Hiking with Diabetes

(A Personal Guide to Managing Type-1 Diabetes in the Backcountry)

You may be inclined to ask...

"This site is about trekking through rainforests... so why the page on Diabetes?"

My answer comes in two parts:

  • I have Type-1 Diabetes (childhood-onset, insulin dependent), and folks often seem surprised that I take ambitious solo treks with my ailment.
  • It's my site, so I'll post whatever the heck I want up here.

But people inevitably ask "Isn't it dangerous?? My friend's little nephew Jimmy has diabetes, and he can barely play outside without having an insulin reaction. Couldn't you die at any moment out there?"

I occasionally get random messages from fellow diabetics... folks genuinely interested in hiking & backpacking, but who don't know how deal with the diet restrictions, insulin doses, and all-encompassing opinions of doctors and well-meaning family members reinforcing the idea that you really shouldn't be doing this with your condition.

Well, baloney. I'll admit, it does complicate things, but there's nothing about this disease that can't be overcome with adequate planning and some willpower. If you're a Type-1 diabetic, your doctor has probably settled you into a routine of insulin, diet and exercise that serves you well at home. Unfortunately, I've found few Diabetes doctors have much experience (personally or clinically) with the extreme physical demands of extended backcountry expeditions. A backpacker in the midst of a strenuous multi-week trek burns calories on par with a professional athlete, and that level of metabolism is beyond what most diabetics contend with. For that reason, I've compiled a list of advice and suggestions for the diabetic hiker who aims to travel far beyond the pavement, but isn't quite sure how to do it healthily. Much of this advice comes through hard-won personal experience, combined with tidbits from other diabetics and various medical professionals.

[Disclaimer: I've done a lot of hiking with diabetes, but I'm not your doctor. Anyone who intends to do this stuff, please consult your physician before changing your diet or insulin. Your results may not mirror mine. Take my advice, talk it over with a doctor, and practice with shorter trips before using it on any large trek. It took years of trial & error for me to get this right.]

Since this page is written with fellow diabetics in mind, I assume that you have a working knowledge of diet and insulin routines for Type 1 Diabetics. If this all sounds new to you, you'd do well to read more about it from the American Diabetes Association®. The link to the right is a good place to get started.
Type 1 Diabetes

So now, I'll address a few of the most common questions I hear about managing Type 1 Diabetes on a backcountry trek. The topics naturally break down into two catagories: Insulin & Supplies, and Diet, Exercise & Blood Sugars. Much of the advice applies directly to Type 1 (insulin dependent) diabetics, but the sections on Diet & Blood Sugar can apply wholeheartedly to any diabetic, so peruse at your will.

Insulin & Supplies

How do you keep your insulin refrigerated?
Although insulin keeps longer in a refrigerator, it's not necessary to always store it there. Basically you've gotta treat it like you would milk. Insulin will last a month at room temperature (according to manufacturer's specs), but spoils much quicker in heat. During mid-summer trips, I keep mine stowed in the middle of the pack (or next to a cold water container), where it's cooler & the heat won't affect it. For longer treks of several weeks or more, I always acquire a new bottle before the trek to help ensure "freshness," but as long as you don't let it get too warm, it lasts quite well inside a pack. Take care in hot weather... if overheated, you can actually "cook off" a bottle of insulin. If your previously-clear insulin suddenly looks cloudy, you've ruined it, so keep it out of direct heat & sunlight when possible. Look for the "cool" places in your backpack, and store it there.

Doing that, I've kept a single bottle in my pack for over a month in mid-summer, and I've yet to ruin a bottle of insulin to heat.

How do you keep insulin from freezing?
If it's truly going to be cold out (well below freezing), during the day I keep my insulin on me in a jacket or coat pocket. That way it stays warm and won't freeze throughout the day. During the night I keep it in the foot of my sleeping bag (along with my camera, which also doesn't handle cold very well). I've done a lot of cold-weather treks, and have yet to have a problem with my insulin freezing using that system.

