ArticlePDF Available

Type 1 diabetes mellitus at very high altitude. The summit of Mount Damāvand (5670 m) safely reached by 18 patients with type 1 diabetes mellitus



Content may be subject to copyright.
2016; 126 (7-8)
performance of medical devices typically used
by type 1diabetes patients, such as glucose me-
ters and insulin pumps, has not been verified
athigh altitudes.
Other problems with met-
abolic control may be associated with altitude-
-related anorexia, increased energy expenditure,
increased risk of dehydration, or diabetic keto-
is makes mountain hiking athigh
altitudes aparticular challenge for patients with
type 1diabetes.1‑6
With these facts in mind, 3years ago we creat-
ed the“5000meters above sugar level” initiative;
theultimate goal of theendeavor being patients
with type 1diabetes reaching apeak of more than
5000m in altitude. We aimed to prove that patients
with type 1diabetes, who have detailed knowledge
To the Editor
Nowadays, agrowing number of
people, including patients with type 1diabetes
mellitus, travel to high-altitude locations. Such
travel is not without risk, and diabetes can in-
crease thepotential dangers of travel atextreme
altitudes. Travelers ascending above 2500m are
susceptible to 3main forms of acute altitude ill-
ness: acute mountain sickness, high-altitude ce-
rebral edema, and high-altitude pulmonary ede-
Physiological responses to high-altitude
hypoxic environments include increased ven-
tilation, heart rate, blood pressure, and hor-
monal responses; however, elevated counter-
regulatory hormones and other hypoxia-related
mechanisms can impair glycemic control in pa-
tients with diabetes.
In addition, theaccurate
Type 1diabetes mellitus atvery high altitude
FIGURE 1 Ontheway
to the summit
LETTER TO THE EDITOR Type1diabetesmellitusatveryhighaltitude 577
and adiabetes technician. Two medical doctors,
who did not have diabetes, supported thegroup.
Our expedition started on July 15, 2016. We
spent 1night atthe Polour Resort, Iran (altitude,
2270m), after which we drove to Goosfand-Sara
(altitude, 3200m), where we began our ascent
to theshelter (4200m). efollowing day, af-
ter spending thenight atthe shelter, we climbed
to 4700m to acclimate to thealtitude. Original-
ly, similar acclimatization ascents were planned
to follow; however, our delayed arrival to Iran
(caused by political situation in atransit country)
left us with thedifficult decision of either stopping
atthat altitude or rescheduling thesummit attack
for thenext day. Eventually, we decided to try to
reach Mount Damāvand, and of the entiregroup,
18patients decided to challenge themountain
(FIGURE 1). All of them reached thepeak without
major problems; however, almost all suffered acute
mountain sickness to varying degrees (FIGURE 2).
We met with themost difficult part of theclimb
about 300m under thepeak, ata location called
“Smoke Mountain”, where steaming sulfuric gas
makes breathing difficult (FIGURE 3). Holding one’s
breath under conditions of severe hypoxia is quite
achallenge! After reaching thepeak, all partic-
ipants descended safely, returning to theshel
ter (FIGURE 4).
eentire expedition avoided severe hypogly-
cemia and metabolic/glycemic decompensation.
We have shown that patients with type 1diabe-
tes, with different levels of physical fitness, can
safely climb to very high altitudes. All of thedata
concerning diabetes management collected dur-
ing theexpedition is currently undergoing anal-
ysis and will be published soon. We believe that
trekking athigh altitude can encourage type 1di-
abetes patients to participate in regular physical
activity, help develop positive interpersonal rela-
tionships, facilitate experience exchange among
and understanding of their disease, could safely
hike to very high altitudes. We also aimed to de-
velop high-altitude insulin management protocols.
Step-by-step, we integrated our group, improving
the“teamwork” approach, and developing thetech-
nical skills concerning mountain climbing.7,8
We defined theinclusion criteria as follows:
type 1diabetes (except patients in remission),
acceptable metabolic control (hemoglobin A1c
[HbA1c] <7.5%), good diabetes self-management
skills, and good compliance prior to expedition.
