eight snacks, a box of protein bars or granola bars has 12 or 24, dried fruit comes in various package sizes, and fruit cups have four packs per box. All of the above can fit into a container the size of shoebox and would last for two weeks even if needed twice a day every day.
Finding snacks or emergency rations can be a problem in foreign countries, but I try to buy locally whenever possible so that I can save my packed supplies as a last resort. Since foods in other countries are not always labeled as they are in the United States, estimating the contents and the carbohydrate counts can sometimes be complicated. Usually, however, there will be something of a familiar nature at the local market. I have found small hard candies, roasted nuts, crackers, cheese, and canned fruit everywhere, even in remote Guatemalan villages. If you count carbohydrates regularly at home, your educated guess at the food ingredients and values is usually accurate enough for a meal supplement or snack. A good food count value book may also be useful in this situation.
When dining in foreign countries where “traveler’s diarrhea” is common, a good rule of thumb is to avoid local water except in better hotels that specifically state that their water is safe for travelers (and that their ice is made with the same purified water). Otherwise, and whenever there is any doubt, bottled drinking water is my first choice. Remember that bottled water should be used for brushing teeth in these situations and that ice cubes should be avoided since they could be made with unpurified water.
Safe foods are usually those that are cooked and very hot throughout; products made with boiled water like coffee, tea, and soups; and fresh fruits that can be peeled such as bananas, oranges, grapefruit, and melons. Fresh, uncooked vegetables and salads should be avoided because they are often washed in unpurified water. Other products to watch out for are raw shellfish, unpasteurized dairy products, food from street vendors (unless piping hot or boiling), and any food that has been left sitting out. Experts now believe that the contaminated hands of food preparers and handlers cause more illness than contaminated water; when in doubt, canned foods and bottled water are always a safe bet.
The climate changes I have encountered when traveling have had little impact on my blood glucose levels and my ability to manage them. More humid areas sometimes make it more difficult to keep my pump infusion set in place, but then I simply use an adhesive dressing to cover the site. This type of product is available at any pharmacy. As an alternative, clear plastic tape, also sold at any pharmacy, can be used to secure the site.
Arid regions pose a different concern, namely dry skin. I find I need to increase my use of skin moisturizers in dry air. Sunscreen and shower gels are also helpful.
Pay particular attention to the condition of your feet in different climates. Excessive dryness or sweating can lead to irritation and infection, which can then result in further problems. I find that a good skin lotion applied early in the morning beneath socks can help keep my feet softer during dry weather. Foot powders designed to absorb excess moisture can be used when wearing tennis shoes, hiking boots, or heavier socks in warmer weather. It is especially important to choose good, comfortable, walking shoes for sightseeing and traveling, and it’s a good idea to bring at least two pairs of shoes in case one gets wet. Always “break in” new shoes at home before the trip to assure that they can be worn comfortably for several hours without pinching you or giving you blisters. Shower shoes (like thongs, flip-flops, or swim shoes) are helpful for preventing infections from any less-than-sanitary floors you might encounter and for protecting your feet from the heat on the beach or at poolside.
Like many things in life, travel tends to get easier with experience. As you go to new places and try new things, you will learn which items you cannot live without and which are simply taking up space in your luggage. You will also learn how best to take care of your diabetes when you’re away from home. But you don’t have to figure it all out on your own. Use the tips in this article, talk to your diabetes health-care team, and ask your friends with diabetes about their experiences. When you’re armed with information, you can make informed choices and plan ahead with confidence. There’s a big world to see, experience, and enjoy.
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