I dispose of used syringes in a Sharps Disposal container at home. What do you do with your used syringes in the backcountry?
If you don't have one already, get an Insulin Syringe Clipper. You can cleanly clip the needle off any used syringe, turning a potential biohazard into a fairly harmless piece of plastic waste. They're small, lightweight, secure, and will store at least a year's worth of syringe needles before needing to be replaced.

Most pharmacies won't carry them, but some local Medical Supply shops will, and you can also find them several places online, including several places online for about $3-6 apiece. No prescription required.

To save weight, do you reuse syringes?
No. I tried that once... for a 16-day unsupported leg of a journey, I figured if I reused each syringe once, I could get by with only 32 syringes instead of the otherwise-necessary 64 (taking 4 shots per day). Lots of syringes get bulky, so why carry all the extras? In the end, I found that even after one injection, the syringes became extremely uncomfortable, and often painfully "caught" on my skin while trying to inject for the second shot. Once returning home, I did a bit of reading and found out why.

Any competent doctor will tell you that insulin syringes are not designed for reuse. Even if you have a way to sterilize them between injections (which you probably don't), today's insulin syringes are designed for comfort, and are built extremely thin, very sharp, and often lubricated. A single injection can cause noticeable damage to the tip of the syringe... not a big deal for one injection, but every injection after is like trying to cut yourself with a dull knife. You're not only prone to infection from a dirty needle, but also much more likely to cause bleeding, pain, and possibly a broken or splitered needle under your skin. Please, carry one syringe per injection (count 'em all out ahead of time to make sure you have enough), and destroy each syringe after use. For more info about syringe reuse, read this article at DiabetesDigest.com.

Diet, Exercise & Blood Sugars

As always, the goal of the diabetic is to keep your blood-sugar at that elusive medium between hypoglycemia (too low) and hyperglycemia (too high). Unfortunatley, both can ruin a backpacking trip, and this is often the single biggest battle for the diabetic hiker. Particularly, most diabetics find on strenuous days (burning several times more calories than you might at home), they constantly battle attacks of low blood sugar that interrupt their hike and take considerable snacks and breaks to manage. This may work for a day-hike or a simple weekend, but it becomes ungainly and impractical for a strenuous week (or month) of hiking.

To address this, I've worked out a system that takes a two-pronged approach to managing blood sugars on a strenuous backcountry journey. Your individual results will undoubtedly vary, but the basic concepts should hold true. Again, I urge you to consult your doctor before making drastic changes to your insulin routine, and test these out yourself on treks of gradually increasing difficulty & length if you intend to undertake a large backcountry journey of your own. To sum up, do not try this the first time alone on a long backcountry trek. Trial & Error have been my teachers for years, and I can't stress enough how important it will be to find your own "sweet spot" when it comes to diet & insulin in the backcountry. This is a personal account of how I've overcome the challenges of Hiking With Diabetes, and I post it for your general information & advice, but I am neither a physician nor a dietician. Just an avid diabetic hiker who's done this for years.

Managing Carbohydrates
Battling low blood sugar reactions (hypoglycemia) is one of the largest challenges to any diabetic hiker. I've heard more than once from diabetics who can't keep their sugar levels up, and are constantly bringing snacks along just to keep going. Personally, I know I've been on strenuous trips where even a half-dozen Snickers bars (and other "high-energy" snacks throughout the day) couldn't save me from constant low blood sugar reactions.
(Image courtesy of HealthLine.com)
Granted, on any large trek, you'll need to eat more carbohydrates than you normally do at home. It isn't unusual for me to double my carb intake on a strenuous trek. The issue isn't so much the amount of carbs, but rather the types of carbs I'm eating. My biggest advice (above all the others) is to eat more whole grains. Or food with fiber. Most off-the-shelf "energy snacks" rely almost entirely on sugar or corn syrup for quick pick-me-ups. That starts a nasty "boom & bust" cycle, in which you'll frequently crash, only to need more energy. Not only do whole grains digest more slowly (giving you a more stable energy level through the day), but soluble fiber actually slows the rate of absorption into your cells... do a Google Search for "fiber blood sugar" and you'll see more documentation than you'll ever care to read. I've moved away from snacks like candy bars, cheap chocolate-chip-injected granola bars, energy gels, and sports drinks. Instead, I take more dried fruits, whole-grain snacks and homemade foods than I used to. You'll still need a lot of calories, but you'll go a long ways to avoid those constant blood-sugar crashes. I don't completely cut sugar from my diet (I still eat a Snicker's bar out there from time to time), but I try not to make it the main staple anymore. Start reading the labels of everything you buy... it'll open your eyes to how much "crap sugar" is dumped into a typical snack line-up.

