Staying Well When Away From Home

Contents

• Introduction
• Blood glucose control
• Hyperglycaemia (high blood glucose)
• Hypoglycaemia (low blood glucose)
• Diarrhoea and gastroenteritis
• High altitude
• Pregnancy
• Foot care
• Miscellaneous points

Introduction

Before you go away, think about how you will manage your diabetes and plan ahead. It may be a good idea to make an appointment with your diabetes care team before you go so that you can discuss your travel plans and get any advice and support you may need.

Blood glucose control

People with diabetes usually aim for a blood glucose level of 4–7 mmol/L (before eating) or less than 9 mmol/L (after eating). However, your diabetes care team may have given you a different target range.

Hyperglycaemia (high blood glucose)

High blood glucose can be caused by the following things:

• Eating too much sugary or starchy food
• Not taking enough diabetic tablets or insulin
• Not exercising or using up as much energy as usual
• Stress or anxiety
• Illness or infection
• Poor injection technique or overusing one injection site
• Some types of medication
• High altitude
• Menstrual cycle – usually before or during a period

You can expect occasional one-off high results, especially if you are travelling and there is a change to your normal lifestyle. If you do have a high result, try to work out the reason for it so that you can prevent it from happening again. If your diabetes care team have explained how to adjust your insulin doses, you can try doing this to prevent another high blood glucose level the next time you are in the same situation.

Symptoms of hyperglycaemia

You may experience the following symptoms if your blood glucose is too high:

• Thirst and a dry mouth
• Passing urine frequently during the day and night
• Lethargy
• Irritability
• Blurred vision

More concerning symptoms are:

• Abdominal pain
• Nausea and vomiting

These symptoms may indicate either that you are in ketosis (when your body doesn’t have enough insulin to break down carbohydrates from food and so it begins to burn fat instead) or that you have gastroenteritis (see below).

If you are unwell whilst abroad follow the appropriate sick day guidance for type 1 or type 2 diabetes. You should have been given a copy of Sick Day Rules by your healthcare provider.

If you are travelling to a place where it will be difficult to get medical attention, it is important that you discuss hyperglycaemia management and the risk of ketosis with your diabetes care team before you go. They will be able to give you advice about making sure you stay well and how to adjust your insulin dose if necessary.

If you use insulin to manage your diabetes, you must never stop taking your insulin. See the sick day guidance for type 1 and type 2 diabetes. Be aware that you should not be taking Metformin or Dapagliflozin/ Empagliflozin if you are unwell and have Type 2 diabetes. There are also some blood pressure medications that you should not take if you are unwell.

Hypoglycaemia (low blood glucose)

Low blood glucose (below 4 mmol/L) can cause a hypoglycaemic episode, known as a ‘hypo’. This can be caused by the following things:

• Taking too much insulin or tablets
• Missing a meal or snack, not eating enough or eating too late
• Increased activity or exercising more than usual
• Drinking alcohol
• Stress or anxiety
• Hot weather (which causes insulin to be absorbed faster)
• High altitude
• Menstrual cycle – usually after a period
• Using the wrong injection site (injecting into muscle can cause the insulin to be absorbed faster – you should never inject into your arm)

Symptoms of hypoglycaemia

Different people experience different symptoms of hypoglycaemia but you will normally be able to recognise your own symptoms.

Mild symptoms

• Sweating
• Going pale
• Trembling
• Feeling light-headed or faint
• Finding it hard to concentrate
• Headache
• Hunger
• Tingling in lips and tongue

You may experience these symptoms when you are not actually having a hypo, so if possible you should check your blood glucose level. If you cannot check it, then take some glucose to be on the safe side. When you are travelling you should always carry some form of glucose with you, especially in remote areas where there may be no shops nearby. If you are carrying Dextrosol or any other glucose tablets in humid conditions, once the packet is opened the tablets will become hard and impossible to eat. After you open the packet, keep it in an airtight container or plastic bag. It may be easier to have some sweets, such as jelly babies or wine gums to use for hypo symptoms

If you do not treat the hypo when you experience mild symptoms, then your blood glucose may continue to drop and the symptoms may become more severe. It is important to treat the hypo as soon as possible. If you have a glucose sensor, consider setting the Low alarm to 5 mmol/l so that you have early warning on your blood sugar falling.

