Travelling with Diabetes

This page is somewhere where I will update any information that I think may be helpful for diabetics considering overseas travel. There is no need to add to good general information already out there on other comprehensive sites like Diabetes Australia – so this will be more experience based observations about the reality of travelling with diabetes.

Planning: Getting your head right

The greatest challenge you will probably face is yourself. Sounds strange I know (and I don’t really know you at all) but fear is a powerful thing. A lot of the diabetic medical advice I received early on was quite limiting and overly cautious. This is to be expected of course. Medical information and support HAS to be conservative so that they cover themselves and people don’t run off and make themselves sick based on vague or risky advice. But you only have to read a “possible side effects” label on any generic pharmaceutical product and you know what I mean. If you worried about all the possible side effects you would be comatose with fear.

Likewise – the list of scary factors with diabetes is pretty long. On top of this everything revolves around consistency and regularity. Knowing what foods do what to your body in what circumstances. It is lovely to find a groove and have your regular regimes that keep sugars under control. On some days you almost forget you have diabetes. Travel obviously flies in the face of this and the whole POINT of travel is newness, unfamiliarity and discovery. Sounds great to most. Those three words are a diabetic nightmare. We want tested, familiar and known.

So before any planning is conducted you need to face into the reality that everything may / will change and that this is the new normal for a while. Obviously this is based upon where you travel to and how remote. Travel from Australia to the UK or USA is very simple. No language barriers and the hardest thing is reading new food labels. Travel to remote, far flung parts of the globe and you need to completely let go of control and normal.

I will go into details later on about getting your way around specific countries – but the first golden principle I have found is this: Have a completely open mind and be prepared to question and challenge your standard diabetic regimes.

My greatest fear leaving Australia was where I would get Weetabix from – because that was my standard breakfast and I knew what it did to my sugars. The fear was slightly unfounded as East Timor strangely has Weetabix. But stepping further into Asia Weetabix don’t exist and cereal just isn’t part of their diet. The solution was to completely question what breakfast was, when I ate it, what I ate and how long it would last me.

Travel through Thailand made me realise that I could go days without any any carbs what so ever and my sugars were brilliant. I would never have dreamed of trying that if I had listened to the standard diabetic advice about diet.

The second principle I have found is: Ease up on yourself and avoid the frustration and self blame

This self blame and anger is a strange phenomenon – but we all know it’s real. Strangely we all also know that it is completely and utterly pointless. Diabetes doesn’t listen, care or give a damn about your anger or frustration. So your sugars will go high for a day or two, you may (will) even have a week where everything is haywire, you will hypo more than you like. But nothing makes it worse than anger and self blame. Having said this I was still known to storm off into the St Petersburg rain swearing at diabetes, life, myself, my genetics and everything else that came close to me…..

The third principle is: See it as a problem to be solved.

I am sure most of you do already – but I record all my sugars in Diabetes Diary and check my graphs, numbers and food to find patterns. It also helps that my wife Mel also never seems to tire or bore of me throwing up suggestions, ideas or theories as to what is going on with my sugars.

The last principle I have found is this: Don’t live with diabetes – make diabetes live with you.

I can’t take credit for that line – it belongs to the famous T1 diabetic Olympic Gold Medallist rower Nigel Redgrave. But if you roll it around in your head and really take it on board then it starts to be liberating. This is why, I must admit, I find some diabetic medical support approaches a little off putting. Sometimes it feels like people are making diabetes too much of a life focus – something they “do”.  It’s a touchy area as you want to celebrate people overcoming odds to do amazing things – but diabetes is a set back not some eternal debilitating condition. It makes life complicated  but it shouldn’t stop you from doing most things. In my mind making too much of a fuss about having diabetes seems to allow one to opt out of risk. So the mindset we approached our travel with was not “I can’t do that I’m diabetic” – but “I’m diabetic – so HOW do I do that safely?”

Planning: Getting your gear right

There is a great list of essential travel items listed on the Diabetes Australia site linked above. The UK Diabetes (Diabetes UK…strangely enough…) is very thorough although this seems slightly excessive with regards to precautions to do with flying.

