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TRAVELS OF PEOPLE WITH DIABETES: TEMPERATURE
Heat Hot sun and exercise may increase the rate of absorption of your insulin. Very hot weather may lead to dehydration and may increase the effects of urine loss associated with raised blood glucose. It is important to drink plenty of fluids. Beware sunburn.
Cold Intense cold may mean that your insulin is absorbed slowly to start with and then is rapidly absorbed later when you warm up by the fire or in a warm bath. If you are out in cold, wet or windy conditions for any length of time, make sure that you are well protected against both wind and wet. The advice I gave in Chapters 9 and 10 on clothing and equipment for energetic expeditions is useful for all trips of this type.People with diabetes who become chilled and hypoglycemic are at special risk of severe hypothermia; and from that you can die, as has been made so clear from recent publicity about the aged, who are also at risk. Studies made in Nottingham, England, showed that if people are put in a very cold room their temperature begins to fall and they start to shiver as they try to keep warm. If they are then made hypoglycemic they stop shivering and their body temperature plummets to dangerously low levels. As soon as their blood glucose is returned to normal, they start shivering again and the fall in body temperature is halted.
Always bear the following points in mind:•   Think ahead. Take out travel insurance. Always carry your diabetes travel pack on your person. Always take twice the number of meals you think you are going to need on a journey.•   Make sure that you are at no risk of hypoglycemia when driving or travelling in a car. Tell the driver and vehicle licensing authorities and your insurance company that you are diabetic.•   Do not run the risk of hypoglycemia in a strange town or country.•   Take motion sickness pills if you suspect you may need them and carry anti-emetics and anti-diarrheal pills.•   Plan any air trips carefully. Never allow your insulin to get frozen in the baggage compartment.•   Adjust your insulin to the way of life of the country you are visiting. Feel free to explore foreign food. If you get ill, start checking your glucose level frequently and adjust your treatment accordingly.•   Beware extremes of heat and cold.•   Learn from your experiences.•   Have a good trip!
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Carbohydrate mainly comes from plant foods, such as cereal grains, fruits, vegetables and legumes (peas and beans). Milk products also contain carbohydrate. Some foods contain a large amount of carbohydrate (e.g. cereals, potatoes, legumes) while other foods are very dilute sources e.g. carrots, broccoli, salad vegetables. The dilute sources can be eaten freely, but they won’t provide anywhere near enough carbohydrate for our high-carbohydrate diet. A salad is not a meal and must be completed by a carbohydrate-dense food such as bread. The following list includes foods that are high in carbohydrate and provide very little fat. Eat lots of them, sparing the butter, margarine and oil during their preparation. Cereal grains including rice, wheat, oats, barley, rye and anything made from them (bread, pasta, breakfast cereal, flour). Fruits such as apples, oranges, bananas, grapes, peaches, melons etc.

Vegetables such as potatoes, yams, sweet corn, taro and sweet potato are all high in carbohydrate. Legumes, peas and beans including baked beans, lentils, kidney beans, chick peas etc.

Milk contains carbohydrate, in the form of milk sugar or lactose. Lactose is the first carbohydrate we encounter as infants. Use low-fat or skim milk and yoghurt to minimise fat intake.

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Why do children with diabetes have to have meals at regular hours?

Meal times are kept to regular hours in order that there is a regular boost of glucose in the blood to balance the action of insulin. If a meal is late the glucose in the blood may be falling at that time so that the child may develop an insulin hypo. A meal taken early may mean that extra glucose is entering the blood while there is still a substantial amount from the previous meal there, and this would lead to excessive glucose in the blood. Perhaps an early meal at one time leads to too long a gap to the next meal with the possibility of a hypo-reaction at that time. At all events keeping a child in good diabetic control is a matter of careful balance between meals and insulin and activities. We can only make a success of this by keeping these things as constant as possible, but it is not necessary to be too rigid.

We would like to set out on a long car trip at 5.00 a.m. What should we do about insulin and breakfast? Should our daughter have insulin and breakfast before we leave?

She could, but it would be better if she had one or more carbohydrate exchanges when she gets up before leaving to prevent a hypo and then you stopped for a family breakfast en route at the usual breakfast time. She could have her insulin then and there would be no upset in usual routine.

Occasionally when we are out, it is difficult to be home in time for the evening meal. What should we do?

You can always cope with delayed meals. The immediate concern is whether delay in a meal will lead to hypoglycemia, so give your child one or two exchanges at the usual meal time to avoid this. Now you don’t need to worry if the insulin and the meal is a bit late, and you can have this when you get home.

Whether you reduce the meal by the exchanges you gave earlier depends on the blood test and on appetite. Only reduce the meal exchange if the test is high.

Of course you may plan ahead and take a syringe and insulin with you (kept cool in the car) just in case you decide to eat out.

It is sometimes possible to defer the evening insulin injection to supper time. In this case the amount of long-acting insulin may be slightly reduced in case its action overlaps the morning insulin the next day. You would vary the amount of short acting insulin according to the blood test that you did before supper.

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Treatment

An insulin reaction is due to lowering of the amount of glucose in the blood, preventing the brain from functioning properly. The brain can only function normally if there is sufficient glucose to use as a source of energy.

The object in treatment therefore is to give the child sugar in some form.

1.     In the early stages, while the child can co-operate, give 3 glucose tablets, or 2 or 3 pieces of barley sugar, or 2-3 teaspoons of ordinary sugar in a drink or 5 or 6 jelly beans. Most hypos are mild and will quickly respond to these measures. All children with diabetes should keep sugar at school and in their school bags. It may be merely necessary for the teacher to allow the child to take sugar in this way if he feels the need.

2.     In the middle stages, when the child cannot co-operate, but is conscious and able to swallow, it may be necessary to make him lie down and put a paste of sugar or jam or honey inside his cheek.

If the child does not respond in a few minutes further help will be required. If his mother is available she may be able to treat him, but otherwise a doctor may be needed, or the child may have to be sent to hospital.

3.      In the late stages, when the child is unconscious, it is urgently necessary to get medical help, either from a doctor or by sending the child to hospital. Never give fluids to an unconscious child.

After treatment: if the hypo has been mild and the child responds rapidly to sugar, he should be allowed to remain at school. Although the immediate treatment of reactions is most important, it is unwise to place too much emphasis on them. To do so makes the child even more self-conscious.

If the hypo reaction has been severe and the child remains unwell, he should be allowed to rest and be kept warm. Ë child should never be sent home alone after a severe hypo in case he has a further one on the way home.

Please report the time and the type of hypo to the mother, so that the insulin dosage can be adjusted if necessary.

A vomiting illness

If the child vomits it is best to give sugar in a form he can tolerate (e.g. flat lemonade or sweets) and notify the parents. If they are unavailable the child’s clinic or doctor can give further advice.

The child should not be left on his own in case he loses consciousness or becomes confused.

Self esteem and self confidence

A child’s self confidence may have been shaken by finding he has diabetes. He may feel damaged or different, and will be aware of his parent’s distress. School may play a major part in restoring self esteem as the child is shown to succeed in learning, maintaining friendships and participating in sport and school activities.

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