Ain’t No Mountain High Enough: Managing Diabetes in High Altitudes (Part I)

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Zachary McCune_Jackson Hole

Zack McCune snowboarding in Jackson Hole, Wyoming

Most people think of the beach when they think vacation. But there are many people, especially in the winter, that flock to the mountains for skiing, hiking or just to take in the views. For people managing diabetes, mountains present a unique set of challenges. In part one of this two part series, we take a look at the most important things to be aware of when traveling to a mountaintop destination.

Traveling to Remote Places

If you’re skiing, camping, or mountain climbing, you have to factor in all the supplies you’ll need to pack. “The key is to figure out what to carry,” says Jacqueline Shahar, M.Ed., RCEP, CDE, a Certified Diabetes Educator and Manager of Exercise Physiology at Joslin Diabetes Center. “There’s a big difference between someone who is skiing for the day and someone who is hiking in the cold for a few days.”

She recommends healthy, easy to eat carbohydrates like granola bars, fast acting glucose, meter and test strips, a glucagon kit in case of emergency, as well as spare insulin and needles. Even if you use a continuous glucose monitor (CGM) or an insulin pump, if the technology fails in the extreme weather you want to have reliable backups. And if you’re hiking at high altitudes, always carry urine strips to check for ketones or a blood glucose meter that specifically check for ketones. Ketones can spike if the patient is suffering from nausea and vomiting secondary to Acute Mountain Sickness (AMS) (more on that in part two) and dehydration. It’s also vital to tell the people you are with that you have diabetes so they can help you if you become ill.

Zack McCune, an avid skiier and Joslin patient with type 1 diabetes, has experienced firsthand the sheer amount of stuff you have to pack if you’re planning to hit the slopes. He says one of the most important things to remember is even if you’re going to a resort, bring extra supplies with you. “Don’t expect there to be a pharmacy close by,” he says, explaining a time his luggage got lost and he had to have a prescription wired in to the next town over.

Facing the Cold

The most obvious problem you’ll face on the mountains is the cold temperatures. Patients are often told how important it is to keep insulin cold, but in below freezing weather there’s also the risk that insulin can freeze solid (optimal temperature is between 36⁰-46⁰F). Not only could this shatter glass vials, but if insulin freezes and then thaws it will separate and clump, rendering it unusable.

Zack points out that this isn’t just a problem while you’re on the slopes. “If you go out to eat or you do any sort of errands you have to take it in with you because you can’t risk it freezing in the car,” he says.

Jackie recommends keeping all of your supplies in one place, preferably close to your body to prevent freezing.  Both Jackie and Zack suggest wearing coats that have large interior pockets close to your body. “I have one dedicated diabetes pocket with my glucose meter, insulin, and little pouch of fast acting sugar gel,” says Zack. “The gels are awesome because they don’t seem to freeze or get damaged and they work within five or ten minutes.”

There’s also the problem of checking your blood sugar while you are on the mountain. Taking your glove off in -20⁰F can be dangerous for extended periods of time, and you might not get a good stick. Zack adheres to a routine cycle of checking that his sugar is stable before going on the mountain, after an hour or two he has a snack or some sugar, and after three hours he goes back to the lodge no matter what to have some water, check his blood sugar and balance before returning to the slopes.  Jackie adds that CGM is an excellent tool to track blood glucose throughout exercise and makes it easier when trying to maintain good glucose control at extreme temperatures.

The cold can also exacerbate diabetic neuropathy in the hands and feet which impairs your performance and increases the risk of frostbite. “That’s concerning, if your feet are freezing and you don’t know,” says Jackie.  “So checking your feet and hands daily, wearing proper footwear, socks, and mittens as well as wearing layered clothing would be essential to prevent injuries due to cold.”

You also need to be vigilant for signs of low blood sugar. “In the cold and at high altitudes there is less oxygen and a greater need for glucose as energy,” says Jackie. “You really need to maintain energy throughout the activity as your skeletal muscles increase their glucose uptake. There’s a real risk of going low when you’re exerting yourself.”

When you’re low you risk a decrease in dexterity, making it much harder to ski, snowboard, or maneuver tricky hiking trails—which can be dangerous. Zack experienced a low while he was going down an advanced slope in Wyoming. “I realized I was reacting about a second slower than usual,” says Zack. “Just before I was able to stop and correct I lost my edge and fell hard. Going low is a serious risk.”

Jackie also advises to watch for a blood glucose drop a few hours after you’ve stopped your activity as the muscles work to replenish themselves and glucose uptake by the muscles is at increased rate. “You could be driving home when that happens or experiencing low blood glucose over night after an active day,” says Jackie. “It’s very important to cut down mealtime (bolus) insulin by 20-50% and reduce long acting insulin by 10-20% for activities that last several days. For those on a pump, reducing basal rate based on trial and error would also be recommended”

If you have diabetes, you need to take precautions while out on the slopes—but it’s nothing to be intimidated by. You just need to spend a little time planning and make sure to listen to your body. “I feel like if I’m checking a lot and balancing a lot then I’m in control,” says Zack. “And there’s nothing that I haven’t been able to do.”

For more information about balancing diabetes with wintertime activities or to make an appointment with one of Joslin’s exercise physiologists, click here.

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