One of the most anxiety provoking activities is planning a vacation and actually enjoying it. Much advance thought is required to map out travel arrangements, destinations, and recreational activities. Considering the additional planning required for a child or teen with diabetes - travel arrangements, different food choices, and activities - these can cause blood sugar fluctuations.
The key to an enjoyable vacation is to "expect the unexpected" and prepare as best as possible for different contingencies. Packing duplicate items (and triplicate) that are required for diabetes self-care and treatment is obligatory. You must remember to carry everything that you may need on board (plane, train, automobile, and boat) so you won't be without equipment or medication in an emergency. A travel letter documenting supplies is good to have on your person (see sample), as well as the original labels on all medication. Carry your diabetes team phone numbers with you so that when in a Paris, France, pharmacie, the pharmacist (who hopefully speaks some English), can give you insulin after you left your insulin on the tour bus! Be prepared to be flexible and expect markedly variable blood sugars. Keep in mind that foods will be prepared differently and that carbohydrate counting will be a major challenge. Still want to go? OK, good!
- Actual travel: I have attached two travel letters that the Children's National diabetes team provides for all "travelers." In addition, I provided an algorithm to help manage insulin while traveling through different time zones. Keep in mind that your diabetes team may have specific unique instructions. I am providing ours in case you do not have any other references.
The following algorithms for adjustment of insulin dosage during travel are based on Management of Diabetes During Intercontinental Travel by Edward Bensen, MD, and Donna Hamilton, RN, CDE, with adaptations by the Diabetes Team at Children's National Medical Center and special assistance by Celia Henderson, RN, CDE, CPT.
Adjustment of Insulin Dosage
The management of diabetes is usually based on a 24-hour medication schedule. When traveling north or south, no adjustments in the 24-hour schedule are needed. However, east or west travel across time zones extends or abbreviates the day, depending on the direction of travel. When five or fewer time zones are crossed, no change is required in the usual insulin routine. When crossing six or more time zones, however, adjustment in the usual schedule is advisable.
Frequent blood glucose monitoring is essential for safety. In addition to the typical measurements before breakfast and dinner, travelers should check blood glucose levels whenever their daily routine is disrupted. When in doubt, measure. If the person feels even slightly ill, blood glucose should be measured.
Traveling East Across Six or More Time Zones
Two or Three Dose/Day Schedule
People who customarily take two or three insulin injections daily will give the usual morning and evening doses the day of departure. If your trip is any shorter than a 3-hour time change, there are no changes in your routine. Keep one watch set to the time of where you are departing from until the first full day at your destination, as it is easier to keep track of the hours. Administer the usual morning dose of NPH the first morning at the destination (Table 2). That evening, simply take the usual evening dose of insulin.
Insulin Adjustment When Traveling East Across Multiple Time Zones
NPH/Regular/rapid acting insulin
Day of Departure
First Morning at Destination
First evening at Destination
Two or three shots/day schedule
Usual morning dose, then give evening NPH dose 10-12 hours later. If evening meal is within 7-9 hours from AM NPH dose, do NOT give regular or rapid acting insulin for the meal
Usual morning N dose plus usual R/H if appropriate
Usual evening dose
*Note: On return journey, people traveling east use westbound schedule (Table 3)
Traveling West Across Six or More Time Zones
Two or Three Shots/Day Dose Schedule
Patients who normally take insulin on a twice-daily schedule should leave their wristwatches unadjusted during the flight. They should take their usual morning dose. Then, 12 hours later give usual regular or rapid insulin dose with a meal and then at bedtime (West Coast Time), give usual evening NPH dose. First full day on West Coast do usual doses, usual time. (Table 2)
Insulin Adjustment When Traveling West Across Multiple Time Zones
NPH/Regular/rapid acting insulin
Day of Departure
First full day at Destination
Two or Three shots/day schedule
Usual morning dose, 12 hours later give usual regular or rapid insulin dose with a meal. 4-6 hours later give another meal bolus with a meal at bedtime (West Coast time) and give usual evening NPH dose. If using rapid acting insulin do 3-4 hours.