Importantly, ahigh level of physical activity/fit-
ness prior to involvement in our trek was not
aninclusion criterion. Our group consisted of in-
dividuals with avery high level of baseline physi
cal activity (2months prior to our trip, 4partici-
pants successfully completed the“Butchers race”:
a84-km mountain marathon), as well as those
with abaseline physical activity similar to that of
anaverage member of thesociety. elatter group
was encouraged to increase their activity prior to
theexpedition according to their individual ca-
pabilities. eexclusion criteria were defined as
follows: presence of complications (retinopathy,
neuropathy, nephropathy), uncontrolled hyper-
tension (systolic blood pressure >150mmHg or
diastolic blood pressure >90mmHg), unaware-
ness of severe hypoglycemia, severe cardiac or
peripheral arterial disease, and smoking.
Our team for thefinal expedition to Mount
Damāvand (Iran) consisted of 19patients (2of
whom were women) with type 1 diabetes.
ey were ata mean age of 32.5years (range,
23–48years), had amean body mass index of
23.8kg/m2 (range, 19.7–30.2kg/m2), a mean
HbA1c level of 6.6% (range, 5.9–7.1%), and
amean diabetes duration of 12.6years (range,
3–29years). All patients were treated with per
sonal insulin pumps. Two patients were medi-
cal doctors; there was also adiabetes educator
FIGURE 2 Damāvand
2016; 126 (7-8)
Corresponding author Tomasz Klupa, MD,
PhD, Katedra Chorób Metabolicznych, Uniwer-
sytet Jagielloński, Collegium Medicum, Poland,
ul. Kopernika 15, 31-501Kraków, Poland, phone:
+48124248300, e-mail:
Conflict of interest
eauthors declare no con-
flict of interest.
Gawrecki A, Matejko B, Benbenek-
-Klupa T, et al. Type 1diabetes mellitus atvery
high altitude: thesummit of Mount Damāvand
(5670m) safely reached by 18patients with type
1diabetes mellitus. Pol Arch Med Wewn. 2016;
126 (7-8): 576-578. doi:10.20452/pamw.3521.
Johnson NJ,Luks AM. High‑altitude medicine. Med Clin North Am.
2 DeMolP,DeVriesST,EelcoJP,etal.Physicalactivityataltitude:Chal‑
3 MohajeriS,PerkinsBA,BrubakerPL,et al.Diabetes,trekking andhigh
altitude:Recognizing and preparing for the risks. Diabet Med. 2015; 32:
DeMol P,De VriesST,De Koning EJ,et al.Increased insulin require
mentsduring exercise at very high altitudein type 1 diabetes. Diabetes
6 MillerSC.Diabeticketoacidosisandacutemountainsickness:case re‑
7 KlupaT,Benbenek‑KlupaT,MatejkoB,et al.Winter mountaintrekking
andcamping—a challenge forpatients with type 1diabetes. Clinical Di
GawreckiA , Benbenek‑KlupaT,Wróbel M. The “5000 meters above
sugarlevel” project—“Alps2015”expedition. Clinical Diabetology.2015;
patients and doctors, and lead to improvement in
diabetes self-management skills and outcomes. Fi-
nally, we have shown that dreams come true and
diabetes does not have to be anobstacle to com-
bating thegreatest challenges.
Acknowledgments eexpedition was support-
ed by Diabetes Poland, Sanofi, Ascensia Diabetes
Care, Vitro-Plus, and Pictures by
Grzegorz Gaj.
Author names and affiliations Andrzej Gawrecki,
Bartłomiej Matejko, Teresa Benbenek-Klupa,
Marta Wróbel, Jerzy Hohendorff, Tomasz Klu-
pa (AG: Department of Internal Medicine and
Diabetology, Poznan University of Medical Sci-
ences, Poznań, Poland; BM, JH, TK: Department
of Metabolic Diseases, Jagiellonian University
Medical College, Kraków, Poland; MB, JH, TK:
University Hospital, Kraków, Poland; TB-K: Di-
abWay, Kraków, Poland; MW: Departament of
Internal Diseases, Diabetology and Cardiomet-
abolic Diseases, School of Medicine with Divi-
sion of Dentistry in Zabrze, Medical University
of Silesia, Poland)
FIGURE 4 Celebration
FIGURE 3 Steaming
... T1DM patients with microvascular complications who wish to undertake travel at altitude should undergo a medical evaluation of conditions that might increase exercise-associated risk; this includes medical history, physical examination, retinal examination, resting/exercise ECG, and/or pulmonary assessments [3]. However, it is of scientific and clinical importance to provide more data in this field [10]. ...
