Diabetes Management While Traveling Abroad
Behind every great voyage are extra medications and supplies, plus months of preparation. Just ask Nanette Char, 66, and her husband Harris Lifshitz, 71. The couple has traveled far from their East Hartford, Connecticut, home—to seven continents and over 130 countries, to be exact—and Lifshitz’s type 1 diabetes has never slowed them down. Their secret: They have backups for everything.
Before jetting to their next destination, Char creates a spreadsheet that calculates the number of pills, insulin vials, syringes, test strips, and other supplies they’ll need. “I think we [bring] over 3,000 items for medications and supplies,” which cover trips that last a few months, Char says. The couple’s vigilance gives them peace of mind—and less risk of a serious emergency halfway around the world.
When considering the amount of supplies to bring, it’s wise to plan for the worst: Stuff can get lost during travel, and it might be difficult to find replacements in a foreign country. “You really have to go under the assumption that you’re going to be self-sufficient for the length of the trip,” says Lifshitz. That means bringing twice the number of supplies you think you’ll use, says Carol Levy, MD, CDE, associate professor of medicine at the Icahn School of Medicine at Mount Sinai and director of the Mount Sinai Diabetes Center in New York.
Help prevent lost supplies in the first place with some smart packing. “Never put any of your diabetes-related supplies into a checked bag,” Levy says. Most airlines will grant you a medical waiver for oversized carry-ons if you call in advance, says Lifshitz, but you may need to negotiate with them. Don’t be afraid to say, “I have diabetes, and I need these supplies with me.”
Consider these items for your carry-on checklist:
Bring snacks, as the airline meal schedule may not align with your typical mealtimes, says Levy. Aim for foods with a good balance of carb, healthy fats, and protein, such as cheese and crackers, a small sandwich, a salad with chicken, or a protein-packed meal replacement bar. On shorter flights, where cooling isn’t an issue, consider hardboiled eggs and cheese sticks.
Bring extra test strips, lancets, syringes and/or pen needles, batteries, infusion sets, ketone strips, fast-acting glucose tablets or gels, and any other diabetes-related tools. You may have to get permission from your insurance plan to obtain extra medication and supplies for travel. Ask your pharmacist for help or call your health insurer directly to get a vacation override.
Marwan Hamaty, MD, MBA, an endocrinologist at the Cleveland Clinic in Cleveland, Ohio, suggests bringing all medications in their original containers, including the prescription labels, to avoid hassles at security checkpoints. If that adds too much bulk to your baggage, carrying only the prescription labels may be sufficient. Char and Lifshitz typically ask their pharmacist to print out extra labels, which they stick onto plastic bags that contain their medications. This saves coveted carry-on space and also proves to security that these are prescription drugs, says Lifshitz.
The Transportation Security Administration (TSA) does not require that you get a letter from your physician stating you have diabetes and need to bring your supplies on the plane, but you may feel more comfortable if you have one, says Levy. Got to tsa.gov or diabetes.org/TSA for more information.
Vicki Sowards, RN, director of nursing resources at Passport Health in Baltimore, suggests wearing a medical ID bracelet throughout your trip to alert first responders during an emergency. Also a good idea: Lock your cell phone’s home screen with a medical alert that reads “I have diabetes,” says Cazzy Magennis, 24, who has type 1 and currently lives in Kent, England. “You can even have that translated to the language of the country,” she says.
It’s OK to store some information digitally, such as your travel insurance plan. But you’ll want to bring photocopies of your passport in case of emergency. Char also stashes instructions on how to change the time on Lifshitz’s pump, photocopied from the manual, in her carry-on.
You’ll want to have at least one extra glucose meter (that works with your test strips) in case yours breaks. If you’re a pump user, consider bringing a backup. For instance, Medtronic offers loaner pumps for U.S. residents at a cost of $50 for 90 days, which you can use when traveling internationally. Pack syringes and long-acting insulin (know how to dose it) or insulin pens and needles in case your pump malfunctions. Other countries may label syringe measurements differently than the United States, which can lead to incorrect dosing, so check to be sure they are designed for use with your type of insulin (U-100 is used in almost all countries).
