Indians are increasingly travelling for vacations, pilgrimages, and sport or just meeting relatives. Given the challenges in maintaining normal glucose during travel, Dr Manoj Chawla addresses concerns of people with Diabetes and gives expert tips to stay in control while on the move. On the move and in controlAs a person with Diabetes, you need to be on your toes all the time, constantly maintaining the balance between meals, medicines and exercise. Habit and routine are your best allies. When your daily routine is disrupted, it becomes even more challenging to manage your blood glucose levels especially when you have to travel.How do you make sure you are eating the right kind of food? How much insulin should you carry? How do you keep up with your exercise?Well, nothing is too difficult if you are prepared to stay in charge.Stumbling blocksA number of factors may fluctuate blood glucose control while travelling. They are:Different level of physical exertionInsulin adjustments across time zonesDelayed meal timingsInsulin storage issuesNon diabetic-friendly foodsMotion sickness and dehydrationDiabetic feet related problemsLack of medical assistancePre-travel checkBefore any long trip, visit your health professional for a check-up well in advance and schedule any vaccine shots if required. Get all your necessary prescriptions and a letter that authorises you to travel with your Diabetes medication and supplies. If you are travelling by air with medication, you should obtain travel letter in order to transit through customs/airport. Travel letter will be helpful to seek medical help during emergency while travelling. This letter can also help during journey keeping medical supplies like insulin/syringes, medicines etc. with you and to find out whether the medicines are available in the foreign country.Wear a medical ID bracelet that indicates you have Diabetes or carry notification in an obvious place, just in case someone needs to find out whether or not you have a medical condition.Pack at least one set of medicines and supplies in your hand luggage. Make sure to have this with you at all times.Pack some snacks and fast acting carbohydrates to deal with possible episodes of low blood glucose (hypoglycaemia).Check your blood glucose levels frequently during the trip.When travelling by plane or long haul bus, alert a member of staff that you have Diabetes so that they are prepared in case you need medical assistance5 tips for a stress free journeyPlan your travel in such a way that you will be able to keep regular meal times and get enough rest. Avoid journeys starting or ending at late night hours, even if that means spending a little extra. Keep medications, meal and snack time as regular as possible.Keep your co-passengers and hosts informed of your Diabetes, so they may try to accommodate your dietary requirements. If possible, wear a Diabetes bracelet. It is a simple way to let everyone around you know when you need attention.Always carry a glucose meter with you, and check your blood glucose more frequently while on the move.Carry double the amount of medicine you think you are going to need, to be prepared for any changes in your itinerary.Ensure that you prevent sunburns, cuts, bruises or insect bites from occurring.Travelling with medicationMedications need to be carried in bulk quantities. People on insulin treatment should extra insulin packed in insulated bags or cool bags to keep the insulin cool. Extra syringes, needles, lancets must be packed to last for the entire trip. Oral medications need to be packed with prescription in a clear and easily accessible zipper-re closable plastic bag.The best practice while travelling by air, train, road or even backpacking, is to carry your vials/pens in an insulated container in your hand luggage. There is a simple way to make an insulated travel kit using an airtight container and sealed ice packages/ice gel packs - both easily available in the market. Alternatively, there are some pharmacies that pre-package your insulin in such travel kits, on request. A proper travel kit for insulin is important..Remember to carry extra supplies of the following:For glucose level testing glucose test strips and lancets, glucose meter, batteries or charger for glucose meter and alcohol swabsGlucagonAnti-nausea drugsAntibiotic ointment, bandage, sterile gauze and micropore tapeSupplies to treat hypoglycaemia - preferably glucose tablets, stored in both check-in and carry-on luggageWhen travelling by air, always carry your medicines in your hand baggage - though you do have to be cautious about liquid medicines since most airlines have a limitation of 100 ml per bottle. Keeping your medicines in your carry-on ensures that they do not get lost and protects them from the uncontrolled temperature and pressure in the cargo. If you