CME INDIA Presentation by Dr. Ashish K Saxena, MD (Medicine), FRCP Edn., FIAE (Echocardiography), PGDD (Diabetes), FIACM, Fellow Indian Society of Hypertension, Consultant Internal Medicine, Diabetes and Non-Invasive Cardiology Diabetes and Heart centre, Delta Heart Centre, Ludhiana.

Based on a presentation at Diabetes India 2023 conference, Indore.

Modern life includes a lot of travel

  • Diabetes mellitus patients have excelled in many spheres of life.
  • The methodical approach to problems includes timely pre-trip evaluation, traveller education and counselling.
  • With this strategy, strain will be lessened and vulnerable groups will be better equipped to handle challenging situations.

Diabetes and Its Impact on Travel

  • Alterations in diet, exercise, sleep patterns and climate.
  • More stress and hormones that are counter regulatory and disrupt glucose regulation.
  • Changes in nutrition patterns have an impact on food consumption and flavour
  • Extreme weather can affect many different things including:
Insulin levels
Glucose metabolism
Sleep patterns
Circadian rhythm
Vulnerability to local diseases
Access to quality treatment
Another communication problems

Diabetes Technology and Travel

  1. Flash glucose monitors
  2. CGM- Continuous glucose monitor
  3. Insulin pens
  4. Smart pens
  5. Insulin pumps
Pearls To Know About Travel and Diabetes

Pre-Travel Evaluation

  • Early immunisation gives the body adequate time to produce sufficient immune response.
  • In order to prevent dose errors, it’s crucial to be aware of regional variations in various medications and equipment.
  • The diabetes education sessions should focus:
Food exchanges in destinations
Carbs counting
Glucose monitoring
Exercise option in destinations
Safeguarding diabetes medications and test equipment
Safe disposal of sharps
Used test strips and wipes
Early recognition of complications like hypoglycemia, hyperglycemia and its prevention methods

Pre-Travel Examination Checklist For DM

  • Comprehensive history, physical examination, relevant laboratory tests, immunizations mandatory for DM.
  • Thorough eye and foot exams, staging of diabetic renal disease and atherosclerotic cardiovascular disease, identification of travel related contradiction, counselling regarding lifestyle and other travel related issues.
  • Prescriptions that have been translated into target language to improve communication includes diabetes medications, diagnostic kits, food prescription, physician’s contact etc.

Real Life Case 1

  • An Indian citizen, 22-year-old with type 1 diabetes, travelling to south Asia.
  • He had CGM and insulin pump to track his blood sugar levels. His pump failed him as soon as he landed at his destination.
  • To manage his diabetes, he utilised syringes and insulin bottles that he had carried.
  • He went to ancestral residence. He needed shots because he ran out of insulin but not syringes.
  • After tripling his insulin dosage, he became uncontrollable and panicked – blaming tropical undeveloped nation for its poor products.
  • Later, Doctor determined that he had given himself two-fifths of recommended dose by mixing U40 insulin with U100 syringes. The correct U40 syringes were replaced normoglycemia.
  • The doctor was relieved that the reverse did not happen. Issue may have been prevented with local knowledge.

Effects of climatic conditions on DM

Warm climate

  • More prone to dehydration, which increases blood sugar level.
  • Hypoglycaemia prompts an osmotic diuresis that worsens dehydration and creating vicious cycle.
  • Those on SGLT2 inhibitors or diuretics are at great risk.
  • DM patients faces more heat related disease and lose metabolic control.
  • Dehydration increases risk of acute renal damage, gastrointestinal illnesses and respiratory illnesses.
Pearls To Know About Travel and Diabetes

Cold climate

  • HbA1C rises in cold climate.
  • Low temperature can harm CGMs, insulin pumps, glucose meters and test strips.
  • Being a protein, insulin denatures in cold.
  • Diabetic patients with diabetic neuropathy and peripheral vascular disease are more prone to cold injuries and hypothermia.
  • Climates that are both hot and cold raise risk of cardiac events.

Effects of High Altitude on DM

  • Low temperature, humidity and less oxygen are seen at high altitudes.
  • Errors might appear on test strips and glucose monitors.
  • Meters and pumps harmed by exposed to cold could not function again after being warmed up.
  • High altitude pulmonary/cerebral oedema, high altitude retinal haemorrhage and more severe mountain sickness.
  • Glucocorticoids and acetazolamide used in high altitude illnesses adversely affect blood glucose control.

Various mode of Travel

Travel on foot

  • TDM who travel on foot will need more preparation like healthy snacks to avoid hypoglycaemia.
  • Any cardiovascular problems that may raise risk of events will be found during pre- travel evaluation.
  • Warm up and cool down intervals should be built into TDM’s schedule.
  • Calluses, bunions, ulcers, sores, deformities, neuropathy, peripheral vascular disease and infection should not exist on feet.
  • Shoes should have insoles that evenly distribute body weight, prevent excessive pressure at bone that could cause injuries.
Pearls To Know About Travel and Diabetes

Real Life Case 2

  • A 48-year-old male with type 1 diabetes from 20 years has religions vow to fulfil. 
  • In summer, he sets out on foot to walk eight miles, without shoes to hilltop temple.
  • There are 1200 steps made of granite rock that you can climb in temperature as high as 60 degrees Celsius.
  • He began journey without receiving any pre travel guidance or insulin.
  • His blood sugar level was 700mg/dL.
  • He had heavy breathing, a fruity odour, painful haemorrhagic blisters on both feet.
  • He was treated in ICU while in DKA.

