Travelling with Type 1 diabetes is the same as for people without diabetes. Like everyone, you must plan efficiently before travelling by land, sea or air.

General precautions when travelling with diabetes
• Prior to the trip, schedule an appointment with your diabetes team as you will need to bring a letter on medical stationary stating you have diabetes and you use pens/pumps/meters.

• Bring a written prescription with generic terms of the medication you are taking in case you need to get extra supplies or need to visit a doctor when abroad. Photocopy all your relevant important documentation and give a copy to your travelling companion or keep a copy in the separate luggage you are bringing.

• Remember to always bring spare insulin (and spare pen devices), at least 2-3 times the normal amount you would use during the same timeframe. If using a pump, make sure you have adequate spare supplies you may need plus backup insulin.

• More frequent testing may be necessary so you will need at least double your normal amount of glucose testing strips for the same timeframe plus a spare glucose meter. Don’t forget to bring ketone testing supplies also. Always split your supplies into two bags and if possible, give one set to a travelling companion in the event your luggage gets lost.

• Look at your travel plans and check what vaccines are necessary. For information on what countries may need vaccines see Tropical Medical Bureau www.tmb.ie. They can provide you with detailed information on vaccines, malaria prevention and the latest health news tailored to your travel plans. It is important to note that there are no special restrictions for vaccinations due to diabetes. Furthermore, it is more important for a person with diabetes to actually get the recommended vaccinations since illness will mean more difficult consequences associated with diabetes control. No precautions will give absolute protection, so, if you develop a fever, or feel ill while travelling or up to three months on return, seek medical assistance immediately.

• Check on the basic forms of carbohydrates eaten in the countries that you are visiting. While away, it should be possible to select familiar food such as rice, pasta, bread, biscuits and fruit. You may need to schedule an appointment with your dietician to discuss the carbohydrate content of some of the basic foreign foods you may come across while away.

• Update yourself on you Sick Day Rules/Management and how to manage in the event of illness and discuss this plan with your travel companions.

• Be Responsible and always carry quick-acting carbohydrates in the case of a hypo (low blood sugar level). Be aware of your hypo symptoms and treat them as necessary. Advise your travel companions about hypoglycaemia, its causes, and symptoms and how to treat a hypo event. You may wish your travelling companion to be instructed on how to use glucagon in case of an emergency.

• Alcohol may also lower your blood glucose level, so do not drink on an empty stomach. You may need to take an extra carbohydrate snack before going to bed as alcohol has the potential to lower your glucose level hours later or the following morning.

• Make sure your travel companions have all emergency contact numbers and home contact numbers to hand if needed.

• Changing normal routines may upset regimes and the only sure way of maintaining glycaemic control is more frequent blood testing. Insulin may be absorbed faster in warm climates, which may cause blood sugar levels to drop which may lead you to reduce insulin doses. You may also have high blood sugar levels from sitting around or eating food with more carbohydrates than usual. The extra excitement of doing something new or travelling can also increase your blood glucose levels.

Travel Insurance
You are advised to obtain full health insurance with comprehensive cover. Check what insurance cover you have or will need and the geographical area of cover. Read all the small print in the policy so that you know what you will be covered and what will not. Make sure your policy will cover you in case of an A&E diabetes-related matter while abroad. Remember that ordinary holiday insurance or backpackers insurance booked through your travel agent may not cover your diabetes as it may be considered a pre-existing condition. Check with the travel agent about the extra premium required ensuring coverage of your condition. If you have private Irish health cover, speak to your provider about their travel insurance.

If you are an EU citizen and need medical assistance while in another EU country, you need to bring a European Health Insurance Card. For more details, see https://www2.hse.ie/services/ehic/ehic.html

Travelling by Air
Most insulin pump manufacturers recommend that you do not expose your pump to x-ray equipment. Request a “walk through” or hand wand inspection. It is important to have some kind of identification on your person showing that you have diabetes. More often than not it will not be required as airport security has become well accustomed to recognising insulin and medical equipment on the monitors over recent years. However, if you experience difficulties boarding a plane, have the matter referred to the airport police.

Regulations state that vital medical equipment can be held as hand luggage within the passenger’s view on all flights.
Keep insulin supplies in your hand luggage, as there is a danger of freezing in airline luggage containers at high altitudes.

Please note: If your trip involves crossing time zones, talk to your diabetes team about the necessity to adjust insulin.
While travelling by air, people with a medical condition, including diabetes, are not permitted to use any exit seat. The main reason stated by relevant authorities is that passengers with diabetes should have access to their medications, blood testing equipment and extra snack supplies throughout the flight so be careful when booking your airline seat.

Generally, meals supplied to passengers on planes are preferably fine for people with diabetes. However, if you desire, long-haul flights or flights greater than two hours in duration may supply diet-specific meals with confirmation reservation needed 24 hours before departure. Although these diabetic meals may be available they usually contain limited carbohydrates. However, make sure that you have adequate carbohydrates packed in your hand luggage to cover all eventualities in case they do not serve food on flight. Do not put your food supplies in the overhead compartments. There is nothing worse than being on a turbulent flight when you are not allowed to move from your seat to access your bag from the overhead compartments.