If >9 hours do regular or rapid acting insulin every 4-6 hours after the initial 12 hours the NPH given. Continue with that regime until destination is reached where you resume your usual schedule.
TIME ZONE CHANGES for Basal/Bolus and insulin pump users
Long journeys often cross several time zones. A regular 24-hour day can be extended or shortened depending on the direction of travel. Either way, you'll have to adjust your insulin schedule accordingly. Blood glucose control can be upset by a change in time, altered activity, or disturbance of body rhythm and sleep patterns.
While traveling, keeping your blood glucose close to target levels can be a challenge.
Here are some guidelines:
- When traveling east, your travel day will be shorter. If you lose more than two hours, you may need to alter the time of insulin dose for long-acting insulin (Lantus)
- When traveling west, your travel day will be longer. If you gain more than two hours, you may need to take extra units of short-acting insulin and more food or alter the time of insulin dose for long-acting insulin (Lantus).
- You can change the time of your injections and meals by up to two hours in a day without adjusting your insulin dose or your meal plan.
- Follow your usual meal plan as closely as possible. If you are crossing more than two time zones, you will need to prepare an individualized meal and insulin schedule with your care team before you leave.
Guidelines for Lantus adjustment:
- Traveling East (Europe): Give Lantus 2-3 hours earlier than usual on day/evening leaving the United States (US East Coast time) and on your first day in Europe give Lantus 2-3 hours earlier than usual (Europe time). On the next day (first full day in Europe) give Lantus at your usual time (Europe time).
- Traveling West (Europe to the United States): Give Lantus 2-3 hours later (Europe time) than usual on day return from Europe (if you have difficulty with knowing what time it is in Europe, keep one watch on Europe time until first Lantus dose). On your first full day in United States give Lantus 2-3 hours later than day before (US time). On the next day give Lantus at your usual time (US time).
- When traveling to between the East and West Coast of the United States (and back) there is only a three-hour time difference, so just give Lantus at approximately the same time - it will be close to within the two-hour window for appropriate Lantus dosing.
Guidelines for Insulin Pump adjustment
- Change date and time on the pump to the end destination either at the beginning of a flight that crosses time zones or at the end.
- When flying through multiple time changes and several flights, make changes with each leg of the journey.
- Can use Temporary Basal increases of 10 percent to 20 percent as needed for high blood sugars associated with traveling.
For all Basal/Bolus regimens, continue to take carbohydrate ratios for all carbohydrate intake and use correction every 3-4 hours as needed. You may need to correct more when traveling; many people experience high blood sugars when traveling.
Remember to change the date/time on your meter as well as drink plenty of water while traveling! Keep snack foods and treatments for lows with you at all times!
- Activity: sitting in the car, bus, train, plane, or boat will most likely cause higher blood sugars due to inactivity. Be prepared to test more frequently and give extra insulin as necessary. Likewise, a visit to an amusement park may provoke a surprise low blood sugar even after eating those delicious treats. Lots of running around, in association with excitement and new activities may cause hypoglycemia. Bring rapid acting carbohydrate to treat unexpected lows and check blood sugars frequently even if everything seems okay. Remember, you can always treat lows with rapid acting carbohydrate; but may not get another chance to go on the rollercoaster at Walt Disney World or to the top of Mount Etna in Italy.
- Food: Unless you plan on cooking at your destination (and even if you do, the ingredients may be different), do the best you can to estimate portion sizes and carbohydrate counts. Check blood sugars frequently to do extra corrections as necessary to avoid surprise highs (or even ketones) later. Most importantly, enjoy! Once again, you don't know the next time that you can enjoy authentic Tuscan cooking or sit in a Parisian café, sipping espresso (or hot chocolate)! Just give more insulin if necessary.
- Bring all supplies in duplicate (or triplicate). I can't reiterate this enough.
- Have a great, safe, and enjoyable vacation!
Published On: April 14, 2009