Background: Travel has become an integral part of life, whether for business, pleasure, sport, or pilgrimage. The increasing number of patients with diabetes mellitus translates to a greater number of travelers with this condition. Primary care physicians have little knowledge to guide patients with diabetes planning travel. Summary: A structured pre-travel evaluation coupled with patient education diminishes health problems during travel. Proper preparation should include completion of all required immunizations, evaluation of diabetes, its co-morbidities, and their control prior to departure. This article discusses travel on foot, by road, railroad, sea route, and air travel; the supplies needed; and the unique features of each modality. This article discusses blood glucose monitoring, air travel security, precautions with continuous glucose monitors and insulin pumps during ascent and descent of aircraft, insulin dosage adjustments during travel beyond time zones, proper preservation of insulin in extreme temperatures, and adaptation to high altitude, hot and cold environments for patients with diabetes. Key Messages: There is a need for standardized guidelines based on expert opinions and best practices for travelers with diabetes, disposal of sharps, used test strips, and swabs in the absence of prospective studies.

Travel is an integral part of modern living, whether for business, pleasure, pilgrimage, or sport. With an increasing prevalence of diabetes mellitus (DM), many travelers will have the disease [1]. DM impeded participation in some vocations and sports in the past. Patients with DM have reached great heights in almost all walks of life today thanks to modern medicine: today, it is not a contraindication for travel [2‒4].

Primary care physicians have scant knowledge of caring for the needs of travelers with diabetes (TDM) [5]. The systematic approach to the problem involves a well-timed pre-travel evaluation, education, and counseling for prospective travelers. This approach will prepare this vulnerable group to handle difficult situations, prevent catastrophes, and substantially reduce the burden and stigma [6]. The following sections explain the pre-travel evaluation, travel by different modes and the effects on TDM, the role of modern diabetes technology, and the effective management of travel with diabetes.

Changes in diet, activity, sleep, climate, and stress pose many challenges to TDM even for those who are well-controlled in their homeland. Travel by itself increases stress and counter-regulatory hormones that can affect glucose control. It can lead to a cascade of events that may end in various complications. The changing diets affect the palatability and consumption of food. Extreme conditions can influence glucose metabolism, response to medications including insulin, hydration status, altered sleep and circadian rhythms, susceptibility to local diseases, access to proper healthcare, and language and communication issues. Poorly managed DM during travel substantially increases healthcare and administrative costs [7, 8].

The optimal management of DM, both type 1 and type 2, demands tight blood glucose control to prevent or delay complications. Technological advances like flash glucose monitors, CGM, insulin pens, smartpens, and insulin pumps are commonplace [9‒11].

Many TDM now use one or more of these gadgets. More time in range and less time below range translate to better glycemic control and fewer episodes of hypoglycemia. Greater flexibility in diet, lifestyle, warning systems for low glucose, including body vibration alerts in noisy environments, and a sense of control of DM are advantages of these modern devices. The extra care required, availability, cost, and the disadvantage of wearing a foreign object on the body are drawbacks [12].

This appointment with the primary care provider will bolster the doctor-patient relationship. The ideal time for this is at least 3 months before the travel date. Early immunization provides enough time for the body to mount an adequate immune response. However, this time frame may not be possible in emergencies, and the physician should proceed with the immunizations. Subsequent visits follow based on individual needs.

Knowledge of the regional differences in various medications and equipment is important in preventing dosage errors and their attendant complications. The diabetes education sessions should focus on reinforcing lifestyle changes in diet; the resources to identify proper food exchanges in the destinations; carbohydrate counting; glucose monitoring; exercise options in the destinations; safeguarding diabetes medications and test equipment; safe disposal of sharps, used test strips, and wipes; and early recognition of complications with particular reference to hypoglycemia, hyperglycemic emergencies, and measures to combat them in different situations. Printed flashcards are of immense value. Identifying resources in the destinations for diabetes supplies and healthcare will help once the patient lands and is in need [13‒15].

  • Comprehensive history

  • Physical examination

  • Relevant laboratory investigations

  • Immunizations mandatory for DM and the destinations

  • Measures for optimally controlling blood glucose, blood pressure, and lipids

  • Comprehensive eye and foot examinations

  • Staging of diabetic kidney disease and atherosclerotic cardiovascular disease

  • Identify contraindications for travel

  • Counseling lifestyle, other travel-related issues

  • Provide education relevant to travel

  • Issue physician letter and translated version (Table 1)

  • Translated prescriptions in the destination language to aid communication

Table 1.