Proteins & Fats
Eat more protein. This is especially applicable for longer treks. Your body needs it to maintain & build muscles, and it also gives you something to digest besides pure carbs, which (like the fiber) helps level your blood sugar. Peanut butter and cheese sticks (which last surprisingly long in a pack) are staples in my lunchtime diets. You'll also find that whole-grain pastas (not the bleached white stuff) contain a fair bit of protein... kill two birds with one stone that way. I also regularly add dehydrated chicken, bacon bits, nuts and/or olive oil to my dinners (many of them prepared & packaged at home, needing only to be rehydrated in camp) to help boost the proteins & fats in my diet. Not only does it help fend off low blood sugars, but it tastes pretty danged good to boot.

You can buy cheese sticks just about anywhere... pick your own favorite variety. I've found my favorite "portable" peanut butter has become Justin's Nut Butter™, an organic non-perishable variety made in Boulder, CO and sold in single-serving foil packets. If you want a cheaper version (albeit less natural), Jif now offers Jif to Go™, personal-sized containers sold at most major grocery stores.

So where do I find meals with Whole Grains and High Protein?
(Image courtesy of REI)
Unfortunately, this is a tough question to answer directly. For many years, I ate the same backcountry meals that most avid backpackers do... a variety of freeze-dried fares from popular vendors like Mountain House™, Backpacker's Pantry™ and Enertia TrailFoods™. And they worked moderately well for me. But the main problem with these vendors is that they almost unanimously use white & processed grains and pastas in their meals. Hardly a single complex carb in the bunch, which (as I explained above) only contributes to the "boom & bust" cycle of blood sugar rebounds. Why do they do this? Because it's cheap to produce and easy to rehydrate a meal made with bleached processed grains. These meals often have little-to-no fiber or protein unless added by additional ingredients. And unfortunately, there's little else out there that's much different.

(Whole-grain Tomato Bruschetta Pasta with added Chicken)
After years of constant battles with severe blood-sugar spikes at mealtime, I decided something needed to change. I did some research, consulted with a few friends, and bought a dehydrator. My backcountry diet hasn't been the same since. Now that I make my own dehydrated meals, I chock my palate full of whole grain pastas and all the long-grain brown & wild rice I can eat, along with dried beef, chicken, spices, and however much olive oil I can fit into a plastic squeeze bottle. Now, I know what you're thinking... "wait, you make all your own food? Isn't that a lot of work??" Y'know, I thought it would be too, but with a dehydrator and a few simple recipies, it's not as tough as you think. A few key sites can get you started easily. Freezer Bag Cooking™ is a wonderful site if you want to make your own meals at home using simple recipes, without a lot of fuss & cleanup in camp. Don't own a dehydrator (and don't plan to)? One Pan Wonders™ is another great site that uses off-the-shelf ingredients with little preparation at home. I've used multiple recipies from both sites, and have been more than happy with the results I've gotten. Regardless of where you get your recipes, I wholly encourage you to think about "breaking free" from the expensive commercial freeze-dried fare and consider making your own meals for about half the price (and twice the nutrition) at home. The biggest benefit for me (as a diabetic) is that I can now concentrate on producing the diet I need out there, with complex carbs and lots of protein to keep my sugars stable and maintain my energy levels. I suggest you at least look into it... I doubt you'll regret the decision.

