Tips for Air Travel With Diabetes
Airport security and tarmac delays won’t faze you if you’re prepared
On a flight to Milan last year, Ilene Raymond Rush made an unfortunate discovery. The vegetarian meal she had ordered in advance contained little more than carbohydrates and wouldn’t work with her eating plan. Rush, who has type 2 diabetes, wanted something that would help keep her blood glucose in check for the 10-hour transatlantic flight. Normally, she packs her own food so she doesn’t have to rely on what’s available on the plane. This time, she assumed the vegetarian option would meet her needs.
Fortunately, a man sitting next to Rush’s husband overheard the couple discussing their concern. He also had type 2 diabetes.
“He reached down and pulled out a package filled with things like cheese and nuts and shared them,” says Rush, 64, a freelance writer who lives in the suburbs of Philadelphia. But that was pure luck. “You can’t count on something like that happening.”
Flying when you have diabetes can be a challenge, and making sure you get the right food is only one part of it. But if you know what to expect—and how to prepare for the unexpected—your diabetes won’t add stress to your time at the airport or in the air.
“It can be overwhelming,” says John Motsko, RPh, CDE, a certified diabetes educator and pharmacist at Apple Drugs Diabetes Center in Salisbury, Maryland, and spokesperson for the American Association of Diabetes Educators. “The most important thing you can do is plan and then overplan.”
BEFORE YOU GO
The key to low-stress travel is getting organized early. “Being prepared is the best cure for anxiety,” says Della Matheson, RN, CDE, director of education and research support at the University of Miami’s Diabetes Research Institute. Matheson has type 1 diabetes. “I feel anxious only if I’m not prepared.”
Prep starts when you buy your ticket. Request an aisle seat. Having one will make it easier to get up regularly and move around the cabin. Frequent walks up and down the aisle help with blood circulation and lower your risk for dangerous clots. This is especially important if you have peripheral artery disease, which restricts the flow of blood and is more common in people with diabetes, says Lucille Hughes, MSN/Ed, CDE, BC-ADM, FAADE, director of diabetes education at South Nassau Communities Hospital in Oceanside, New York, and a spokesperson for the American Association of Diabetes Educators. “You want to be able to easily get up and go for a walk every 30 minutes or so.”
Some flights offer a meal, especially if you are traveling overseas or flying first or business class on a longer domestic flight, but you may get a complimentary meal on a domestic economy flight as well. Always check when booking. Some airlines offer meals designed specifically for people with diabetes, but you must request one in advance (Delta and American Airlines, for example, require at least 24 hours’ notice). Also ask for nutrition information to be certain the meal will meet your needs.
Talk to Your Doc
Once you’ve booked your flight, contact your doctor for a letter that details the diabetes supplies and medicine you must have with you on the plane. Transportation Security Administration (TSA) officials are aware that passengers with diabetes often must carry supplies such as syringes, but you can expedite the screening process at the airport’s security checkpoint if you have a letter that clearly explains your needs. “If you use a pump, the letter should state that you must be able to use the pump during the flight,” says endocrinologist Elizabeth Halprin, MD, of the Joslin Diabetes Center in Boston.
The letter should be dated and printed on your doctor’s letterhead. Already have such a letter from previous travels? If it’s more than a year old, play it safe and request a new one. And be sure to ask for the letter well in advance of your flight to give your doctor’s office plenty of time to get it to you.
If you’re traveling to a different time zone, talk to your physician about how that will affect the timing of your long-acting insulin doses and what adjustments you should anticipate. If you use a pump, tap your doctor or diabetes educator for tips on how best to use it in flight, instructions for using insulin syringes or pens in case your pump breaks, and when to start a replacement pump. “The best thing to do is talk to your educator for advice regarding the particular pump that you carry,” says Hughes.
Make a List
Create a checklist of everything you need to bring, such as snacks and sufficient medication and supplies for your entire trip. (See “Well Supplied,” below.) Tick items off as you go. Pen and paper work well, of course, but there are also plenty of apps (such as Google Tasks and Evernote) to help you manage your list. On the day of your departure, or the night before if you have a morning flight, give your list a once-over.
Plan for Security
Fill out a TSA Disability Notification Card to show to agents at the airport’s security checkpoint.
Pack It Up
Your carry-on bag should hold everything you will need at the airport and on your flight: medications, supplies, and food. Do not pack any of these essentials into luggage you plan to check. It might get lost or delayed, and the hold of the plane may reach temperatures low enough to freeze your insulin. If that happens, it will be less potent when it defrosts. And that means your normal dose won’t be strong enough to prevent a rise in blood glucose. Matheson recalls a patient who learned this lesson the hard way after a winter flight from Germany to Miami. Unaware that his insulin had frozen and defrosted, he used it as normal. Within a few days, he had developed diabetic ketoacidosis (DKA), a dangerous condition that results from too little insulin.
Halprin recommends that you also pack backups of all your meds and supplies in your carry-on. Keeping them in their bottles with the original labels, though not required by the TSA, may help speed your trip through airport security. This is something you should attend to well in advance because you may need to make arrangements with your insurance company to cover extra medications, says Motsko.
Pack your diabetes supplies in a see-through plastic bag that allows TSA officials to give it a visual scan. Place that bag at the top of your carry-on so you have easy access to it when going through security. In addition to diabetes supplies, Halprin recommends anti-nausea medication if you’re prone to motion sickness. “If you vomit, you are at increased risk of hypoglycemia,” she says.