... In the paper, we focused on the differences between the 3 days of the expedition using the Borg and AMS scales [10]. We measured lactate blood concentrations at the beginning of the day, i.e., directly before trekking started, and at the highest altitude achieved during the day, up to 5 minutes after reaching the highest point (Lactate Scout, EKF-Diagnostics; registered to work at temperatures ranging from 5°C to 45°C, at 10-85% humidity, and up to an altitude of 4000 m.a.s.l., as per the instruction manual). ...
Full-text available
In this study, the aim was to provide observational data from an ascent to the summit of Mount Damavand (5670 meters above sea level (m.a.s.l), Iran) by a group of people with type 1 diabetes (T1DM), with a focus on their physiological characteristics. After a 3-day expedition, 18 T1DM patients, all treated with personal insulin pumps, successfully climbed Mount Damavand. Information was collected on their physiological and dietary behaviors, as well as medical parameters, such as carbohydrate consumption, glucose patterns, insulin dosing, and the number of hypo-and hyperglycemic episodes during this time frame. The participants consumed significantly less carbohydrates on day 3 compared to day 1 (16.4 vs. 23.1 carbohydrate units; p = 0:037). Despite this, a gradual rise in the mean daily glucose concentration as measured with a glucometer was observed. Interestingly, the patients did not fully respond to higher insulin delivery as there was no significant difference in mean daily insulin dose during the expedition. There were more hyperglycemic episodes (≥180 mg/dL) per patient on day 3 vs. day 1 (p < 0:05) and more severe hyperglycemic episodes (>250 mg/dL) per patient on days 2 (p < 0:05) and 3 (p < 0:05) vs. day 1. In summary, high mountain trekking is feasible for T1DM patients with good glycemic control and no chronic complications. However, some changes in dietary preferences and an observable rise in glucose levels may occur. This requires an adequate therapeutic response.
... La corretta gestione del diabete ha richiesto numerosi accorgimenti e adattamenti della terapia non sempre facilmente prevedibili. In alcuni casi è stata descritta una diminuzione del fabbisogno insulinico (5,8), mentre in altri il fabbisogno di insulina è rimasto invariato (12) o è aumentato con l'aumentare della quota (9,13,18,(34)(35). ...
Full-text available
Questa rassegna fa parte di un percorso di formazione a distanza accreditato a livello nazionale e disponibile gratuitamente nell'aula virtuale della SID ( Per partecipare al corso occorre: 1. Leggere la rassegna (disponibile anche on-line) 2. Registrarsi all'aula e iscriversi al corso "il Diabete" 3. Rispondere on-line al quiz di verifica e compilare il questionario di valutazione dell'evento FAD. Una volta eseguito con successo il test di valutazione e compilato il questionario di valutazione dell'evento, sarà cura della Segreteria ECM della SID far pervenire l'attestato ECM del corso ai diretti inte-ressati nei tempi e nelle modalità stabiliti dalla regolamentazione vigente. Per ulteriori informazioni: In alta quota con il diabete tipo 1 Aldo Maldonato Comitato per l'Educazione Terapeutica (ComET-onlus) 257 INTRODUZIONE A quasi un secolo dalla scoperta dell'insulina, la terapia del diabete tipo 1 ha fatto e continua a fare enormi pro-gressi, tanto che un diabetologo degli anni Settanta (per esempio chi scrive) piovuto improvvisamente oggi fra noi farebbe fatica a raccapezzarsi fra insuline "ingegneriz-zate", penne monouso, microinfusori, misuratori della glicemia in continuo e algoritmi di correzione. Da una parte ciò non soddisfa appieno né i pazienti né gli opera-tori sanitari, i quali-tutti-auspicano che si arrivi alla scomparsa della malattia (guarigione anziché cura, ovvero cure vs care), tuttavia non si può negare che i progressi del-la cura hanno liberato i pazienti da tante schiavitù che li affliggevano ancora trent'anni fa, e ciò ha consentito ai giovani con diabete di cimentarsi con successo in tutte le discipline sportive (1-2), incluse quelle considerate "estre-me" e una volta "proibite" ai diabetici. Fra queste, l'alpinismo-in tutte le sue declinazioni-presenta caratteristiche particolari perché, accanto ad alcuni aspetti decisamente favorevoli, come la durata medio-lunga dell'esercizio e un'intensità di sforzo che si mantiene per lo più nell'ambito aerobico, esso si svolge in un ambiente in cui le normali attività metaboliche avven-gono in presenza di una minore pressione parziale di ossi-geno atmosferico, e chi lo pratica deve sapere far fronte a numerosi pericoli oggettivi e soggettivi (3). Le modificazioni ormonali, cardio-respiratorie, renali e metaboliche indotte dall'alta quota sono state ogget-to di studio da molti anni, ma non sempre è stato facile definirle in modo univoco a causa dell'elevato numero di variabili in gioco (tipo e intensità dello sforzo, grado di allenamento, stato nutrizionale, condizioni ambientali e meteorologiche, quota effettiva…), e della difficoltà di effettuare studi controllati su numeri sufficienti di sog-getti in condizioni riproducibili. Per quanto riguarda le "persone con diabete tipo 1" (D-T1), le poche ricerche ef-fettuate hanno mirato a chiarire se l'alta quota è alla loro
... His clinical characteristics have been presented before [2]. He previously captured Aconcagua mountain [2], participated in Damavand expedition [3], and completed a trail running ultramarathon, to list only few of his achievements. His last available HbA1c determined 2 months before competition was 6.8% (50.8 mmol/mol), current weight 78 kg, and BMI 23.8 kg/m 2 . ...