Travel checklist and components of physician letter

 Travel checklist and components of physician letter
 Travel checklist and components of physician letter

Patients who travel must know that insulin vials are in U100 concentration in most nations but U40 in some. Corresponding syringes labeled U40 are also available in these places. The author once met a director of an insulin-producing pharmaceutical company and asked him about this disparity in insulin strengths. He answered it was a marketing strategy – the volume of a vial of insulin of either strength is 10 mL; U40 insulin would total 400 units in a vial and would be less expensive than a U100 strength would cost. Dosing errors and panic will occur using the incorrect insulin-syringe combination. However, insulin pens and cartridges are all uniformly U100. New formulations and higher strength insulin (U300, U500) are not uniformly available everywhere.

A 22-year-old male with type 1 diabetes, a North American citizen whose ancestors came from a South Asian country, visited his extended family in Asia. He had a diagnosis of type 1 diabetes made 8 years ago. He used an insulin pump and had a CGM to monitor his blood glucose. As soon as he landed at his destination, his pump failed him. He had no spare pump. The Asian office of the insulin pump company did not have a replacement at hand. He used insulin vials and syringes he brought with him to control diabetes.

He subsequently visited his ancestral village. There was only one small pharmacy in that village. He ran out of insulin but not syringes, purchased one vial from the pharmacy, and gave his shots. Uncontrolled after doubling his insulin dose, he was in panic and started blaming the tropical developing country for its substandard products.

A physician trained both in Asia and North America saw him the next day and found that he had used U40 insulin with a U100 syringe (giving himself two-fifths of the required dose). The appropriate U40 syringes restored normoglycemia. The physician said he was relieved that the reverse did not happen (U40 syringe with the U100 insulin). Knowledge of local conditions would have avoided this situation.

Effects of Climatic Conditions on DM

Warm Climate

A warm climate poses many disadvantages for TDM. They are more prone to dehydration, which raises blood glucose. The ensuing hyperglycemia causes an osmotic diuresis that worsens dehydration, increases blood glucose, and produces a vicious cycle. Those on diuretics or SGLT2 inhibitors are at greater risk.

The tropical climate prevents heat loss through the skin and an inability to reduce body core temperature in TDM compared with controls. In those with co-morbidities, reduced sweating and poor cutaneous blood flow hasten the process. For similar reasons, diabetes patients can quickly suffer heat-related illnesses and suffer a loss of metabolic control. Dehydration predisposes to acute kidney injury in TDM. Caffeine and alcohol consumption should be minimal [16, 17]. Prevention of respiratory and gastrointestinal infections should receive priority to prevent metabolic deterioration. The feet need protection with proper footwear – patients with DM must never walk barefoot [18].

Studies have shown increased hospitalizations for diabetes patients during hot weather and increased mortality for acute cardiac events. The goal is to prevent these incidents by planning, education, adequate hydration, frequent blood glucose monitoring, and therapeutic adjustments [19].

Exercise can cause and worsen dehydration in hot weather. The body should acclimatize to the tropical environment before physical activity. Avoiding midday and choosing early mornings or late evenings will lessen the chances of heat illnesses and metabolic decompensation.

Sunburn causes inflammation and increased insulin resistance. Light-colored, loose-fit absorbent clothing will increase comfort and dissipate body heat.

Medications, glucose meters, monitors, insulin, and insulin delivery devices should receive protection from direct sunlight and high ambient temperatures. The average atmospheric temperatures in warm climates far exceed 30°C, and gadgets to keep medications cool (between 18°C and 26°C) become necessary [20]. The commercially available FRIO wallet is a double pouch made of cotton-based insulation surrounding a pack of crystals that, when exposed to water, will gel and maintain the cool temperatures for up to 45 h. This device is reusable by wetting it with water every time and is a handy tool for TDM in warm climates. It comes in various sizes to suit different quantities of medicines [21]. Gilligan et al. [22] tested home-made acrylate polymer bead sewn in a cotton pouch. Ogle et al. [23] tested clay pots and goatskin-based cooling devices. All these were comparable to the commercially available FRIO wallet, and a great boon in countries with poor resources.

Absorption of insulin is faster in warm weather and reduces blood glucose faster; hypoglycemia is preventable by careful dosing and titration. CGM sensors need special skin grip patches that absorb the excess perspiration and prevent them from dislodging. They also need protection from direct heat and sunlight to function efficiently.

Cold Climate

Studies reveal HbA1C increases during cold weather [24]. The exact reasons for this increase are still unclear, although decreased physical activity, increased insulin resistance, and increased glucagon secretion are potential causes.