Rely on yourself rather than the airport or the airline for nutritious foods that will help you manage your blood glucose levels. Bring foods that provide a balance of protein and carbohydrates, such as walnuts and almonds, raisins, cheese sticks, apples, crackers with peanut butter, and vegetables such as carrots.
How much food should you bring with you? That depends in part on the length of your flight, but factor in potential delays. “Don’t assume you are going to get on a plane that will take off on schedule,” says Hughes. “You need to be prepared for low blood sugar.”
Another thing to keep in mind: Airplane cabins circulate very dry air, and that can dry you out, especially on longer flights. For people with diabetes, dehydration causes more than discomforts such as dry skin. It can also raise your blood glucose levels. Pack an empty water bottle that you can fill once through security and then take it on the plane.
AT THE AIRPORT
Ask anyone, and they’ll tell you the biggest air travel hassles happen at the airport. Between the crowds, the slowdown at security, and the fast-food temptation that is airport dining, making it from the drop-off to your seat can be full of stress. But knowing what to expect is half the battle.
Get Through Security
Arguably the biggest concern for people with diabetes, especially those who rely on pumps and/or syringes: Will it be very difficult to get through airport security?
The short answer: not really.
The likelihood of encountering trouble has dropped in recent years, as TSA officers have become more knowledgeable about the needs of passengers with diabetes. “They understand what pumps and other equipment are, and you don’t get an argument about it,” says Matheson. “Just be sure to build in extra time.” She recommends arriving an hour earlier in anticipation of delays.
Here’s why: You’ll want to avoid the body scanner if you wear an insulin pump or continuous glucose monitor (CGM). According to manufacturers, it’s not yet known whether such scanners might damage pumps and CGMs. Avoid X-ray machines, too. They emit radiation that may harm your device. However, you may safely proceed through the airport’s metal detector.
If you use a pump or CGM, ask for an individual inspection. Your medications, including liquids and gels, also require scrutiny. Medicine containers that hold more than 3.4 ounces—the TSA’s limit on how much liquid a person can bring through security—are permitted but will get extra attention. Have your doctor’s letter ready, and explain your circumstances when you first arrive at the checkpoint. Then, expect a pat down, a trip through the metal detector, and a test for explosive residue on your hands.
Once through security, you likely will have a wait ahead of you—and another opportunity to see how well your preparations pay off. If you need a snack to curb your hunger or avoid a low, your carry-on bag should have you covered. Airport shops and eateries have gotten better about offering healthy fare, but you can’t count on finding what you want. And, of course, you’ll pay more for what you do find. Rush, who packs foods like nuts and dried fruit, agrees. “Food at the airport is so expensive,” she says.
IN THE AIR
You’ve finally boarded. What next? First, stash your carry-on bag within easy reach so that you have quick access to your food and medications. If you are traveling by yourself, let your flight attendant know that you have diabetes. That way, if you have a low and need a snack or juice right away, you won’t have to explain your request.
“I hate calling attention to myself, but if your flight attendant knows, she or he can get you what you need very quickly,” says Matheson, who always tells the flight attendants about her type 1 diabetes.
Changes in cabin pressure during both takeoff and landing may cause your pump to give you an unnecessary dose of insulin. Follow your educator’s advice about whether you need to turn off your pump prior to takeoff and again as the plane preps to land.
Throughout the flight, check your blood glucose more frequently than you normally do. Stress, changes in your eating schedule, dehydration, and other factors can affect your levels and your insulin requirements. Not everyone responds to flying the same way, however. Talk to your diabetes educator for advice specific to you.
Matheson says that her blood glucose always goes up on planes. “When I’m sitting, I’m always high,” she says. “That’s because I’m an active person, so I have to be careful.”
If your flight offers a meal, time mealtime insulin carefully. “Don’t bolus before your meal is in front of you,” says Halprin. Delays in meal service can happen at any time, even when the cart is just one row ahead of you. For example, sudden turbulence may require that attendants discontinue service, and if conditions don’t improve, you may never get a meal, putting you at risk for hypoglycemia. If you have taken your insulin only to find meal service cut short, speak up. “Tell the flight attendant that you have taken insulin and that you have to eat,” Matheson says. Should you become hypoglycemic, reach into your carry-on for the glucose tablets, gels, or liquids you packed. Eat 15 grams of carb, wait 15 minutes, then check your blood glucose. If it’s still below 70 mg/dl, eat another 15 grams of carb.
Once You Land
Now that your flight has ended, the fun can begin. With all your planning, you likely had no problems on your flight and have already begun to relax and enjoy yourself. If you need to, now’s when you should change the time on your pump to reflect your new time zone. And, says Motsko, there’s one last thing to remember: Thank the flight attendants for their consideration of your needs. “A little thank-you and a smile go a long way for the individual with insulin who may be on the next flight,” he says.
Pack your carry-on with these essentials
- Prescription medications, including insulin and/or other diabetes drugs (with prescription labels, ideally)
- Insulin syringes, if used
- Pump supplies, including extra batteries, reservoirs, infusion sets, and alcohol swabs
- Loaner pump, which the manufacturer may offer as a backup for international travel
- CGM supplies, including extra sensors
- Extra prescriptions, if needed to cover the length of your trip
- Glucose meter, along with strips, extra batteries, lancets, and lancing device
- Ketone test strips
- Over-the-counter medications to prevent nausea, diarrhea, and allergies
- Medical ID
- Glucagon, if you use insulin
- Glucose tablets or gels to treat low blood glucose
- Nonperishable snacks such as nuts, dried fruit, protein bars, peanut butter on crackers, and other foods to help get you through your time at the airport and on the plane