Diabetes

With good pre-travel health preparation, most people with diabetes travel without experiencing health problems Diabetes
Image provided by NHS Photo Library

 

Key Messages

With good pre-travel health preparation, most people with diabetes travel without experiencing health problems.
Travel plans should be made in conjunction with a travel health professional, and with a diabetic specialist for those taking medication. The condition should be stable at the time of travel.
Potential drug interactions and reduced kidney function should be considered when selecting antimalarial medication.
Travel vaccine recommendations are the same as for those without diabetes per se; additional considerations may be needed if other medical conditions exist.
Advice in regards to the carriage, storage and/or adjustment of insulin may be necessary.
Travellers with diabetes should have comprehensive travel insurance and consider carrying identification to inform others about their condition.

Overview

Diabetes is a very common medical condition. In 2014, the World Health Organization (WHO) estimated that worldwide 8.5 percent of adults aged 18 years and over, had diabetes [1]. Diabetes is the most common pre-existing long-term condition affecting travellers [2].

Diabetes occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. Insulin is a hormone that regulates blood sugar. There are two main types of diabetes, type 1 and type 2. Type 1 diabetes is characterized by deficient insulin production and requires daily administration of insulin [1]. Type 2 diabetes is far more common and results from the body’s ineffective use of insulin [1]. Type 2 diabetes is treated with a healthy diet, increased physical activity; also, medication and/or insulin are often required. All travellers with type 1 diabetes and some with type 2, will need to regularly monitor their blood glucose levels during travel. Those requiring insulin or certain tablets to control diabetes may experience episodes of hypoglycaemia (low blood glucose levels) which requires prompt management to avoid serious illness.

While some travel-related health risks may be greater or potentially more serious in those with diabetes, with careful planning, preparation and self-care, diabetic travellers can travel without problems [3].

Pre-travel preparation

Insurance

Comprehensive travel insurance is recommended for all travellers. Those with diabetes should declare their full medical history and ensure that planned activities are covered.  An EHIC card should also be obtained if travelling to countries within the European Economic area and Switzerland.

Contact airline

Travellers should contact their airline to check their rules on travelling with medical devices and equipment. Insulin pumps may need to be switched off during take-off and landing. It is advisable to have an insulin pen available as a back-up.

Those using an insulin pump may also want to check with the manufacturer of the equipment if the device can go through the screening equipment at airports.

Pre-travel consultation

All travellers should book a pre-travel consultation with their GP/travel clinic. In addition to checking standard pre-travel advice, methods of glucose monitoring, insulin storage and delivery, and a safe means of disposal of sharps, should be discussed (see below). Discussions on what to do if the traveller gets sick abroad should include written instructions. Travellers should know how to adjust their medication, use self-treatment measures, and know when and how to seek medical assistance.

Resources and expertise for managing complications of diabetes may be limited in many low and middle-income countries. Travellers should carry with them a summary of their medical record, including a medication list, extra supplies of medication and monitoring equipment. A medical letter explaining the carriage of needles, insulin and other equipment for medical reasons is advisable, this is particularly important for those travelling by air. Back up insulin pens may be required for some travellers.

Travel across several time zones on long haul flights may require adjustment to insulin or other medication. When travelling east the day shortens, when travelling west, the day lengthens. A plan should be made with a diabetic specialist prior to travel.

Packing

Travellers with diabetes should consider wearing identification, such as that available from the MedicAlert Foundation, to inform others about their condition.

Extra supplies of medication, monitoring equipment and snacks should be carried.

When travelling, blood glucose should be monitored more frequently. A number of factors can affect blood glucose control such as changes in activity levels, food/drink, dehydration, travel stress, illness and jet lag. Insulin is absorbed more quickly in warm temperatures and more slowly in cold temperatures.  The performance of testing equipment (glucometers, test strips etc.) can be affected by temperature, humidity and altitude [4].

Availability of suitable food and drink (including unsweetened drinks) varies in different countries. Simple carbohydrate sources, such as glucose tablets and sweets, should be carried to relieve symptoms of hypoglycaemia; complex carbohydrate sources, such as cereal bars and biscuits, should also be carried to supplement/replace a meal. Diabetes UK suggest ordering the ‘standard’ rather than ‘Diabetic’ food on aircraft. They highlight that airline meals in general may not contain sufficient carbohydrate [5]. Cabin crew may be able to supply extra, but it is helpful to have supplies just in case.