CGMs, insulin pumps, glucose meters, and test strips are all subject to damage from low temperatures and need protection. Insulin is a protein and denatures in the cold just like it does in hot weather, rendering it ineffective. Cold weather absorbs insulin poorly, secondary to cutaneous vasoconstriction and decreased blood flow. For similar reasons, finger-stick glucose readings underestimate capillary blood glucose results.

TDM and co-morbidities like neuropathy and peripheral vascular disease are increasingly susceptible to cold injuries and frostbite and need to protect their hands and feet at all times. Warm and cold climates alike increase the risk of cardiac events. Knowledge of these factors helps in management planning during travel to colder conditions.

Effects of High Altitude on DM

Higher altitudes have low temperatures. Apart from the hazards of exposure to cold, there are problems inherent to high altitude that TDM must combat. These are low oxygen, low humidity, and higher ultraviolet radiation. These factors also affect testing and therapy equipment. Glucose monitors and test strips may read errors [25]. Meters and pumps damaged by exposure to cold may not recover function on rewarming.

More severe acute mountain sickness, high-altitude pulmonary/cerebral edema, and high-altitude retinal hemorrhage may occur. It is not uncommon to misdiagnose hypoglycemia as acute mountain sickness. Glucocorticoids and acetazolamide used in high-altitude illnesses adversely affect blood glucose control, but the former is life-saving in acute edema [26].

The glucose response to exercise varies in type 1 diabetes compared to normal subjects. In the former, slow climb mountain trekking increases catecholamines, raises blood glucose, and results in higher insulin doses; the higher the altitude, the more insulin resistance. In people without diabetes, there is a similar rise in catecholamines, glucose, but there is a compensatory increase in insulin from the normal pancreas. If the ascent is rapid, the energy spent by exertion lowers insulin requirements [27, 28]. The unique problem of altitude-induced anorexia (perhaps due to increased leptin and mild cerebral edema) complicates diabetes management significantly.

Minor injuries to the skin, soft tissues, and infections of the gastrointestinal and genitourinary systems should receive intensive treatment as they may progress rapidly to more life-threatening conditions. It calls for meticulous hygiene, including frequent antiseptic handwashing.

Various Modes of Travel

Travel on Foot

TDM who travel on foot will need prior preparation [29]. Apart from all essential equipment, they will need all diabetes supplies in surplus. Beginning with blood glucose monitoring at the start of their journey, repeating it at frequent intervals, they should snack healthy during and between sessions to prevent hypoglycemia.

The pre-travel examination will detect any overt cardiovascular conditions that may increase the risk of events. Optimal blood pressure control is the treatment goal before travel. TDM should incorporate warm-up and cool-down periods into the itinerary. The feet should be free of calluses, bunions, ulcers, wounds, deformities, neuropathy, peripheral vascular disease, and infections. Shoes should have insoles that disperse the body weight and avoid undue pressure at bony prominences that may predispose to injuries and under soles that resist penetration from sharp objects [30]. Also, adjustable velcro-fitted straps that accommodate swelling will prevent injuries. A similar extra pair already broken-in will be a valuable reserve [31‒34].

The socks should be absorbent and elastic garters released. Frequent foot inspections and replacing socks will avoid skin maceration from perspiration and build-up of fungal infections [35]. It is best to travel as part of a group. If not, at least one attendant conversant with diabetes management should accompany. TDM should rest at frequent intervals. A remote tracking device and mobile apps for remote monitoring of blood glucose from the continuous glucose monitor can be a great backup.

A 48-year-old male from a tropical country with type 1 diabetes for 20 years has a religious vow to fulfill. He starts on foot to trek eight miles barefoot in summer to reach the place of worship on a hilltop. There are 1,200 steps built from granite rock to climb that can get up to 60°C.

Without pre-travel advice or insulin, he started the trip. He ate erratically at odd times. On his return, he appeared very ill with heavy breathing, fruity odor, and severely painful hemorrhagic blisters on both feet. He was in DKA with a blood glucose of 700 mg/dL and received treatment in the intensive care unit. His discharge was after several surgeries and weeks of hospitalization.

It is clear from the above vignette that religious obligations take priority and overtake health in many cultures. A non-judgmental attitude is vital when counseling such patients. The help of religious leaders and the family will aid negotiations in arriving at the best compromise and prevent such disasters.

Driving by Road

TDM who decide to drive their way have rules to follow [36] (Table 2). They should balance the right to drive with safety. Driving is a complicated art that, apart from the skills of driving, depends on adequate vision, hearing, cognition, coordination, and reaction-time. TDM may have impairments in one or more of these factors that increase the risk of accidents for themselves and others.

Table 2.