Moderate symptoms

• Mood changes, often irritability or aggression
• Visual disturbances
• Confusion
• Inappropriate behaviour (rudeness, laughter)

It is important that whoever you are travelling with understands how to deal with hypos, as by this stage you will be confused and will need help. They should treat the hypo immediately.

Severe symptoms

If you are having a severe hypo you will be very drowsy and will perhaps even lose consciousness, so it would be dangerous to give you something to drink. You may appear to be having a fit. For more information on this see Hypoglycaemia.

Diarrhoea and gastroenteritis

This is the most common problem encountered by travellers. It can be caused by contaminated food or water, over-indulgence in rich food or alcohol, or stress.

The risk of diarrhoea and gastroenteritis also depends on the local standards of hygiene and how safely food and drink is prepared in the country you are visiting.

If you do become ill it can cause problems with hyperglycaemia, which means you may have to adjust your insulin dose. Talk to your diabetes care team before you travel to find out more about this.

Prevention is always better than cure. Reduce the risk of becoming ill by following these tips:

• Wash your hands often, or use anti-bacterial gel if you have no access to soap and water.
• Avoid tap water, even when you are cleaning your teeth. Instead drink bottled water (check the seal is intact). Never have ice in your drinks as the ice may come from a contaminated source of water.
• In less developed countries, you can use water-purifying tablets or boil water if you have the facilities to do so.
• Avoid unpasteurised milk and dairy products, ice cream, raw or undercooked meat, poultry and seafood, salad and raw vegetables, ready-peeled fruit and food that has been kept warm for a long time.
• If you are travelling to a remote or less developed country, before you leave you should talk to your GP and ask for a supply of antibiotics. Avoid buying them locally as you don't know what you will be given and what the potential side-effects may be.

If you become ill despite taking these precautions, then follow these tips:

• Drink plenty of fluids as you can easily become dehydrated. It is better to drink little and often. Avoid drinking milk. If you have severe diarrhoea you will lose a lot of fluid. You should take an over-the-counter rehydration treatment, such as Dioralyte, which you should buy before you travel.
• Eat frequent small, bland snacks, such as bread, rice, plain biscuits or crackers.
• Check your blood glucose level before each meal, in case you develop hyperglycaemia. See the hyperglycaemia section above. If you have a glucose sensor, set the High alarm on it so that you are informed if your blood sugar is increasing.
• You should seek medical attention if you develop a fever and high temperature, if your stools contain blood or mucus, if you experience a sudden onset of very watery diarrhoea and cannot drink enough to compensate or if your diarrhoea lasts longer than a week.

Vomiting

Vomiting and diarrhoea may be caused by gastroenteritis, but vomiting alone may be caused by raised ketones as a result of hyperglycaemia (particularly if you have type 1 diabetes). If you have type 1 diabetes you should know how and when to check for ketones, how to deal with raised ketones and when to seek medical help. See Ketones and Diabetic Ketoacidosis for more information.

High altitude

If you are travelling to a high-altitude location, be aware that this could affect your blood glucose.

The symptoms of altitude sickness include:

• Breathlessness
• Dry cough (which may be blood-stained)
• Headache
• Loss of appetite
• Nausea and vomiting
• Tiredness

It is important to regularly check your blood glucose. Many travellers experience hyperglycaemia in high-altitude areas. 