I am not going to go through what is on the other websites – as taking all your required insulin and other sugar testing paraphernalia is logical. Safest it to not rely on there being any easily accessible diabetic supplies at all in your destination.  Obviously the more remote you go the more serious that is. For our 18 months away I took EVERYTHING…..a needle and insulin carrying nightmare though not impossible. I made some amateur mistakes with my estimation. For some reason I over estimated insulin and WAY under estimated testing strips and needles (and that was re-using needles so I only needed 2 per day). Luckily I got a resupply from my parents that visited us one year into the journey.

Now having said “take your own gear” – the reality is that there are diabetics all over the world and therefore there are diabetic supplies all over the world. Before I left I discovered that most of the countries had some form of diabetic organisation who you could contact if you are concerned.

While the diabetic supplies may be present the hardest thing is knowing if you can actually 1: Get those supplies and 2: Afford it.

With testing supplies – I found that every country I went to had supplies available – albeit in small quantities and in some pretty old looking, dust covered boxes hiding behind the counter. So you can access it but the question is cost. As mentioned in my travel blogs I discovered that testing supplies and needles were freely available – at exorbitant cost. Needles in China were AUD $0.70 EACH……I don’t want to think what test strips cost. So for peace of mind you can bet supplies are there but for peace of wallet – take your own subsidised supplies from Australia or your home country.

With regards to insulin the UK diabetic site lists some (UK phone number) contacts for the big drug companies to see if they supply medication to the country you are going to. Then you need to find out if you can actually get the medication if you need it. This will need to be done country by country. However I would say two things: First – it would be pretty remarkable if a local hospital even in developing countries would not administer insulin to you after a doctors consultation. The medical attention we received for Zoe’s broken arm in a small remote Chinese city was simply world class. I also noted ample insulin supplies in the hospital pharmacy. Second – remember that the official country rules may be very different to what happens on the ground. My endocrinology professor said he would be very doubtful if I could obtain insulin overseas as even Australia doesn’t allow tourists to purchase it. In the streets of Vietnam I was able to walk into a pharmacy and purchase insulin over the counter (I didn’t need to but the pharmacist offered it to me).

As for food…well there begins the fun. Take enough muesli bars and sugary hypo treats to get you through the travel TO the country then start exploring. Every single country we crossed – no matter how remote – had ample supplies of the short acting dietary needs  – fruit juice, muesli bars, biscuits. With regards to low GI sustenance it can be both challenging but also highly surprising and – without fail – educational. You will learn more about diet in a few weeks overseas than months back at home in your usual routine.

The last thing to mention about preparation is the strong focus there seems to be on carrying letters from doctors explaining your condition and authorising you to carry drugs and medical supplies. I even had a letter written in Chinese from a doctor back in Australia just in case I needed it.

I am sure there is some reason that this has become a focus but all I will say is that in crossing the world by land from one side to the other, with a few plane hops thrown in, I was not questioned or asked for any information ONCE. That’s travelling with a years supply of insulin and needles through countries that are notorious for their strict or grumpy approach to customs. Even before we left on this journey I was doing  many international business trips (to places with jumpy flight security like the USA) and no one has even asked to look inside my insulin bags let alone grilled me for doctors letters, prescriptions and ID.

So while I would take a letter just in case (its a simple task that could save a major headache) I would not lose a seconds sleep about being questioned. Diabetes is a global problem.

Carrying Insulin: Where

Obviously you are going to get the required amounts of insulin for your trip – so the most critical thing is storage and carrying this safely. We planned for worst case scenarios. I even went to the extreme of imagining how I would respond if a natural disaster occurred in a remote or developing country. The worst case scenario rule of thumb I used was to ensure that at ALL TIMES I could be completely self sufficient for up to 3 weeks. The general rules I followed were as follows:

• Insulin always stored in my day pack (which was usually with me at all times) and never in my larger luggage.
• The years supply of insulin split between Mel and me in case one of our bags got lost or we got split up.
• I carry a small shoulder bag with glucose monitor, food and insulin just like home.
• Mel carried back up insulin pens (rapid and lantus) and blood glucose monitor in her handbag (kept on her at all times)
• In my day pack I had an emergency kit of food that I thought would get me through the 3 weeks worst case scenario. This was a bag of oats, muesli bars and sugary sweets. I thought that worst case scenario I could drop my insulin dosage and eat meagre amounts of oats every day when needed. Having said this I reduced the size of this emergency kit as we got through the more remote locations. An earthquake in Nepal or tsunami in Indonesia would mean weeks without supplies while a disaster in say- Berlin – would only means several days of disruption. In Tibet we were staying in an earthquake prone area and I even had my emergency kit packed and ready in case we had to get out double time. The last thing I wanted to think about as I dragged our three kids from a shaking crumbling building was “where’s my insulin??!!”
• I never allow my insulin to be checked in the hold of a plane as you are never sure of the temperature or air pressure in there. Safest to be in your bag in the cabin.

Carry Insulin: How

The question most medically minded people ask me is “What the hell did you do with your insulin?”

As I said I was carrying 18 months of insulin as well as 18 months of Thyroxin. Obviously keeping it cool was the prime concern as we were travelling through the tropics. However a little further afield as we hit winter in China and Russia I suddenly had to think about how to keep the insulin WARM. Where we stayed on the Tibetan plateau the toilets would freeze over at nighttime.

My system was this:

• Two separate squashable cool packs with freezer / cooling sachets (purchased in Australia and very hard to find throughout Asia). Mel had one I had the other. In hot weather this only stayed cool for between 4-8 hours depending on the environment we were in. After that it was starting to get a little warm. As soon as we hit our accommodation I would put it into a fridge and the freezer bags into the freezer. Our accommodation through the tropics was VERY budget – so there were no fridges in the rooms but every single hotel was happy to store it for me.
• My cautionary note…..the most stress I encountered was the two times that my insulin was frozen by the staff at the accommodation we were in. Frozen insulin loses its effectiveness – so it may not be completely destroyed but you also don’t know if it is working properly. The first time (remote Indonesia) I think it was actually a bad refrigerator so they did listen to my emphatic instructions but the “non frost free” fridge froze the top layers of stored insulin. Even in good fridges occasionally you see the odd tomato or lettuce frozen because it is in the wrong position in the fridge. The second time was a lapse of judgement on my behalf in Europe. I explained what had to happen to the young hostel staff member but against my gut instinct I failed to to double check where he had actually put the insulin. Sure enough when I went to get it was IN the freezer…..So my point is to CHECK and CHECK AGAIN. Walk with them to the fridge and check the fridge quality. Check to see that nothing else in the fridge is frozen (lettuce is not crispy and all fluids are fine) and the go back and check on it again a few hours later. Do this and you should be fine.
• There were times when we were away from a means of re-freezing our cooler bags for days. This was stressful – but you have to realise that not matter how remote you are people always have some form of keeping food cool. So in Thailand there were small carts selling cool drinks sitting on blocks of ice. At one point we were given blocks of ice free and we stuck this in the cooler bags.
• We also carried two evaporative cooling units called Frio Cooling Packs. These are GREAT. They work through evaporative cooling not ice so longer periods in hot weather is fine. (Though I did notice that in high humidity the evaporative process was less than optimal and you still need to take care.) Despite this though it was fantastic. You soak them full of water every few days and then you can relax knowing that the insulin is cool. At most of my spot checks I was amazed at how cool it felt inside. These are essential. The only catch is they were not quite big enough for our needs and we had to carry small amounts in them and still carry the ice cooled freezer bags – but for most situations they are probably more than sufficient.

So the real question is: Did it all work?

I am happy to say that in general it has and is still working. My insulin has survived freezing (though I threw the completely frozen vials out), days without proper cooling, outside temperatures that ranged from -20 to +35 degrees Celsius, and some pretty rough handling.

My observations though are that the Novo Rapide has travelled better than the Lantus. I had read about some variation in the robustness of insulins but the endocrinology professor had not heard anything about this. What I do know is that over the course of one year I have thrown out ONE vial of Novo Rapide that I though was not working and I have thrown out between 5 – 8 vials of Lantus that I felt were not working.