take multiple medicines then systematic and labelled storage is essential to avoid taking an incorrect medicine.For a road journey, insulin should not be stored in the car's glove compartment or left in a locked car with closed windows. Oral anti-Diabetes medication should be packed in zip lock bags and stored away from sunlight. A proper travel kit for medicines allows systematic storage and facilitates easy labelling. Along with detailed dosage directions of all your medicines, make sure you keep your doctor's name and contact information with you at all times. This often proves to be vital in an emergency.It makes sense to do a little homework to ascertain if it is possible to source the required medicines in your travel destination and if your prescription is accepted (for overseas travel). In case it is not, carry extra stocks accordingly.However, as a general thumb rule - always travel with at least a week or ten days of extra medicines, just in case your trip is extended.If you are using insulin vials, it might be a smart move to buy and store your disposable syringes in bulk. This could help you get a better price and lacks risk, as they do not have an expiry date. At home, ideally you must place your used syringes and needles in a sharp disposal container, which is usually available at any pharmacy. While travelling, you should carry a hard plastic container jar with an airtight lid to store your used syringes. You can then safely dispose of them later. If space is a concern then re-sealable or self- adhesive packets can work too, just be careful of the sharp needles.Why original packaging?The safest way to store medicines is in its original packaging as it is airtight. It acts as an additional safety measure for storage and protects its quality. When managing multiple medicines, one tends to sort out ones weekly medicines by removing them from their original packaging and placing them into pillboxes. The use of pillboxes is highly recommended as it helps you adhere to your medicines. However, the pillbox will still solve its purpose of adherence if each pill is still in its original packaging. These basic tips for storing your Diabetes medicines at home and during travel should be sufficient to help you stay organised and make sure your medicines remain effective. However, some additional quality checks, like the ones mentioned below, are always advisable.When you start taking a new medicine, read the medicine label or speak to your pharmacist about any special storage instructions.Verify the appearance of your medication before ingesting it. It is important to not take medication whose colour, texture or even odour has changed.Shake the vial of insulin before using it. Avoid injecting it if the liquid remains cloudy even after shaking it or if there are visible deposits or flakes in the vial or cartridge.Eating rightPeoples with Diabetes need to be aware of how different foods can affect their Diabetes control. Peoples should actively monitor how their blood glucose is affected by new foods and have foods which are generally low in carbs. Checking of blood glucose more frequently will help them to adjust insulin doses according to the readings.While you cannot always control the food that you are served while travelling, you can try and control the portion sizes. Specifically control carbohydrate portion..Pack food in case of delayed meal. Always carry some readymade non-perishable food stuff like cookies or candies with you in case you are low in blood glucose.Carry food to snack like snack bars, diabetic cookies, khakra, lighted sauté rice puff, curd low fat, or only dry fruits (roasted ones) and fruits like apple and pear with you.Take a quick bite in-between meals, to avoid over-eatingAsk the restaurant staff about the ingredients used in particular dishes and make sensible judgment whether to avoid it, or consume in small portion.If you are in a buffet setting, try having controlled calculated portion and move away from food.Always choose healthy options. Dig for fresh salads, veggies and fruits - they are rich in fibre, and give you a sense of fulfilment without piling up the calories and raising much of blood sugar.If you are travelling by car or bus, you can carry your own meals in coolersFor your beverages, you can choose low-calorie drinks such as unsweetened tea, coconut water or diet drinks, buttermilk over thick milk shakes. Avoid alcohol. Drink plenty of water to stay hydrated.If you are travelling internationally, ask if your airlines has a diabetic meal option available.Creative exercisesYour travel plan might not allow you time for your regular exercise routine. The best way is to be flexible, innovative and try to squeeze in as much physical activity in your day as you can!.If it is difficult to get your 30-minute walk during a busy