Travelling by land
When travelling by land, remember that closed vehicles parked in direct sunlight can get very hot inside the vehicle, so it may be more appropriate to put your supplies in a cooler bag in the boot.

If you suffer from travel sickness, medication, which is available without a prescription, may be purchased. Travel sickness can mask the symptoms of hypoglycaemia or hyperglycaemia attacks therefore, frequent blood glucose testing is essential. Vomiting can cause hypoglycaemia and dehydration so plan ahead and try to avoid these unnecessary risks.

If you do feel sick, continue to take your medications and take carbohydrates in a liquid form. Follow your Sick Day Rules/Management and seek medical assistance if not responding.
Driving in foreign countries

If you are planning to drive while on holiday, you should ensure that your driving licence is valid for the duration of your trip and that you are covered by your travel insurance policy for driving, especially when abroad. Refer to the section on driving www.diabetes.ie/drivingandtype1diabetes to review recent safety and licencing guidelines for Class 1 and Class 2 drivers.

Diabetes and Altitude
Up to 7000 feet above sea level, it is unlikely that you need to be concerned with altitude levels affecting your blood glucose levels. Most meters are guaranteed for reliable readings up to 16,000 feet and within a temperature range of 18-30 degrees centigrade. Outside these ranges, meters can give incorrect high or low readings, or even stop working completely. Check with your meter manufacturer about the height and temperature ranges of your meter. Keep meters close to the body for optimum temperature operation.

Diabetes and Hot (>25 degrees C) /Cold weather (<3 degrees C)
It is important that your insulin supplies are kept at the correct temperature. In a hot climate, it is a good idea to request a room with a fridge or to bring your own cool box or a ‘frio’ bag. ‘Frio’ bags are activated by cold water and are reusable every 48 hours. If a fridge is not available or you do not have a cooler box, keep the insulin in the coolest and darkest part of the room and if warm, cover it with a cold wet cloth. In normal conditions, it is acceptable to carry a preloaded insulin pen on your person to use during the day. However, in extreme sunshine, you may need to bring a cool box or ‘frio’ bag with you during the day. For those people considering backpacking trips, Frio bags are the most convenient way to carry insulin.
In cold climates, insulin should not be allowed to freeze. In freezing conditions, keep your insulin or pen injector in the inner pocket of your clothing or bag. You must examine the insulin for crystals and discard the insulin if any are found. Even if it looks okay, you should test your blood glucose levels more frequently and if they appear abnormal, discard the insulin as it may be damaged or ineffective. Keeping the needle on your insulin pen, when exposed to temperature changes between injections leaves an open passage to the insulin, allowing insulin to leak out and/or air to leak in when exposed to extreme temperatures.

If you are travelling to an area that is likely to experience very extreme temperatures, check with your meters manufacturers about limits on the reliability of their machine.

Tips to avoid ‘holiday tummy’

• Avoid tap water, even when brushing your teeth.
• Avoid ice cubes in unclean environments
• Be careful of milk, cream and mayonnaise (including anything that might have these products in it for example coleslaw)
• Ensure juices are diluted with reputable water supplies
• Be vigilant when sampling
• Cold buffets- remember that anything that needed washing will have been washed in cold tap water.
• Shellfish for example sushi.
• Salads
• Raw food

Water Intake
With diabetes, you will be more sensitive to dehydration so always drink plenty of fluids when in a hot climate. If you do not drink enough when outdoors in a hot climate your insulin will be absorbed more slowly. Later, when you drink properly, more insulin will be absorbed and you are at risk of having severe hypoglycaemia. Bottled water from a reputable company with the seal intact is the best source to keep hydrated. You may need to contact your diabetes team to clarify any issues with insulin absorption, sites, exercise and temperature prior to travelling.
NB – paying the extra cost for air conditioning may be beneficial to help prevent nighttime glucose fluctuations.

Footcare
Footcare is another important issue to keep in mind when travelling abroad. Consider if, in a hot climate, you may be wearing summer shoes. Ensure shoes have been broken in prior to departure. Never walk in your bare feet especially on hot sand as if you have sensory neuropathy (reduced feeling in your feet), you may not be aware of the true temperature of the sand and could burn yourself without realising it. There may be shells and broken glass on the beach and wearing footwear it avoids accidental injury. Also, ensure your feet are protected from the sun, by applying sunblock. Again, if neuropathy is present, you may not feel sunburn until blisters develop.

Final Tip

• It is a good idea to have a few phrases in the local language for example, I have diabetes, please give me something sweet, and please call a doctor.
• You should always have some identification on you stating you have diabetes. We suggest you buy a bracelet you like from a Jewellers and have it engraved and this bracelet will support you long-term.
• Carry the contact details of your travel insurance medical division with your passport.

For longer vacations

• Have the contact details for the Irish Consulate of the area you are visiting.
• Have the contact details for the national diabetes association of the country you visit – see http://www.idf.org/membership

And finally, remember that blood glucose is measured in mmol/L in Ireland but in mg/dl in many other countries for example in the United States. So if you need to contact a healthcare professional abroad, the conversion rate is 1mmol/L= 18mg/dl. e.g. 6 mmol/L= 108mg/dl.

Here is a BLOG written in March 2016 on the results of 75 people with Diabetes who reported on their experience travelling with Insulin and Monitors through some Airports.  Some airports are better than others.