(For some diabetics who have never had insulin go “off” I will describe the steps briefly – as it can be a mysterious and highly annoying situation. With the bad Lantus I first notice that my mid morning BG test is unusually high though by lunch it may have come down. Any attempt to correct highs with Novo Rapide usually results in a plummet of my sugar levels. Correcting this hypo then results in another high. So a roller coaster of sugar levels begins. The confirmation that my Lantus is bad is when I have two or more strangely high morning BG readings. I generally wake up at between 4.5 mmol on a good day and 6.5 when I have “indulged” the night before. With a bad Lantus I wake up at between 7.0 and 9.0 mmol. Changing the vial results in an overnight correction back to normal. Spotting a bad Novo Rapide is a little simpler as my sugars are high and even with a correctional dose nothing seems to happen. Though as I said this is pretty rare for me. The Lantus has caused the most problems.)

Food

Once you have your insulin and diabetic supplies sorted your mind obviously wanders to the eternal question facing diabetics….”What will I eat?”

The question kept me up at night a little before we left Australia soil for the mysterious bustling beauty of South East Asia. The reality is though that the same rules that apply at home generally apply overseas. Even in countries where the menu was a complete mysteries and you sometimes can’t even identify the actual type of meat in a certain dish you can still get a general notion of the food groups.

The same rules about the GI of foods apply overseas. So in Asia the rice dishes posed great challenges as they would send my sugars through the roof (and they were soooo hard to resist!). The breads in Asia are in general sweet and highly processed so to be avoided at all costs. You need to be careful of the sugar levels in Thai curries which are usually very high. Another challenge was the variation in the actual food used in the cooking across Asia. One dish cooked by one street vendor was good for me then another cooking the same dish was terrible.

So – where does it leave you? Well it made me waver through periods of feeling like I was mastering it to periods where I felt like a complete failure and nothing would work. Referring back to my opening principles – there is not much to do but stay focused and solve the problem.

What I would encourage is to explore and question the “low carb” option for diabetics. I have referred to it in several blog posts but my early experimentation was fascinating and very liberating. By experimenting with how my body responded to days without carbs a great deal of fear and uncertainty about travelling with diabetes was reduced.

A great fear before we left Australia was “Where do I get good, low GI carb meals?” After experimenting I realised that by dropping my insulin and consuming no/low carb meals I was able to maintain fantastic sugar levels for many days – without a carb in sight. So the fear of “How do I get my carb meals?” evaporated and now I found myself looking for protein based meals and being less concerned with carb intake.

Obviously you need to be happy to adjust your insulin levels to suit and this can be either nerve racking or fascinating and liberating depending on your mindset.

At present without great control over what foods are available I have not set out to follow a strict low carb diet. That is something I am going to experiment with back at home where the environment is more controlled. However I would encourage an open mind to it as it can be a lifesaver for those travel days where all you see is mile after mile of meat based food dishes – and not a low GI carb meal in sight.

 I hope this helps a little with your planning and more information will be added as we continue our travels….

Update: Travelling in the UK

I was in a pharmacy today and had a great chat with a helpful pharmacist who took me through the options for getting diabetic supplies whilst travelling here.

The summary is as follows:

• Insulin and all diabetic supplies are readily available. The catch is the cost.
• Obtaining insulin would be a simple case of seeing a doctor, possibly showing them a letter outlining your insulin regime back at home and then obtaining a prescription.
• In the UK you may also need this for needles and test strips as well.
• Now comes the catch……the pharmacist was not sure of reciprocal arrangements with Australia concerning subsidies for the cost of diabetic supplies. You may need to look into this further. But to her knowledge you would have to pay full price (ouch!). The full price for basic supplies is as follows:
• Box of insulin vials: £20 (approx $AUD 40)
• Box of 100 insulin pen needles: £15
• Big box of testing lancets: £12
• Packet of 50 Freestyle testing strips…….£25!!

