Diabetes Management in wilderness athlete: WMS Guidelines

• Diabetes-specific healthcare maintenance should be up to date prior to wilderness activity. Athletes with diabetes may need to undergo additional and more frequent speciality evaluations


• Individuals with diabetes should undergo comprehensive risk assessment for cardiovascular disease with their primary care provider and/or endocrinologist prior to wilderness travel


• Individuals with pre-existing diabetes complications (including nephropathy, peripheral neuropathy, and retinopathy) should be counselled on minimizing additional risks to these organ systems with wilderness activity


• Wilderness athletes should be counselled on a complete packing list of routine and emergency diabetes supplies


• For glucometers and other monitoring equipment, the product guide should be reviewed carefully before an expedition. Individuals should carry a backup monitor and battery supply


• In the wilderness, insulin should be protected from environmental extremes, such as high or low temperatures, light exposure, and physical agitation. Any method of physical and/or temperature protection should be tested in a low-risk environment prior to use in the wilderness. A contingency supply of insulin should be kept in a separate location


• Those with insulin-dependent diabetes travelling to high altitude should be counselled on the potential for increased insulin requirements. Athletes should consider close monitoring on shorter trips to learn about their own glycemic trends prior to a major high altitude expedition


• Those with insulin-dependent diabetes travelling to high altitude should be counselled on the potential for increased insulin requirements. Athletes should consider close monitoring on shorter trips to learn about their own glycemic trends prior to a major high altitude expedition


• Acetazolamide should be used with caution in individuals with diabetes


• In wilderness athletes with diabetes, oral corticosteroids should be used with caution in light of the risk of hyperglycemia


• There are insufficient data to describe the effect that cold exposure has on diabetes management


• Wilderness athletes with diabetic peripheral neuropathy and peripheral vascular disease are at increased risk of frostbite


• There are insufficient data to describe the effect that heat exposure has on diabetes management


• Wilderness athletes with diabetes are at increased risk for heat illness


• In insulin-dependent diabetes, blood glucose should be monitored before, during, and after intense and/or prolonged exercise


• Those planning protocols for glucose monitoring and carbohydrate intake in exercise should understand how to adjust carbohydrate intake based on blood glucose and exercise. This plan should be individualized based on patients’ medical and exercise history and the environmental stressors to which they are exposed


• Individual hydration strategies should be developed prior to embarking on wilderness activities and should be adjusted based on real-time factors, including environmental temperature, altitude, and exercise type and duration


• Wilderness athletes with type 1 diabetes should understand how to adjust insulin doses via either MDI or CSII. This should be individualized based on their medical and exercise history and the environment to which they are exposed. This should be discussed in detail with their primary care provider and/or endocrinologist prior to embarking on wilderness activities. Any device should be explained thoroughly prior to an expedition


• Use of noninsulin diabetes medications should not be considered a contraindication to wilderness athletic involvement, though participants should be cautious regarding side effects. Particular attention should be paid to the individual risks of each specific class of medication


• Wilderness athletes with diabetes should have a plan and carry supplies for treating hypoglycemia. They should be prepared to use a glucose repletion and glucagon strategy


• Wilderness athletes with diabetes should have experience with individualized methods for managing nocturnal hypoglycemia prior to wilderness activity


• Those with insulin-dependent diabetes should know the signs and symptoms of ketosis, carry a serum and/or urine ketone testing kit, and know how to treat ketones during wilderness activities. It may be prudent to carry both as a contingency in the event of failure due to environmental conditions


• Ketosis may be safely managed in the wilderness if an athlete with diabetes and the athlete’s healthcare provider are comfortable with a treatment protocol and if the patient is able to take oral hydration and nutrition and shows no signs of altered mental status


• Those with insulin-dependent diabetes should understand how to adjust insulin doses when hyperglycemia occurs during activity. This should be based on their individual experiences during exercise, training, and previous exposures to environmental stressors. This should be discussed in detail with their endocrine provider prior to embarking on a wilderness adventure


• Although it is insufficient in vivo data on continuous glucose monitoring or novel hybrid closed-loop insulin delivery systems to recommend their use for wilderness athletes with diabetes, the use of such technology may be considered after discussion with an individual’s endocrine provider

Wilderness & Environmental Medicine