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Advance planning keeps control on an even plane
Summer sun on a Greek isle. Balmy moonlit nights in exotic Aruba. Pina coladas on a Hawaiian beach at sunset. Even a rowdy trip to Disney World with the kids. What sounds like a dream vacation might pose health problems for your patients.
Not so, say experts. Those idyllic dalliances are easily within the grasp of anyone with diabetes Type 1 or Type 2 — with a little advance planning — and a little self-restraint in the diet department.
"People with diabetes should get to experience being on vacation just like anyone else. They can have a dessert, but maybe trade it for the potato at dinner," says Elizabeth Walker, MD, the American Diabetes Association’s president for health care and education and associate professor of medicine at Albert Einstein College of Medicine in Bronx, NY. "They shouldn’t feel trapped by their diabetes. They shouldn’t let it ruin their lives."
Traveling with diabetes means dealing with an unpleasant-sounding menu of management challenges: Different food and alcohol consumption, different exercise levels, time zone changes, jet lag, even new stresses caused by climatic changes and possible exposure to exotic diseases.
All it takes is a little preparation, particularly for patients who use insulin, says Walker.
Encouraging patients to discuss their vacation plans with you as far in advance as possible gives them time to optimize glycemic control and collect information to help them connect with health care professionals at the destination, should they be needed.
Here are some high-priority tips you should provide for travelers with diabetes regardless of their level of disease or their need for medications and/or monitoring:
• Keep all diabetes supplies in a carry-on readily available at all times. Patients should never be separated from their supplies. In addition, insulin should never be checked with luggage because fluctuating temperatures in cargo holds may alter its effectiveness.
• Pack at least twice as much medication, insulin, and other supplies that they expect to consume.
• Carry snack foods since meal times are often irregular during vacations.
• Carry a prescription for all medications, signed by a physician. It’s also a good idea to have a detailed letter from a physician describing the patient’s condition and all medications and supplies needed to treat diabetes.
"Travel can throw the whole system off, especially if they are traveling across time zones," says Walker. "That’s why it’s essential for them to have snack foods like crackers, cheese, peanut butter, juice, and glucose tablets to help them deal with possible hypoglycemia."
Tweak dosage for time changes
Travel across time zones may require adjustments in insulin dosage, since days become shorter going from west to east and longer going from east to west.
Travel often means greater levels of physical activity, leading to increased insulin sensitivity, as well as the desire to indulge in exotic foods, drinks, or extra desserts, which may raise blood sugars. Either way, this can require adjustments in medication.
"In the long run, we don’t recommend trying to cover’ extra food intake with increased insulin dosing because it will lead to weight gain," says Walker. "But occasionally doing that on vacation isn’t a big problem. I work with them and help them get back on track when they get home."
A big caveat: Patients shouldn’t make assumptions about glucose levels. Frequent monitoring will prevent unpleasant mistakes.
Another recommendation: Care must be taken in filling syringes on an airplane because it can lead to introduction of pressurized cabin air into the insulin bottle, making it more difficult to measure and administer the dose.
Refrigeration is another insulin issue that may arise while traveling. This is an individual choice, and most patients have good results with unrefrigerated open insulin bottles as long as they are consumed within 30 days. Those who prefer to refrigerate their insulin can carry it in insulated bags, such as cooler-type lunch bags and check ahead at their destination to be sure refrigeration will be available.
And insulin, available in U-100 concentrations the United States, is not sold in that form in some countries, where the concentrations are sometimes diluted to U-40 to U-80. Tell patients to check ahead.
For extended trips, it may not be possible to carry all supplies needed. In all but the most remote areas of the world, however, they can be shipped overnight or in a few days by Federal Express or UPS.
Other things to remind your patients before it’s too late:
• Be sure to have comfortable, well-broken-in shoes to avoid blisters. Not only can blisters cause painful and potentially serious foot ulcers, the open skin can also lead to infections that affect glucose control. Proper footwear, even at the beach, can prevent injuries. Don’t go barefoot.
• If you are traveling to a remote area or to an area where there are frequent disease outbreaks, check in advance with the Centers for Disease Control and Prevention and see what, if any, immunizations are needed. Illness during a vacation is no fun for anyone, but it could be doubly complicated for someone with diabetes.
• When traveling abroad, avoid tap water and ice cubes.
• See a physician at first sign of illness. Delay could lead to glucose problems that could make a minor illness much more serious when you’re away from home.
Children require extra planning
Advance planning is even more crucial when traveling with children with diabetes, says Juvenile Diabetes Association volunteer Sandra Silvestri of Carmel, CA. Silvestri is not a health care professional, but has even more intimate experience with Type 1 diabetes through her 10-year-old son, Joey, who was diagnosed with diabetes when he was 2 years old.
The Silvestri family has always loved to travel, and Joey’s diabetes hasn’t changed that.
She became such an old hand at traveling with a backpack of insulin and other supplies Joey needed that she volunteered to chair the Juvenile Diabetes Foundation’s Children’s Congress in Washington, DC, a year ago.
"This was a big group of people, many of whom had never traveled at all after their children were diagnosed," says Silvestri. "They needed the confidence to know they can do this."
So she got her thoughts together and sent out a set of guidelines.
"I think of you all as my kids’ and my family,’ so I say to you as I do to my kids, Plan ahead!’ and Be prepared!’" Silvestri wrote to prospective participants in the congress. "Try to think ahead and plan for the inevitable delays that summer travel often brings to the airlines. When I travel with Joey, I always make sure to have cheese and crackers, juice, and Starbursts in my backpack. I cannot tell you how many times this has saved the day for us as we wait in airline terminals."
Joey, who now uses an insulin pump, always carries a spare pump. "I always have a backup for everything, just to be sure," Silvestri says. "And a new pump can be delivered within 48 hours almost anywhere."
Silvestri also says children with diabetes don’t seem to adjust to time changes as easily as adults.
"We make a gentle segue to the new schedule as soon as possible," she says. "We test every two hours and get a carb count. If we’ve traveled over several time zones, we’ll use Humulog for 48 hours until we get a grasp of where we’re going."
One last warning from Silvestri that applies to adults, as well: "Feed the child, don’t feed the insulin!"
[Contact Elizabeth Walker through the American Diabetes Association. Telephone: (703) 549-1500. Sandra Silvestri can be contacted through the Juvenile Diabetes Foundation. Telephone: (800) 533-2873.]