So obviously the point is pretty clear. Take it from home or maybe mortgage the house……

Update: France, Spain, Portugal

I have had no troubles at all travelling through mainland Europe. Ice for the insulin is freely available in France, Spain and Portugal at:

• Petrol stations (most of them)
• Alcohol shops
• Major supermarkets (Carrefour is the largest and best – but most of them are great. Beware that Lidl was very unreliable for stock of ice. They had a spot for the ice but in many stores this was empty)

The large supermarkets were the most reliable. The range of diabetic friendly food is also identical to anything you would find in Australia or any other western country.

There is also a great range of sugar free snacks that I discovered in Spain (I will find the brand name and put it in – but sugar free in Spanish is “Sin Sucre”) which are great for morning & afternoon teas and fantastic for post hypo as you can have a nice measured, tasty, small 5g-per-biscuit dose of carbs without any other sugars in it. All major breakfast cereals are available as well.

I found the tapas in Spain was brilliant for a carb free light dinner which didn’t mess with my BSL and of course the glass of red wine is obligatory……

I have not asked in a chemist for insulin or diabetic supplies but I noticed them in the chemists. There seems to be a million chemists in every Spanish town and they don’t follow “siesta hours” and seem to be open all day. Even very small Spanish towns had chemists and I am sure they would be able to help you find supplies if needed.

Apart from that just don’t forget the siesta hours and shops are shut generally from 2pm – 5pm. Supermarkets are open all hours though except be careful of Saturday (close at 12:00pm) and Sunday when they are closed.

Major cites in France may be different but in general don’t count on getting food or supplies on Sundays in most towns.

A small note is that away from France the frequency of fluent English speakers seems to decrease dramatically so ensure you get a SIM card or internet access so you can use Google Translate. Charades to explain diabetes, insulin and blood glucose levels generally makes you look like a mad tourist who wants and needs recreational drugs….

Update: Travelling in Morocco

Travelling in Morocco has been a little more complicated than mainland Europe for one reason only: ice for the esky (or cooler box for the non-Australians) to keep the insulin cold. We discovered that ice is not very common at all. In some tourist centres they have bags of ice but it required walking around town for hours asking every store we could.

The major supermarkets (Carrefour, Marjane and Acima)  in the Northern cities generally have ice stocked in the frozen food sections. This was reliable. However for some strange reason in the Southern Cities like Azrou, Midelt and Erfoud the same supermarkets had nothing. In one supermarket I was able to get a bag of ice from the fresh fish section.

What they seem to do is freeze water bottles and sell these – but again it is almost impossible to identify which shops do this. You need to ask again and again and again – and even then this sometimes ended up with a fruitless search. The best method has been to carry small bottles of water which I give to the hotel or campsite and they put these in the freezer for me overnight. This gets me through 24 – 36 hours.I am also back to placing the insulin in the fridge of the campsite for the length of our stay.

There are medical centres at most towns and I have not been into these but they would most certainly have emergency supplies of insulin.

The food here is incredible. The tagines can be had with no carbs at all – but the bread they serve seems to be stable enough for sugar levels. There is brown bread available in many stores but generally it is white (but not overly processed like the Asian breads.)

The large supermarkets have a great selection of diabetic friendly foods (cereals, oats etc) so meals are relatively normal. The range of fresh fruit is great, through vegetables must be got from the markets.

Like all developing countries the normal care must be taken with avoiding stomach upsets. I have carried something unpleasant for the last 5 days and it is NOT fun. This is the first one on the trip so not sure how it got through the normal awareness of and hand washing, fruit washing and drinking bottled water. Just be careful that TAP WATER is often served at cafes and  restaurants. We even had one campsite owner proudly tell us that we can drink the tap water like the locals do. Unless you have lived in Morocco for 6 months I would advise strongly against this one.

Obviously travellers diarrhoea brings a whole range of complications and personal management to keep fluids up and sugars stable as digestion is compromised. Having said that though my sugars have been OK despite the unpleasant stomach upset.

INSULIN: I popped into a pharmacy and asked about getting insulin. The pharmacist simply asked what type I needed and then said that he had it in stock (I asked about Lantus). The price was 160 Dirham – so at the time of writing about AUD $23. This was at a small pharmacy, in a small town on the coast near Agadir. So I would be confident that larger ones in the main cities would stock the same. Good to know as a back up if something happens to your supplies.