Guidelines for driving by road

 Guidelines for driving by road
 Guidelines for driving by road

DM contributes to eighteen percent of road accidents caused by medical conditions, and hypoglycemia while driving enhances the risk [37, 38]. Prevention of hypoglycemia include safe blood glucose levels throughout travel, in-vehicle real-time interstitial glucose monitoring from CGM transmitted via infrared, wireless, and Bluetooth technologies and displayed on the vehicle dashboard or tracked by satellite navigation systems with warning alarms in place. The time lag between interstitial glucose and blood glucose is less than 6 min during falling glucose levels and is a reliable indicator of impending hypoglycemia [39].

Travel by Railroad

The railroad is a frequent travel mode in many countries. TDM should prepare well with supplies in surplus and coolers.

On the Asian subcontinent, the longest railroad journey is 36 h. There are no pharmacies or healthcare providers at most stations on the way and certainly not for diabetes. Therefore, the traveler should be well armed. Many trains supply meals en route but are less advanced than air travel to cater to diabetes patients with specially prepared meals. Most trains have dedicated air-conditioned coaches that are expensive but useful for summer travel. It is helpful to inform the train manager beforehand.

Amtrak is a railroad in the USA used by many passengers. It has issued an advisory asking TDM to inform the train authorities and warns them to keep a stock of snacks to handle delays in serving meals [40].

Travel by Sea

Some TDM use the sea route. The general rules for preparation apply to this travel modality as one cannot stop by a pharmacy at sea.

In addition, some factors specific to sea travel are worth noting. Many cruise ships have a variety of rich foods served on deck. The foods chosen should not upset diabetes control [41, 42].

There are many opportunities available for exercising aboard these ships if not contraindicated. Otherwise, long walks on the deck will serve well. It is mandatory to wear suitable footwear during the walks and never barefoot.

Measures to prevent routine illnesses that occur aboard equally apply to TDM at sea and affect them with greater severity; they include sea sickness, gastroenteritis, norovirus, influenza, and other respiratory infections.

Air Travel

Among the various modes of travel, air travel needs the most detailed preparation because of its complexity. The increase in terrorist threats has mandated security checks at every stage of air travel.

In addition, air travel increases the risks of dehydration, DKA, and hypoglycemia. Stress of travel, dietary changes, delays in schedules, alterations in cabin pressure, and changing time zones affect TDM. Olateju et al. [43] investigated the effects of a simulated altitude on the functions of glucose meters and found them reliable.

Airline administrators have organized protocols for TDM. Most airline staff and security personnel are cognizant of health problems, although regional differences in the health literacy of airline staff exist. Hence, TDM must have a letter from their doctor and prescriptions and hand-carry medications, testing equipment, accessories, glucose tablets/gel, and carbohydrate snacks in double quantities to cater to delays and loss during travel (Table 1). It is where Murphy’s law comes into play. It states that anything that can go wrong will go wrong. The journalist Catherine Price, herself type 1 diabetic, applied this law to DM. She states, “All things necessary for a well-balanced diabetic life will function well as long as one is within driving distance of a well-equipped 24-h pharmacy but will fail the moment one steps outside those boundaries” [44].

There are precautions to be taken in subjecting various diagnostic and medication equipment to scanners to prevent damage [45, 46] (Table 3). Some testing and treatment equipment may interfere with radio communications and require switching off during the flight.

Table 3.

Security options for insulin pumps and CGM during air travel

 Security options for insulin pumps and CGM during air travel
 Security options for insulin pumps and CGM during air travel

Most airlines serve special meals for DM when ordered in advance. It is better to administer medications after the meal is on the table in flight to avoid hypoglycemia if there is a delay in serving meals. This mandates more frequent blood glucose monitoring.

All medicines and testing equipment should accompany the hand luggage because the cargo compartment is subject to extreme temperature changes and can damage them; insulin will denature and undergo freezing and thawing. TDM must not sit motionless for long periods but take frequent walks down the aisle; in addition, leg exercises and adequate hydration will reduce the risks of deep vein thrombosis.

TDM using insulin injections will need dosage adjustments if they travel over five time zones east or west or when they stay over 3 days at the destination. Among the many sources for calculating these doses, the article by Pinsker et al. [47] is practical and simple. It is based on sound clinical judgment, extremely reliable even when crossing the international date line, and needs dosage change in the long-acting (basal) insulin only. An online insulin dosage calculator is available [48]. Bevier et al. [49] in a pilot study found insulin degludec and glargine were comparable as basal insulin during travel across time zones. TDM on a fixed combination dose prior to travel (70/30, 50/50) should switch to a basal/bolus regimen well before the travel date.