Bring extra medications, including insulin, says Hamaty. While the TSA allows airplane passengers no more than 3.4 ounces of individual liquids in carry-on luggage, people with diabetes are exempt from this rule when it comes to their medications and diabetes supplies, including frozen or partially frozen ice packs for unopened insulin.
Once you get to your hotel, you can store extra insulin in your room’s fridge, if the temperature is not too cold. Macgennis travels with a Frio bag to keep her insulin cool. These compact cooling cases are activated by water and do not require refrigeration or ice packs. “I used them for four months straight, and I didn’t lose a single insulin vial,” she says.
Carry plenty of glucose tablets, powders, or gels to treat lows both on the plane and off. It’s especially important not to rely on food sources of glucose when traveling abroad—if you can’t read the language, you can’t read the grams of carb per serving.
Keep this lifesaving kit with you on the plane and while you’re exploring your destination. “If you have a severe hypoglycemic reaction in a remote area, it might be challenging to get resources or help,” says Levy. Traveling alone? Inform the flight attendants that you have diabetes, and let them know where you keep your glucagon.
Understanding your rights as a person with diabetes will ensure that you and your equipment pass through security unscathed.
No to X-ray
If you use a continuous glucose monitor (CGM) or insulin pump, never put your device through the X-ray machine, says Hamaty—it may cause damage or possibly void the warranty. Check with the manufacturer to see if your pump or CGM can safely go through the full-body scanner.
Yes to Pat Down
If your device can’t go through the X-ray machine, in the United States, you can always request a pat down and an inspection by hand for your device instead. “You have to be ready for just about anything,” says Lifshitz. “And you have to sometimes explain to them firmly that you can’t put your monitor or pump through the X-ray.”
When you take flight, you may have to modify your diabetes regimen. Be sure to focus on these key steps.
Adjust for air pressure. Changes in air pressure can cause your pump to deliver more or less insulin. When air pressure decreases during takeoff, bubbles can form in an insulin cartridge, displacing insulin in the pump and pushing out more than your dose. During landing, air pressure increases, which sucks insulin back into the pump and leads to less insulin being delivered to your body, according to one study. This may not be an issue for most people, but “some patients are very sensitive to little changes in the dosage of insulin,” says Hamaty. If you have concerns, talk with your doctor about suspending your pump for a few minutes during takeoff and landing.
Pressure changes can affect vial and syringe users, too. If you need to draw insulin into a syringe while in flight, be careful not to inject air into the vial, says Sowards. Changes in air pressure can make it difficult to measure your insulin dose accurately.
Time mealtime doses. You can never be too sure whether you’ll be served an in-flight meal, which makes mealtime medication doses tricky. Packed snacks, or a small meal, help you avoid lows when you’ve already taken sulfonylureas, meglitinides, or insulin, says Hamaty. To avoid situations like that, wait to take your medication or insulin until you get the meal. Otherwise, you could go too low before the food gets to you. Another option: For doses in the air, take your medication after the meal.
In Case of Emergency
When you plan a trip, you’re mostly thinking about the fun adventures ahead. But when you have diabetes, you’ll need to prepare for worst-case scenarios, too.
Insure travel. Sowards recommends buying travel insurance to cover emergency room visits, evacuation costs, and more. Medicare does not cover medical costs outside of the United States, except in certain circumstances. Not on Medicare? Check with your private insurer to see if international coverage is offered, she says.
Ask for help. Remember to program your phone with the number of the U.S. embassy in your destination city, so it’s handy in the event you have a medical issue. “They can give you a referral for the best place to go for medical care,” Sowards says. U.S. embassies do not provide translation services but may provide a list of official translators to contact.
