Diabetes Management in Wilderness Athletes

Publication Date: December 1, 2019

Recommendations

Diabetes Management in Wilderness Athletes

Diabetes-specific healthcare maintenance should be up to date prior to wilderness activity. Athletes with diabetes may need to undergo additional and more frequent specialty evaluations. (1 – Strong, C)
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Athletes with diabetes should meet with their primary care provider and/or endocrinologist prior to wilderness travel. (1 – Strong, C)
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Cardiovascular screening

Individuals with diabetes should undergo comprehensive risk assessment for cardiovascular disease with their primary care provider and/or endocrinologist prior to wilderness travel. (1 – Strong, B)
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Routine pre-participation ECG screening of wilderness athletes with diabetes is not recommended. (2 – Weak, C)
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Routine exercise ECG to screen for coronary artery disease in asymptomatic wilderness athletes with diabetes is not recommended. (1 – Strong, B)
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Diabetes-specific medical conditions

Individuals with pre-existing diabetes complications (including nephropathy, peripheral neuropathy, and retinopathy) should be counseled on minimizing additional risks to these organ systems with wilderness activity. (1 – Strong, C)
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All individuals with diabetes planning high altitude travel should be up to date on yearly dilated fundoscopy. If any degree of retinopathy is present, ophthalmologic risks of wilderness travel should be discussed. (1 – Strong, C)
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SUPPLY PREPARATION

Wilderness athletes should be counseled on a complete packing list of routine and emergency diabetes supplies. (1 – Strong, C)
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Wilderness athletes should carry documentation of their medical history, basic diabetes management plan, and basic emergency action plan. (1 – Strong, C)
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GLUCOMETERS

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. (1 – Strong, C)
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INSULIN

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. (1 – Strong, B)
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Environmental Considerations

HIGH ALTITUDE

Change in insulin requirements

Those with insulin-dependent diabetes traveling to high altitude should be counseled 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. (2 – Weak, C)
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Acetazolamide should be used with caution in individuals with diabetes. (2 – Weak, C)
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High altitude illness

Acetazolamide
Individuals with diabetes should be counseled on symptoms and management options for high altitude illness and dysglycemia. More frequent blood glucose and ketone checks are recommended if symptoms of high altitude illness occur. (1 – Strong, C)
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Dexamethasone
In wilderness athletes with diabetes, oral corticosteroids should be used with caution in light of the risk of hyperglycemia. (1 – Strong, C)
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COLD ENVIRONMENTS

There are insufficient data to describe the effect that cold exposure has on diabetes management. (G-U)
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Cold illness

Wilderness athletes with diabetic peripheral neuropathy and peripheral vascular disease are at increased risk of frostbite. (2 – Weak, C)
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HOT ENVIRONMENTS

There are insufficient data to describe the effect that heat exposure has on diabetes management. (, U)
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Heat illness

Wilderness athletes with diabetes are at increased risk for heat illness. (1 – Strong, C)
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MONITORING AND TREATMENT

Glucose monitoring

In insulin-dependent diabetes, blood glucose should be monitored before, during, and after intense and/or prolonged exercise. (1 – Strong, B)
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Carbohydrate intake

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. (1 – Strong, B)
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Hydration

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. (1 – Strong, C)
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Insulin management

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. (1 – Strong, B)
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Noninsulin medications

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. (1 – Strong, C)
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GLYCEMIC COMPLICATIONS

Hypoglycemia

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. (1 – Strong, C)
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Hyperglycemia
If someone with diabetes is found to be hyperglycemic (plasma glucose level >250 mg·dL-1), it is important to determine whether the individual is in an acute hyperglycemic crisis, including hyperosmolar hyperglycemic state (HHS) or DKA. To help differentiate between hyperglycemia and HHS/DKA, individuals with type 1 diabetes should be able to test for blood or urine ketones if they have unexplained hyperglycemia.
(G-U, U)
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Wilderness athletes with diabetes should have experience with individualized methods for managing nocturnal hypoglycemia prior to wilderness activity. (1 – Strong, C)
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Hyperosmolar hyperglycemic state

HHS is a state of progressive hyperglycemia and hyperosmolarity typically seen in individuals with poorly controlled or undiagnosed type 2 diabetes, limited access to water, and a precipitating medical event. The development of HHS is attributed to insulin resistance, deficiency, or both, in addition to increased hepatic gluconeogenesis, osmotic diuresis, and dehydration. The hyperglycemia in HHS is profound, with serum glucose level usually >600 mg·dL-1 and extreme dehydration with a fluid deficit of 8 to 12 L. ( G-U , U)
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Diabetic ketoacidosis

In the wilderness environment, focus should be on close monitoring and prevention of worsening ketosis. It is important to prevent potentially severe or life-threatening conditions with careful planning. (G-U, U)
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Ketone monitoring and management

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. (1 – Strong, B)
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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. (2 – Weak, C)
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Both HHS and DKA should be considered medical emergencies managed by emergent removal or evacuation to definitive care. (1 – Strong, A)
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Healthcare providers covering events or expeditions in the wilderness should have the ability to monitor blood glucose and ketones and have a basic familiarity with how to treat and triage glucose abnormalities. (1 – Strong, C)
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There should be a plan for evacuation in the case of a hyperglycemic emergency. (1 – Strong, A)
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Exercise-induced hyperglycemia

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. (1 – Strong, B)
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EMERGING TECHNOLOGY

Although there 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. (1 – Strong, C)
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Recommendation Grading

Disclaimer

Overview

Title

Diabetes Management in Wilderness Athletes

Authoring Organization

Publication Month/Year

December 1, 2019

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Long term care, Outpatient

Intended Users

Diabetes educator, athletics coaching, nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D056352 - Athletes, D048909 - Diabetes Complications, D055814 - Wilderness

Keywords

diabetes, insulin, glucose, complications, altitude, diabetic ketoacidosis

Methodology

Number of Source Documents
123
Literature Search Start Date
January 1, 1980
Literature Search End Date
October 11, 2019
Specialties Involved
Internal Medicine General, Sports Medicine