For insulin pump users, they adjust the clock on the pump to the destination time upon landing. Special precautions when wearing insulin pumps are necessary to avoid dosing errors. The difference in cabin pressure from the atmospheric pressure at sea level causes dissolved air in liquids to convert to gaseous form (Henry’s Law) and expand (Boyle’s Law). It may push insulin in the pump tubing into the body without a command and cause overdosing during take-off. The reverse happens during landing and causes underdosing. There may be problems with insulin vials and pens for similar reasons [50].

A 30-year-old male type 1 diabetic traveled by air from Switzerland to New Delhi. He removed his insulin pump, went into security check, and then boarded the aircraft.

Nearly 2 h into the flight, he reached for his insulin pump to dial the pre-meal bolus. To his utter dismay, he found the pump was missing – he had forgotten to collect it back from the security tray after the inspection before boarding! He did not inform the flight staff about his health condition.

His co-passengers noticed he was drowsy but arousable. When the flight staff came to him, he disclosed the story of his missing pump. He had a glucose monitor that read 21 mmol/L (378 mg/dL), which quickly climbed to 30 mmol/L (540 mg/dL) (by that time, he had lapsed into a stupor), and some cartridges of fast-acting insulin, but no device to inject it.

A fellow passenger, also diabetic, had long-acting insulin pens but administering them in a desperate attempt did not reduce his blood glucose. He emergently needed rapid-acting insulin. The cartridges were not fully compatible with the long-acting insulin pen.

Another fellow passenger, an engineering student, ingeniously fitted a spring from a ballpoint pen and made the insulin pen work, injecting the rapid-acting insulin successfully, saving the patient, and preventing an emergency landing in trouble-stricken Afghanistan. It highlights the importance of meticulous preparations and a backup plan [51].

Wilderness Travel

Wilderness is an uninhabited area with its natural condition undisturbed. Travelers to such places not only appreciate nature but also take part in ultramarathons, mountain biking, mountain trekking, and other high-risk activities. Some of these athletes have type 1 or 2 diabetes.

The wilderness may include warm and cold climates and high altitudes. TDM pursuing wilderness have the hazards described in the preceding paragraphs and need similar preparation and planning. The wilderness medical society has issued guidelines for TDM [52] (Table 4).

Table 4.

Wilderness society guidelines for DM

 Wilderness society guidelines for DM
 Wilderness society guidelines for DM

As traditional medical help will be far away, great improvisation is the rule. Modern technology may have a role in management, even though evidence-based studies are not yet available.

Grey Nomads

Grey nomads (GN) are a group of people who have retired from routine life, drive around the Australian continent by road using fully equipped vehicles called caravans, and choose isolated rural locations for life- and health-enhancing experiences. The geography of the Australian continent enables them to practice this lifestyle. Camping for days to months on end at one spot, they move to another place, and the process goes on.

They have one or more chronic conditions, and studies reveal that one in twelve has type 1 or 2 diabetes. The GN prepare well for their travel needs but are ill-prepared for their health needs. Many do not undergo pre-travel evaluations or carry health records from their physicians. Their camping sites are far away from the nearest pharmacy or health center. Studies have shown that about one-fourth of GN had a health emergency during travel. The rural pharmacy was the first post they contacted for help, while the overburdened rural clinics could not accommodate them. Seeing different practitioners fragmented health care [53, 54].

The conversion of the health record to the electronic format in Australia has made access to the medical records of GN easier in distant remote locations. The recent COVID-19 pandemic has led the way in utilizing effective telemedicine [55].

There is an increasing tendency for GN to use these resources, and the future of their diabetes management is optimistic. Educating GN, their primary providers, and the rural providers who are likely to care for them will be a stepping stone in improving healthcare for this group.

Travel with DM is safe today with proper preparation. A pre-travel evaluation, education, and counseling will help meet the challenges of travel, changing environment, and prevent complications.

TDM should carry all supplies of medicines and testing equipment in double quantity in the hand luggage. A physician letter and prescriptions should be in hand to convince security personnel in airports.

Precautions with medications, glucose meters, test strips, CGM, and insulin pumps during security checks and extreme climates will prevent damage to vital equipment. Frequent blood glucose monitoring, judicious use of diabetes technologies, telemedicine, and necessary dose adjustments of insulin will circumvent disastrous situations. International guidelines dedicated to the care of TDM, disposal of sharps, and prospective studies will help develop standards of care [56].

No financial or other conflicts of interest.

No funds received.

Sole author is responsible for the idea generation, literature search, initial draft, analysis, and final version of this article.