• If you are inactive due to tiredness this may cause hyperglycaemia.
• If you lose your appetite you may decide to reduce your usual insulin dose to allow you to eat less.
• If you feel sick or are vomiting have a glucose drink, e.g. fizzy drinks (not sugar-free), fruit juice, milk or milk shakes.
• Drink plenty of water. In high altitudes the air is dry and you lose fluid when you breathe, which can cause dehydration if you are breathing more quickly. You should avoid alcohol and sedatives.
• Even if you feel ill you should not stop taking your insulin. You may even need to increase your dose if your blood glucose level is high.
• Check your blood glucose at least before each meal. If you have blood glucose of 17 mmol/L or more for two tests in a row, or if you are vomiting, check your urine or blood for ketones. If your ketone levels are rising, you may experience the usual hyperglycaemia symptoms, i.e. tiredness, thirst, frequently needing to urinate, blurred vision, nausea and vomiting, abdominal pain and breathlessness.
• Avoid exercise if you are feeling ill.
• If you have a blood ketone level of 0.6 – 3.0, then you need to calculate your total daily dose of insulin ( long plus short acting ) then divide by 10 and take this amount as a correction dose of short acting insulin. For example, total daily dose of insulin is 20 long acting + 10 units of short acting with each meal so total =50 units .50 units divided by 10 = 5 so take 5 units of short acting insulin every 2 hours till blood ketones are less than 0.6mmols.
• If you have a blood ketone level greater than 3 mmols, then you should calculate your total daily dose of insulin ( long plus short acting ) then divide by 5 and take this amount as a correction dose of short acting insulin every 2 hours till blood ketones are less than 3.0mmols, then take total daily dose divided by 10 till blood ketones are less than 0.6mmols. For example, total daily dose of insulin is 20 long acting and 10 units of short acting with each meals so total is 50 units. 50 units divided by 5 =10 so take 10 units of short acting insulin every 2 hours till blood ketones are less than 3.0mmols then take 5 units of short acting insulin every 2 hours till ketones are less than 0.6mmols.
• If blood ketones continue to rise after several hours of following these rules, then you must seek medical help urgently

Insulin pens and pumps

If you use an insulin pen, always make sure it is working properly. You should do an air shot of two to four units before you dial up your dose. If you find you need to do a few air shots before getting a squirt of insulin, check that when you dial up your dose you still get insulin coming out. This sometimes doesn't happen due to the air pressure.

Pumps – ensure that your pump is working properly and take extra supplies of infusion sets, sensors, insulin cartridges.

Pregnancy

If you become pregnant when you are away you should contact your diabetes care team immediately to let them know. They will be able to advise you on how to manage your diabetes when you are pregnant. In addition, you should note the following points:

• Start taking 5 mg of folic acid every day.
• It is extremely important to have perfect blood glucose control to protect your baby. Check your blood glucose at least before each meal, aiming for a level below 5.3 mmol/L before meals.
• You are more at risk of hypoglycaemia during early pregnancy.
• Make arrangements to get home. It is important to see your diabetes care team as soon as possible, as it is important to control your blood glucose in the early stages when the baby is developing.

Foot care

If you are going on a trekking holiday or if you are concerned about your feet, make an appointment to see a state-registered podiatrist before you leave. They will give you advice on how to prevent and treat any foot problems that may occur when you are travelling. Bear in mind the following points:

• Break new shoes in before you leave and never wear shoes that hurt your feet.
• Wash your feet every day in warm water, using a mild soap. Check them at least once a day for any blisters, breaks in the skin, pain or signs of infection such as swelling, heat or redness, just as you would at home.
• Don't walk barefoot, especially on a beach.
• If your feet become dry, apply moisturiser or hand cream.
• Take toenail clippers, blister plasters, sterile dry dressings, tape and antiseptic spray.
• If you get any wounds or injuries they may take longer to heal, especially if your blood glucose readings are running higher than normal.
• Never use sharp instruments or corn plasters on your feet.
• If you get a blister, never burst it. Keep your foot clean, dry and covered and try not to let the blister rub against your footwear.
• If you have a cut, clean it regularly with saline, or if this is not available, use salty boiled (but cooled) water. Apply a sterile dressing.
• If you have a cut or blister and you notice increased redness of the skin, pain or throbbing, or discharge, this may mean that you have an infection. You should seek medical attention. If you are unable to do so, start taking antibiotics if you have them. Keep the wound clean. Keep your blood glucose well controlled.

Further information on how to practise good foot care is available at Footcare Advice and Footwear Advice.

Miscellaneous points

• Take condoms with you when you travel. Don't trust foreign ones that don't have a kitemark or other quality mark on them.
• If you wear contact lenses take plenty of cleaning solution with you. You don't want to be at risk of getting an eye infection.
• If you are travelling to a less developed country, take your own sterile injection kit, which you can get from a pharmacy before you go. Carry it with you at all times. It can be used if you are admitted to hospital.
• Remember that all infections can cause hyperglycaemia.
• Know your Sick Day Rules