Use backups. Purchasing new devices in a pinch can pose its own set of problems, which is why it’s smart to bring backups. If you lose your meter, it may be difficult to obtain a new device that measures blood glucose in milligrams per deciliter (mg/dl) and works with your test strips. Instead, many countries measure in millimoles per liter (mmol), which can make it challenging to get a quick reading. You can multiply the reading in millimoles by 18 to get the equivalent of mg/dl, says Hamaty, but it’s easier to bring extra devices from home.
Once you land in your vacation destination, jet lag or excitement may take over, but keep a few things in mind:
Change The time. If you use a pump or take multiple daily injections of insulin, time zone changes can throw you off schedule. For instance, if you take long-acting insulin at 8 p.m. at home, that might be 2 a.m. in the new time zone. Talk with your endocrinologist or certified diabetes educator to come up with an adjusted schedule, says Hamaty. Experts typically recommend dosing insulin according to your home time zone until you arrive at the new destination. It’s best to consult your doctor before traveling if the time zone change is greater than two hours, says Levy. Blood glucose fluctuations are not uncommon during this transition. “Things are not going to be perfect for the first 48 hours,” Hamaty says. “More frequent monitoring is advised.”
Scope out healthy eats. Research the restaurants and cuisine in your vacation spot before you arrive. That’s what Phillip Barone, 51, of West New York, New Jersey, does. Barone, who was diagnosed with type 2 diabetes three years ago, says he also prefers a rental house with a kitchen so he can cook some of the time.
Talk the talk. Translation apps, such as Google Translate, are good resources for everyday communication and ordering at restaurants, says Levy. Brush up on important phrases, such as “I have diabetes,” in the language of the location you’ll be visiting. They can also be used during an emergency, though a translator in the hospital would be even better in that situation, says Sowards.
Walk the walk. Sightseeing and exploring can mean you’re walking a lot more than usual, says Hamaty. All that exercise can lower blood glucose, so keep an eye on your levels, carry treatments for lows if you’re at risk, and, if you use insulin, adjust it as needed.
Protect your feet. It may be tempting to walk barefoot in the sand, but it’s important for people with diabetes who have neuropathy or poor wound healing to wear closed-toe shoes to avoid cuts and wounds on the feet, says Sandra Arevalo, MPH, RD, CDN, CDE, director of the nutrition and community outreach program at Montefiore Medical Center in New York. Take time each night to check your feet for cuts and blisters. Left untreated, even small areas of open skin can become infected.
Drink up. Whether you’re lazing on the beach or exploring a city, be sure to drink enough water. Dehydration can increase glucose levels.
By Land And Sea
Avoid these pitfalls when sailing the high seas or taking an extended road trip.
Beat the buffet. Access to large quantities of unhealthy food is a major temptation on a cruise ship. “I tell people to enjoy a little bit of everything, but eat small, frequent meals rather than indulge in two huge meals a day,” Arevalo says. The same goes for cross-country trips, where roadside dining often means cheap all-you-can-eat fare, fast-food joints, or packaged goods from a gas station.
Sip smartly. Vacation might mean extra indulgences when it comes to alcohol, but Arevalo suggests women stick to one drink a day and men no more than two. Avoid sweet cocktails, such as strawberry daiquiris and margaritas, which have lots of added sugar. While sugary drinks can raise blood glucose, alcohol can cause your blood glucose to drop if you take insulin or sulfonylureas, so it’s best to drink in moderation.
Adjust based on activity. When driving in an RV for long stretches of time, or lounging on a boat all day, be aware that your activity levels are lower than normal, says Levy. Find ways to fit in exercise. During long drives, make the most of your pit stops by walking around the parking lot. With any changes in activity, you may need to test your blood glucose more often.
Drive safely. Hypoglycemia is the biggest diabetes safety concern when driving across the country. “You need to be careful about your glucose levels,” says Levy. Stay safe by stashing sources of fast-acting glucose in the car. Make sure to build meals into your schedule, take breaks as needed, and check your blood glucose more frequently. If you’re feeling low, pull over to check and treat to steer clear of potential accidents.