1.
Mullin
R
,
Kruger
D
,
Young
CF
,
Shubrook
JH
.
Navigating travel with diabetes
.
Cleve Clin J Med
.
2018 Jul
;
85
(
7
):
537
42
.
2.
Gallen
IW
,
Redgrave
A
,
Redgrave
S
.
Olympic diabetes
.
Clin Med
.
2003 Jul–Aug
;
3
(
4
):
333
7
.
3.
Lin
IW
,
Chang
HH
,
Lee
YH
,
Wu
YC
,
Lu
CW
,
Huang
KC
.
Blood sugar control among type 2 diabetic patients who travel abroad: a cross sectional study
.
Medicine
.
2019 Mar
;
98
(
13
):
e14946
.
4.
Milewski
M
.
Peak performance
.
Diabetes Forecast
.
2006 Oct
;
59
(
10
):
60
3
.
5.
Alduraibi
RK
,
Almigbal
TH
,
Alrasheed
AA
,
Batais
MA
.
Knowledge, attitudes, and practices of primary health care physicians regarding the pre-travel counselling of patients with type 2 diabetes in Riyadh, Saudi Arabia
.
BMC Fam Pract
.
2020 Sep 24
;
21
(
1
):
200
.
6.
Izadi
M
,
Hosseini
M
,
Pazham
H
.
Travel guidance for people with diabetes; A narrative review
.
Int J Trav Med Glob Health
.
2015
;
3
(
4
):
143
7
.
7.
Li
Y
,
Lan
L
,
Wang
Y
,
Yang
C
,
Tang
W
,
Cui
G
,
.
Extremely cold and hot temperatures increase the risk of diabetes mortality in metropolitan areas of two Chinese cities
.
Environ Res
.
2014 Oct
;
134
:
91
7
.
8.
Zilbermint
M
.
Diabetes and climate change
.
J Community Hosp Intern Med Perspect
.
2020 Sep 3
;
10
(
5
):
409
12
.
9.
Li
A
,
Hussain
S
.
Diabetes technologies: what the general physician needs to know
.
Clin Med
.
2020 Sep
;
20
(
5
):
469
76
.
10.
Daly
A
,
Hovorka
R
.
Technology in the management of type 2 diabetes: present status and future prospects
.
Diabetes Obes Metab
.
2021 Aug
;
23
(
8
):
1722
32
.
11.
Yeoh
E
,
Choudhary
P
.
Technology to reduce hypoglycemia
.
J Diabetes Sci Technol
.
2015 Jul
;
9
(
4
):
911
6
.
12.
Simonson
GD
,
Martens
TW
,
Carlson
AL
,
Bergenstal
RM
.
Primary care and diabetes technologies and treatments
.
Diabetes Technol Therapeut
.
Apr 2022
:
S143
58
.
13.
Pinsker
JE
,
Schoenberg
BE
,
Garey
C
,
Runion
A
,
Larez
A
,
Kerr
D
.
Perspectives on long-distance air travel with type 1 diabetes
.
Diabetes Technol Ther
.
2017 Dec
;
19
(
12
):
744
8
.
14.
Education Programs and Classes. Available at: Joslin Diabetes Center Oct 27.
15.
Diabetes Advocacy (internet): how to master travel with diabetes
. Available from: http://www.diabetesadvocacy.com/diabetes-care/travel-with-diabetes/.
16.
Centers for Disease Control (CDC)
.
Managing diabetes in the heat
. Available from: https://www.cdc.gov/diabetes/library/features/manage-diabetes-heat.html.
17.
Cook
CB
,
Wellik
KE
,
Fowke
M
.
Geoenvironmental diabetology
.
J Diabetes Sci Technol
.
2011 Jul 1
;
5
(
4
):
834
42
.
18.
Jayasinghe
SA
,
Atukorala
I
,
Gunethilleke
B
,
Siriwardena
V
,
Herath
SC
,
De Abrew
K
.
Is walking barefoot a risk factor for diabetic foot disease in developing countries
.
Rural Remote Health
.
2007 Apr–Jun
;
7
(
2
):
692
.
19.
Algeffari
M
.
Diabetes and Hajj pilgrims: a narrative review of literature
.
J Pak Med Assoc
.
2019 Jun
;
69
(
6
):
879
84
.
20.
Heinemann
L
,
Braune
K
,
Carter
A
,
Zayani
A
,
Krämer
LA
.
Insulin storage: a critical reappraisal
.
J Diabetes Sci Technol
.
2021 Jan
;
15
(
1
):
147
59
.
21.
FRÍO (internet). Keeps insulin, and other medications, cool and safe
. Available from: https://www.frioinsulincoolingcase.com.
22.
Gilligan
MM
,
Linnes
JC
,
von Oettingen
JE
,
Altenor
K
.
From toy to tool: using water beads for insulin storage in Haiti