Driving by road

  • The right way to drive should be balanced with safety.
  • Driving requires good eyesight, hearing, cognition, coordination and response time in addition to driving skills.
  • 18% of traffic accidents involving medical conditions are caused by DM, driving if hypoglycaemia increases the risk.
  • When blood glucose levels are falling, the interval between interstitial glucose and blood glucose is fewer than 6 minutes, which is reliable sigh of coming hypoglycaemia.

Travel by Railroad

  • TDM who want travel by railway should be well prepared with extra supplies and coolers.
  • Most station along route don’t have pharmacies or other medical facilities.
  • Many trains offer meal while travelling but not special diet for therapeutic patients.
  • A popular railway in USA is called Amtrak.
  • It has sent out warning requesting TDM to alert train authorities and advising them to maintain supply of snacks on hand to deal with delays in meal service.

Travel by Sea

  • One can’t visit pharmacist when at sea, general preparation standards continue to apply to this mode of transportation.
  • Many cruise ships have variety of rich foods served on deck.
  • The food chosen should not upset diabetes control.
  • Lots of options for exercising on board these ships.
  • It is mandatory to wear suitable footwear during walks.
  • People with diabetes similar susceptible to normal illness that occur abroad and are more severe for them includes gastroenteritis, norovirus, influenza and other respiratory infections.

Air Travel

  • Air travel needs more thorough planning out of all modes of transportation.
  • Every stage of aviation travel must now undergo security inspections due to rise in terrorism threats.
  • Plane travel raises dangers of hypoglycaemia, DKA and dehydration.
  • TDM is affected by travel related stress, food changes, schedule changes, change in cabin pressure and time zone shifts.
  • TDM must have letter from their doctor, carry their prescriptions, testing equipment, accessories, glucose tablets/gel, carbohydrates snacks in double quantity.

Real Life Case 3

  • A 30-year-old male with type 1 diabetic travelled from Switzerland to New Delhi by air.
  • He took off his insulin pump, passed through security and then got on a plane.
  • After 2 hours, he realized that pump was missing because he had forgotten to get it from security tray.
  • He did not inform flight staff about his health condition.
  • Another traveller who had diabetic tried desperately to lower his blood sugar with long-acting insulin pens, but it did not work.
  • He urgently needed insulin with a short half-life. The long-acting insulin pen couldn’t fully use cartridges.
  • Another passenger, an engineering student, successfully altered a ballpoint pen spring to enable insulin pen to function.
  • He successfully injected rapid acting insulin, saving the patient.

Unique Environments

Wilderness Travel

  • Wilderness is an empty place where natural environment has not been altered.
  • Visitors to these locations not only enjoy natural beauty but also engage in risky sports like mountain biking, trekking and ultramarathons.
  • Type 1 and 2 diabetes affects some of these athletes.
  • High elevations, chilly climates and both can be found in wilderness.
  • TDM recommendations have been published by wilderness medical society.

Grey Nomads

  • A group of people known as grey nomads (GN) are retired individuals who travel the Australian caravans and seek out remote rural areas for life and health enriching experiences.
  • They spend days to months camping at one location before moving on to another and repeating the process.
  • They are well prepared for their travel requirements but inadequately so from their requirements for health.
  • Many of them do not carry their doctor’s health documents with them.
  • Effective use of telemedicine has been pioneered by recent COVID- 19 pandemic.
  • Future of GN’s diabetes management is hopeful as there is a growing tendency for them to utilise these tools.
  • First step in enhancing healthcare for this group will be
    •  Educating GN
    • Healthcare providers
    • Rural healthcare providers

Quick Take-Aways

  1. DM travel is safe today with right planning.
  2. Difficulties of travel and changing environment can be met through education, counselling and pre trip evaluation.
  3. TDM should bring double amount of all testing supplies and medications in their hand luggage.
  4. Damage to essential equipment can be avoided by taking precautions with drugs, glucose meters, test strips, CGMs and insulin pumps during security checks and harsh climates.

CME INDIA Tail-Piece

Pearls To Know About Travel and Diabetes

References:

  1. Zilbermint M. Diabetes and climate change. J Community Hosp Intern Med Perspect. 2020 Sep 3;10(5):409–12.
  2. Centers for Disease Control (CDC). Managing diabetes in the heat. Available from: https:// www.cdc.gov/diabetes/library/features/managediabetes-heat.html.
  3.  Education Programs and Classes. Available at: Joslin Diabetes Center Oct 27.
  4. Travel tips at sea (internet). 10 tips for cruising with type 1 diabetes. Available from: https:// www.diabetesadvocacy.com/10-tips-forcruising-with-type-1-diabetes/.
  5. Flying with an insulin pump and CGM (internet). Available from: https://www.diabetesadvocacy. com/traveling-with-an-insulin-pump-andcgm/.
  6. https://www.karger.com/Article/FullText/527144


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