conference schedule, break it into three 10-minute routines any time during the day.You can also do some simple stretches and a little yoga inside your room. Your physiotherapist or Diabetes educator might suggest simple exercises that you can do almost anywhere.Don't over-work. Give your laptop or mobile some rest and use the time between meetings, between flights or before bedtime for some mild physical activity, even if it is just strolling around a bit.Try some creative ways to keep moving around more - window shopping at the airport terminal, exploring the surroundings of your hotel, offering to help with the grocery shopping (while visiting relatives), taking the stairs whenever you can, walking around for sight-seeing. These little things will make your trip more refreshing, and keep you active while on the move!Summer travelInsulin will spoil quicker in very hot temperature. Insulin should be stored in a flask with ice or in a proper container if the outside temperature is > 30° C. When travelling to places where a refrigerator is not available, put the vial in a plastic bag, tie a rubber band and keep it in a wide-mouthed bottle or earthen pitcher filled with water. Other storage options such as thermal-insulated bags or canisters are also useful.Insulin will be absorbed more quickly from the injection site in hot weather too and this increases the risk of hypoglycaemia. People will need to monitor their levels more often and be ready to adjust diet or insulin dose. When hiking/camping in hot weather, keep the insulin and oral medication in the coolest place of backpack.Winter travelIn cold weather, insulin is absorbed more slowly at first, but can then be absorbed suddenly when you warm up later in the day. This can cause a people to have hypoglycaemia. So, it can be useful to wear more clothes in colder climates which will help to keep you warm and avoid complication.Insulin can spoil quicker in extreme cold climate. Frozen insulin will not work and must be discarded. In cold weather keep the insulin in coats, trousers or coat pocket to keep it warm. Keeping it close to the body will prevent insulin from spoiling. Use a medical grade insulin cooler to prevent insulin from freezing while camping..Changing time zonesIf the person with Diabetes who is on oral anti-diabetic medication, there is unlikely to be any particular problem. Very occasionally, it may be necessary to take extra tablets to cover a longer day. In fact, in some cases it may be preferable to skip a dose and risk slight hyperglycaemia for a few hours rather than take medication too close in time and risk hypoglycaemia.As time zones change, day length changes and consequently the 24-hour regimen many peoples follow may change. When travelling east with a time change greater than 3 hours, the day will be consequently shortened. As a rule, traveling east results in a shortened day, requiring a potential reduction in insulin, because insulin doses will be administered closer than normal and thus could cause hypoglycaemia. While traveling west results in a longer day, possibly requiring an increase in insulin dose. However, this may not be applicable to everyone. It is best to consult your doctor prior to your trip. In general, peoples should leave their wristwatches unadjusted during flight so that they continue to correspond to the time at their point of departure. This will make it easier for peoples to judge the timing of their insulin injections and meals.High altitude activitiesPeoples should proceed for high-elevation activities with utmost caution. With many glucose meters, every 1,000 feet of elevation results in a 1 to 2 per cent underestimation of blood glucose, which could result in an inaccurate reading. If high-altitude activities are planned, people with Diabetes should bring multiple meters to crosscheck glucose readings to avoid inaccuracies (due to elevation) in blood glucose readings..It is important that people with Diabetes undergo a heart check-up to rule out a silent heart disease. Silent heart attacks have either no/minimal or unrecognised symptoms. Uncontrolled Diabetes is associated with inflammation of the inner lining of the arteries leading to damage and blockage of the artery resulting in heart attack. People with Diabetes may have such an attack without any symptoms. When missed, the condition may lead to a major attack - which in turn could turn fatal. Prior to planning for any high-risk adventure activity, people with Diabetes must undergo a cardiac testing with an ECG. This may be followed by, if advised, a stress test (also called exercise ECG) to detect whether exercise can bring out ECG changes that prove underlying heart disease.Day tripsYoungsters with Type 1 Diabetes on school picnics and excursions could be prone to diabetic ketoacidosis as there is a