.
Pediatr Diabetes
.
2021 Aug
;
22
(
5
):
729
33
.
23.
Ogle
GD
,
Abdullah
M
,
Mason
D
,
Januszewski
AS
,
Besançon
S
.
Insulin storage in hot climates without refrigeration: temperature reduction efficacy of clay pots and other techniques
.
Diabet Med
.
2016 Nov
;
33
(
11
):
1544
53
.
24.
Meyers
L
.
Cold weather increases A1Cs
.
Diabetes Forecast
.
2005 Oct
;
58
(
10
):
28
.
25.
Adolfsson
P
,
Ornhagen
H
,
Eriksson
BM
,
Gautham
R
,
Jendle
J
.
In-vitro performance of the Enlite Sensor in various glucose concentrations during hypobaric and hyperbaric conditions
.
J Diabetes Sci Technol
.
2012 Nov 1
;
6
(
6
):
1375
82
.
26.
Brubaker
PL
.
Adventure travel and type 1 diabetes: the complicating effects of high altitude
.
Diabetes Care
.
2005 Oct
;
28
(
10
):
2563
72
.
27.
de Mol
P
,
de Vries
ST
,
de Koning
EJP
,
Gans
ROB
,
Bilo
HJG
,
Tack
CJ
.
Physical activity at altitude: challenges for people with diabetes: a review
.
Diabetes Care
.
2014 Aug
;
37
(
8
):
2404
13
.
28.
Malcolm
G
,
Rilstone
S
,
Sivasubramaniyam
S
,
Jairam
C
,
Chew
S
,
Oliver
N
,
.
Managing diabetes at high altitude: personal experience with support from a Multidisciplinary Physical Activity and Diabetes Clinic
.
BMJ Open Sport Exerc Med
.
2017 Aug 16
;
3
(
1
):
e000238
.
29.
Lemaster
JW
,
Reiber
GE
,
Smith
DG
,
Heagerty
PJ
,
Wallace
C
.
Daily weight-bearing activity does not increase the risk of diabetic foot ulcers
.
Med Sci Sports Exerc
.
2003 Jul
;
35
(
7
):
1093
9
.
30.
Foto
JG
,
Birke
JA
.
Evaluation of multidensity orthotic materials used in footwear for patients with diabetes
.
Foot Ankle Int
.
1998 Dec
;
19
(
12
):
836
41
. https://doi.org/10.1177/107110079801901208. Erratum in: Foot Ankle Int 1999 Feb;20(2):143.
31.
Chatzistergos
PE
,
Gatt
A
,
Formosa
C
,
Farrugia
K
,
Chockalingam
N
.
Optimised cushioning in diabetic footwear can significantly enhance their capacity to reduce plantar pressure
.
Gait Posture
.
2020 Jun
;
79
:
244
50
.
32.
Waaijman
R
,
Arts
MLJ
,
Haspels
R
,
Busch-Westbroek
TE
,
Nollet
F
,
Bus
SA
.
Pressure-reduction and preservation in custom-made footwear of patients with diabetes and a history of plantar ulceration
.
Diabet Med
.
2012 Dec
;
29
(
12
):
1542
9
.
33.
Wallberg-Henriksson
H
,
Rincon
J
,
Zierath
JR
.
Exercise in the management of non-insulin-dependent diabetes mellitus
.
Sports Med
.
1998 Jan
;
25
(
1
):
25
35
. https://doi.org/10.2165/00007256-199825010-00003. Erratum in: Sports Med 1998 Feb;25(2):130.
34.
Perry
JE
,
Ulbrecht
JS
,
Derr
JA
,
Cavanagh
PR
.
The use of running shoes to reduce plantar pressures in patients who have diabetes
.
J Bone Joint Surg Am
.
1995 Dec
;
77
(
12
):
1819
28
.
35.
Cook
K
.
Clinical implications of diabetes on the foot
.
J Athl Train
.
1997 Jan
;
32
(
1
):
55
8
.
36.
American Diabetes Association
.
Diabetes and driving
.
Diabetes Care
.
2012 Jan 1
;
35
(
Suppl 1
):
S81
6
.
37.
Cox
DJ
,
Gonder-Frederick
L
,
Clarke
W
.
Driving decrements in type I diabetes during moderate hypoglycemia
.
Diabetes
.
1993
;
422
:
239
43
.
38.
Graveling
AJ
,
Warren
RE
,
Frier
BM
.
Hypoglycaemia and driving in people with insulin-treated diabetes: adherence to recommendations for avoidance
.
Diabet Med
.
2004
;
21
(
9
):
1014
9
.
39.
Kerr
D
,
Olateju
T
.
Driving with diabetes in the future: in-vehicle medical monitoring
.
J Diabetes Sci Technol
.