Another great place to find advice on homemade recipes (both meals & snacks) is on any of several online backpacking bulletin boards. These loose-knit communities of backpackers often harbor a wealth of information and recipes, and most are willing to share if you ask. My favorite place to hang out is the Backpacker.com Backcountry Cooking Forum, hosted by Backpacker Magazine. I've managed to get more than a few recipes for jerky, snack bars, desserts, meals, and all sorts of other ideas that'd have been difficult to find in any other single place. If you ever stop by, don't be afraid to say hi... I post there under the "GoBlueHiker" moniker.

Changing Your Insulin Doses
(Image courtesy of DiabetesMonitor.com)
You'll probably find that despite healthy changes to your diet, you'll need to cut back your insulin doses to keep sugars in check. Most Type-1 Diabetics these days take a mix of two insulins... a long-lasting "basal" insulin (such as Lantus™ or UltraLente™) and a "quick-acting" insulin (Humalog™, Novolog™, Regular, et al) before meals. You're burning so many more calories out there than you ever do at home... your cells simply don't need as much insulin to absorb it so quickly. Metabolism is a funny thing, and I find that for a strenuous trip, within a couple days (after my metabolism has begun to "ramp up" to compensate for my increased exercise) I often need about 60% of the insulin I normally take (both basal and fast-acting insulins). The only exception (in my case) is supper at the end of the day... then I often need slightly more to give me a decent blood sugar level before bed. (That's in part because I'm done exercising for the day, and also because I often eat a carb-rich pasta or rice dinner.) Bring your glucometer, and test your sugars frequently... you'll soon figure out your own trends as to what insulin & food levels work for you. Everyone's different. I often find myself testing up to 6-8 times a day (occasionally more)... it's important to know where my sugars are, especially when I'm out there solo. Test, test, test!

Hydration
Drink plenty of water. This should kinda go without saying, but it's especially important for the diabetic. One of the many benefits of drinking adequate water is that it helps maintain all your endocrine systems (including insulin/glucose) a little easier. It can help your system keep things under better control, which (in turn) may help fend-off nasty reactions and other side-affects that poor hydration often brings. Drink up!

As I've said before, most of this advice has come from my own experience, and as such, I cannot claim it to be comprehensive or all-inclusive. If you have suggestions, helpful additions, arguments, or other comments about this page, please Contact Me at any time. I welcome the feedback and suggestions of other diabetics who've undergone similar struggles, and I'm never too old or experienced to learn new tricks. In the meantime, happy hiking, and I wish you the best out there!


Et cetera...

If you'd like an inpiring place to hang out with fellow diabetics and adventurers, there's a great members' blog online called Mountains for Active Diabetics. Fellow diabetics over there go ice-climbing, mountaineering, adventure racing, and succeed at various other activities that most diabetics generally don't do. Whether you're a diabetic rookie or a seasoned vet, you might pick up a few pointers and brag about your own adventures over at the MAD site.

I want to give one final kudos to a friend and inspiration of mine. He's a fellow Type-1 Diabetic who's done far better than I have at breaking down boundaries of what he shouldn't be able to do with his conditions. I want to introduce you to Bob Coomber, also known as "4WheelBob," quite possibly the world's most prolific wheelchair hiker. I've known him for several years, and last year he was inducted into the California Outdoors Hall of Fame (with colleagues like Ansel Adams and John Muir). His story is featured in multiple articles of Backpacker Magazine, a segment of the Early Show, and several other columns & programs that I can't hope to keep track of all at once. Last August he making his third attempt to summit California's White Mountain, and became the first wheelchair hiker to scale that 14,000' peak unaided. He now has his sights set on higher peaks (Kilimangiaro has crossed his mind, for instance). I applaud his efforts, and if you're Jones'ing for a bit of inspiration (no more excuses!), you'd do well to check out his site. Go Bob!