chance of missing an insulin dosage. Children with Type 1 Diabetes require lifelong insulin injections and if insulin is not taken a dangerous and fatal condition, called ketoacidosis can result. Diabetic ketoacidosis results in coma and may even lead to death..It is important for parents of children with Type 1 Diabetes to setup timely reminders for the child to take insulin as per schedule. It is also important to carry a diabetic friendly meal to avoid low blood glucose levels.Love your feetIf you are travelling in a mountainous area, the cold and frosty conditions might reduce blood supply to the feet. People with Diabetes are prone to frostbite which is dangerous and can even lead to amputations. It is important to wear correct footwear.Barefoot walking anywhere can be problematic in people with Diabetes. Asmall injury may allow an infection to creep in, and cause a foot problem. Sometimes people on a pilgrimage walk barefoot while taking a long circumambulations or pradakshina around the altar that surrounds the shrine. These paths lined with stones are hot during the day and cause burns. People who have nerve damage lack the protective sensation to perceive that the hot stone lined path is burning their feet.In fact, people with Diabetes must not walk long distances if they have Diabetes related nerve damage - this can damage their feet leading to foot ulcer. The importance of a podiatrist's (a foot care specialist) advice prior to choosing appropriate footwear is very important.People with Diabetes should also avoid waiting in queues for long hours as this can damage the feet People with Diabetes tend to put pressure on one part of the foot for long hours, and this can hasten the development of a diabetic wound called a neuropathic ulcer.People with Diabetes are at the greater risks of developing foot problems. It becomes very important to do daily diabetic foot checks. Peoples must continue daily inspections of their feet while traveling. If blistering, erythema, or skin breakdown occurs, immediate action should be taken to avoid further trauma.Prevent Deep Vein ThrombosisPhysical activity during long duration air travel is very important in elderly people with Diabetes who are prone to excess clotting - leading to blockage of their blood vessels of the feet - is called deep vein thrombosis.This is especially common in elderly women and women taking oral contraceptives. This is not just true for air travel, but also for long distance rail or road travel in a constant sitting position. Deep vein thrombosis can be a life threatening condition because sometimes the clot may dislodge from the vein to reach the lung causing breathing problems..One of the key reasons for development of deep vein thrombosis during air travel is the pooling of blood in the lower limb veins. Many airline websites describe methods to prevent deep vein thrombosis during long flights. Some of the important steps to prevent deep vein thrombosis are:Take a brisk walk before the flight - this keeps your blood circulation going well for some time.Walk in the aircraft, to the extent possible. This improves blood circulation.Wear elastic flight socks or even compression stockings this will prevent foot swelling. This is useful especially if you have varicose veins. However, it is important to consult a Diabetes foot specialist prior to this.Keep your lower limb away from the edge of the seat as pressure may compress veins.Do some in-flight exercises like for instance rotating your ankles a few times in each direction.If you are on aspirin, please do not forget to take it. Aspirin is a blood-thinning agent and keeps your legs clot-free. Some doctors even advise aspirin for preventing episodes of deep vein thrombosis.Drink plenty of water this keeps your blood dilute and running in the blood vessels and prevents clotting.In case of emergencyPeoples should have an emergency contact number, healthcare professional contact information along with proper prescription of medications and instructions of what should to be done in case of emergency. They should have medical id bracelet stating I HAVE DIABETES. Carrying a hypoglycaemia handout will help flight attendant what to do in case of a sudden hypoglycaemia episodes..Keeping simple and fast acting carbohydrate in handbags like glucose gel/tablets, fruit juices, glucose biscuit, sugar candy etc. Learn to say, "I have Diabetes" and "Sugar or orange juice, please" in the language of the country, you plan to visit.In case of emergencies, efficient labelling helps others easily administer the correct medicine to you.Dr. Manoj Chawla is Director and Consultant Diabetologist at Lina Diabetes Care & Mumbai Diabetes Research Centre. He is also Consulting Diabetologist at P D Hinduja Hospital, SL Raheja Fortis, and BSES Municipal General Hospital in Mumbai.