2010 Mar 1
;
4
(
2
):
464
9
.
40.
Amtrak (internet). Personal food, beverages & medication; planning for contingencies. Available from: https://www.amtrak.com/personal-beverages-medication.
41.
Lumber
T
,
Strainic
PA
.
Have insulin, will travel. Planning ahead will make traveling with insulin smooth sailing
.
Diabetes Forecast
.
2005 Aug
;
58
(
8
):
50
4
.
42.
Travel tips at sea (internet). 10 tips for cruising with type 1 diabetes
. Available from: https://www.diabetesadvocacy.com/10-tips-for-cruising-with-type-1-diabetes/.
43.
Olateju
T
,
Begley
J
,
Flanagan
D
,
Kerr
D
.
Effects of simulated altitude on blood glucose meter performance: implications for in-flight blood glucose monitoring
.
J Diabetes Sci Technol
.
2012 Jul 1
;
6
(
4
):
867
74
.
44.
ASweetLife (internet). Murphy’s Law of Diabetes. Available from: https://asweetlife.org/murphys-law-of-diabetes/.
45.
Flying with an insulin pump and CGM (internet). Available from: https://www.diabetesadvocacy.com/traveling-with-an-insulin-pump-and-cgm/.
46.
Garg
SK
,
Liljenquist
D
,
Bode
B
,
Christiansen
MP
,
Bailey
TS
,
Brazg
RL
,
.
Evaluation of accuracy and safety of the next-generation up to 180-day long-term implantable eversense continuous glucose monitoring system: the PROMISE Study
.
Diabetes Technol Ther
.
2022 Feb
;
24
(
2
):
84
92
.
47.
Pinsker
JE
,
Becker
E
,
Mahnke
CB
,
Ching
M
,
Larson
NS
,
Roy
D
.
Extensive clinical experience: a simple guide to basal insulin adjustments for long-distance travel
.
J Diabetes Metab Disord
.
2013 Dec 20
;
12
(
1
):
59
.
48.
Sansum Diabetes Research Institute
.
Using the calculator
. Available from: https://diabetestravel.sansum.org.
49.
Bevier
WC
,
Castorino
KN
,
Axelrod
C
,
Haroush
G
,
Farfan
CC
,
Shelton
N
,
.
Traveling across time zones with type 1 diabetes: a pilot study comparing insulin degludec with insulin glargine U100
.
Diabetes Care
.
2022 Jan 1
;
45
(
1
):
67
73
.
50.
King
BR
,
Goss
PW
,
Paterson
MA
,
Crock
PA
,
Anderson
DG
.
Changes in altitude cause unintended insulin delivery from insulin pumps: mechanisms and implications
.
Diabetes Care
.
2011 Sep
;
34
(
9
):
1932
3
.
51.
This IIT engineering student used classroom skills to save a diabetic during a mid-flight emergency (scroll.in). Available from: https://scroll.in/article/878195/an-iit-student-explains-how-he-use.
52.
VanBaak
KD
,
Nally
LM
,
Finigan
RT
,
Jurkiewicz
CL
,
Burnier
AM
,
Conrad
BP
,
.
Wilderness Medical Society Clinical Practice Guidelines for Diabetes Management
.
Wilderness Environ Med
.
2019 Dec
;
30
(
4S
):
S121
40
.
53.
De Bellis
A
,
McCloud
CH
,
Giles
J
,
Apolloni
M
,
Abigail
W
,
Hill
P
,
.
Grey nomads with diabetes self-management on the road: a scoping review
.
Rural Remote Health
.
2021
;
21
(
3
):
6517
.
54.
De Bellis
A
,
Hill
P
,
McCloud
C
,
Abigail
W
,
Giles
J
,
Apolloni
M
.
Grey nomads with diabetes on the road. Abstract from Australasian Diabetes Congress 2021
.
Brisbane, Queensland, Australia
;
2021
. https://www.xcdsystem.com/adc/program/vPZbWzx/index.cfm.
55.
Argento
NB
.
A Pandemic Forces United States to Leap Forward
.
J Diabetes Sci Technol
.
2020 Jul
;
14
(
4
):
710
1
.
56.
Zhang
JY
,
Shang
T
,
Krisiunas
E
,
Heinemann
L
,
Liepmann
D
,
Klonoff
DC
.
The need for sharps waste disposal guidelines for commercial airports
.
J Diabetes Sci Technol
.
2021 Jul 30
;
16
(
6
):
1370
5
.