Insulin should be stored away from direct sunlight and protected from temperature variations by use of a thermal insulated bag/flask. Insulin remains stable for up to one month when stored at room temperature (approximately 20°C). It will deteriorate more rapidly in warmer climates. Insulin should be carried in hand luggage as it may freeze in the aircraft hold. Additional quantities of insulin should be supplied. Obtaining insulin overseas is discouraged as names, brands, strengths and qualities of insulin vary considerably worldwide. Glucose levels and insulin doses may use different units in other countries. A conversion table is available from Diabetes UK.

A medical kit tailored to the destination should be prepared; items such as a first aid pack with basic analgesia (pain killers), gauze, antiseptic, non-stick wound dressings, tape, plasters, tweezers and a thermometer are helpful. Sun screen, insect repellent, impregnated mosquito net, diarrhoea treatment medication, oral rehydration solution, condoms, and water disinfection equipment may also be required depending on the destination and travel plans.

Journey risks

Travellers on insulin should remember to monitor their blood glucose more frequently and be prepared to adjust their medication as needed. See also ‘pre-travel preparation’ section regarding carrying extra supplies of snacks, monitoring equipment and medication in case of delays.

Venous thromboembolism (deep vein thrombosis or pulmonary embolism) can occur as a result of long periods of immobility associated with any form of travel. Certain travellers are at increased risk including those who are obese, pregnant and those over 60 years of age (see our VTE factsheet for further risk groups). Diabetes itself may not be an independent risk factor for developing venous thromboembolism [6] but the impact of a blood clot in the deep veins of the legs or in the lungs should be considered. All travellers on journeys over four hours are advised to mobilise their legs on a regular basis. Travellers with diabetes should check with their GP or specialist team if compression socks are suitable for them and if any other preventive measures are required.

Food and water-borne risks

Travellers’ diarrhoea (TD) is the most common health problem of travellers to low-income regions of the world [7]. TD can affect travellers to any destination. Although care with food and water hygiene is sensible, it does not provide reliable protection [7]. Travellers with diabetes should be prepared to manage the symptoms of TD and know when to seek medical advice. Illness and dehydration can affect blood glucose control.

Vector-borne risks

Travellers should take insect bite avoidance measures. Insect bites should be kept clean and not scratched. An antihistamine cream and/or tablet may be useful to reduce itching. Travellers should seek early advice if there are signs of infection or the wound is not healing.

Dengue

Travellers with diabetes, who contract dengue, may be at higher risk of developing severe dengue (also known as dengue haemorrhagic fever) (DHF) [8]. This disease is transmitted by mosquitoes which predominantly feed been dawn and dusk.

Malaria

Some studies among local populations in areas where malaria is endemic have found an increased risk of malaria in people with diabetes [9]. However, diabetic travellers from non-endemic countries such as the UK, who are taking antimalarial medication, are not thought to be at higher risk of malaria than non-diabetic travellers.

In malaria endemic areas, travellers with diabetes should adhere to strict mosquito bite-avoidance measures to reduce their risk. When selecting antimalarial medication, renal impairment (reduced kidney function) and potential drug interactions with other medications must be taken into consideration.

Malaria can cause hypoglycaemia (low blood sugar), as can the drug quinine which is sometimes used to treat malaria. The summary of product characteristics for chloroquine contains this warning “Chloroquine has been shown to cause severe hypoglycaemia including loss of consciousness that could be life threatening in patients treated with and without antidiabetic medications. Patients treated with chloroquine should be warned about the risk of hypoglycaemia and the associated clinical signs and symptoms. Patients presenting with clinical symptoms suggestive of hypoglycaemia during treatment with chloroquine should have their blood glucose level checked and treatment reviewed as necessary” [10]. We have been unable to identify any information regarding the occurrence of this effect with chloroquine used for malaria prophylaxis.

Vaccination

As for all travellers, those with diabetes should be up to date with routine immunisations according to the UK schedule. Influenza and pneumococcal vaccinations are recommended for those with chronic medical conditions, including diabetes [11]. Travel vaccine recommendations are not different for those with diabetes per se, though there may be additional considerations due to other illnesses or medication. For example, when a traveller has steroid-induced diabetes due to high doses of prednisolone given to treat an inflammatory condition, then they would also be immunocompromised and therefore not suitable for live vaccines.

Other health risks

Urinary and fungal Infections

Women with diabetes are at increased risk of urinary tract infections. The risk of vaginal candidiasis (thrush) is also increased, particularly if taking an antibiotic such as doxycycline for malaria prevention. Travellers should be advised of self-treatment options and know when to seek medical advice. Standby antibiotics and antifungal cream may be useful for some female travellers.

Foot and skin care

Travellers with diabetes, especially those with peripheral nerve symptoms, should avoid injury to their feet. They should wear comfortable, well-fitting shoes and avoid walking barefoot. Feet should be checked regularly for injury, and kept clean, dry and moisturised. Cuts and abrasions should be carefully attended to, and travellers should be aware of signs of secondary infection such as spreading redness, localised swelling, pain and fluid discharge (pus).

Travel to high altitude

The International Mountaineering and Climbing Federation (UIAA) have information for travellers with diabetes going to the mountains.

Travellers with diabetic retinopathy should be cautious about ascending to high altitude, as those with pre-existing diabetic retinal vascular disease are likely to be at significantly higher risk of high altitude retinal haemorrhages. It is recommended that all diabetics should be seen and advised by an ophthalmologist prior to ascending to high altitude [12].

Monitoring equipment

The performance of testing equipment (glucometers, test strips etc.) can be affected by temperature, humidity and altitude [4, 13]. Discussion with a diabetic specialist prior to travel is recommended.

Tuberculosis

Globally people with diabetes have a two to three times greater risk of developing tuberculosis (TB) than those without diabetes [14]. This may be important for long-term travellers in areas where TB is very common or in diabetic healthcare workers who may be at greater risk of exposure to TB through their work. Specialist advice should be sought for these travellers.

General advice for those who get sick abroad

Blood glucose levels should be monitored frequently during illness. Illness in a traveller with diabetes can lead to hypoglycaemia (low blood sugar) or hyperglycaemia (high blood sugar) which can still occur even if not eating.

Travellers should continue to eat and drink if they can. Medication should still be taken even if they are not eating (doses may need to be adjusted).

Those who need to seek medical advice abroad should contact their insurance company and keep receipts so they can claim back the costs from the insurance or EHIC as appropriate.

First Published :   20 Apr 2016
Last Updated :   12 Oct 2016

  1. World Health Organization. Diabetes factsheet. March 2016. [Accessed 20 April 2016].
  2. Wieten RW, Leenstra T, Goorhuis A et al. Health Risks of Travelers with Medical Conditions—A Retrospective Analysis. Journal of Travel Medicine 2012; 19: 104–110
  3. Levy-Shraga Y, Hamiel U, Yaron M et al. Health Risks of Young Adult Travelers with Type 1 Diabetes. Journal of Travel Medicine 2014; 21: 391–396
  4. Brubaker PL. Adventure Travel and Type 1 Diabetes. The complicating effects of high altitude. Diabetes Care 2005; 28, 2563-72
  5. Diabetes UK, Diabetes and travelling guide, Summer 2015 [Accessed 14 April 2016].
  6. Heit JA,,Leibson CL, Ashrani AA et al. Is Diabetes Mellitus an Independent Risk Factor for Venous Thromboembolism? A Population-Based Case-Control Study. Arterioscler Thromb Vasc Biol. 2009 Sep; 29(9): 1399–1405. [Accessed 20 April 2016].
  7. Steffen R, Hill DR & Du Pont HL. Traveler’s Diarrhea, a clinical review. JAMA 2015; 313(1):71-80.
  8. Figueiredo MAA, Rodrigues LC, Barreto ML et al. Allergies and Diabetes as Risk Factors for Dengue Hemorrhagic Fever: Results of a Case Control Study. Plos Neglected Tropical Diseases 2010; 4: e699
  9. Danquah I, Bedu-Addo G, Mockenhaupt FP. Type 2 Diabetes Mellitus and Increased Risk for Malaria Infection. Emerging Infectious Diseases 2010; 16:1601-4
  10. Alliance Pharmaceuticals, Avloclor Tablets Summary of Product Characteristics, 17 June 2016 [Accessed 29 June 2016].
  11. Public Health England. Immunisation of individuals with underlying medical conditions. Ch 7 in Immunisation against infectious disease. May 2014, [Accessed 20 April 2016].
  12. Mader TH, Tabin G. Going to high altitude with pre-existing ocular conditions. High Alt Med Biol 4:419–430, 2003
  13. Richards P and Hillebrandt D. The Practical Aspects of Insulin at High Altitude, High Altitude Medicine and Biology, Volume 14, Number 3, 2013.
  14. World Health Organisation. Diabetes and TB factsheet [Accessed 20 April 2016]

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