... Relevant experience is scarce. In 2016, 19 Polish people with T1D climbed Mount Damavand (5670 m) in Iran (Gawrecki et al., 2016;Matejko et al., 2017). Participants' mean age was 32.5 years (range, 23-48 years), had a mean BMI of 23.8 kg/m 2 (range, 19.7-30.2 ...
Full-text available
Koufakis, Theocharis, Spyridon N. Karras, Omar G. Mustafa, Pantelis Zebekakis, and Kalliopi Kotsa. The effects of high altitude on glucose homeostasis, metabolic control, and other diabetes-related parameters: from animal studies to real life. High Alt Med Biol. 19:000-000, 2018.-Exposure to high altitude activates several complex and adaptive mechanisms aiming to protect human homeostasis from extreme environmental conditions, such as hypoxia and low temperatures. Short-term exposure is followed by transient hyperglycemia, mainly triggered by the activation of the sympathetic system, whereas long-term exposure results in lower plasma glucose concentrations, mediated by improved insulin sensitivity and augmented peripheral glucose disposal. An inverse relationship between altitude, diabetes, and obesity has been well documented. This is the result of genetic and physiological adaptations principally to hypoxia that favorably affect glucose metabolism; however, the contribution of financial, dietary, and other life-style parameters may also be important. According to existing evidence, people with diabetes are capable of undertaking demanding physical challenges even at extreme altitudes. Still, a number of issues should be taken into account, including the increased physical activity leading to changes in insulin demands and resistance, the performance of measurement systems under extreme weather conditions and the potential deterioration of metabolic control during climbing expeditions. The aim of this review is to present available evidence in the field in a comprehensive way, beginning from the physiology of glucose homeostasis adaptation mechanisms to high altitudes and ending to what real life experience has taught us.
... Detailed characteristics of this group were previously described. 6 Good weather conditions occurred during the expedition in July. There was no wind or snow, and based on values recorded on patients' sports watches, the temperature remained above 0°C even at the peak (for most of the time it was >10°C). ...
Full-text available
High-altitude trekking can expose people to extreme environmental conditions, like low temperatures and hypobaric hypoxia. Such extreme conditions make it more difficult for people with type 1 diabetes mellitus (T1DM) to maintain glycemic control. Intensive blood glucose monitoring using either glucose meters or continuous systems is imperative in these cases. In this observational study, we report metabolic control of T1DM patients and the performance of various insulin pumps at high altitude. All 19 patients with T1DM included in this study participated in the final step of the "5000 meters above sugar level" initiative, which involved trekking Damavand Mountain to an altitude of 5670 meters above sea level. We found that all pump models worked well without any disruption and no cases of diabetes decompensation or severe hypoglycemia occurred. Therefore, healthy, physically fit, and experienced individuals with T1DM should not be discouraged from participating in mountain trekking activities, as modern personal insulin pumps work well at high altitudes.
Nabrdalik, Katarzyna, Hanna Kwiendacz, Monika Gubała, Kinga Tyrała, Mariusz Seweryn, Andrzej Tomasik, Tomasz Sawczyn, Michał Kukla, Władysław Grzeszczak, and Janusz Gumprecht. Diabetes-related knowledge of Polish national mountain leaders. High Alt Med Biol 00:000-000, 2018.-Mountain trekking is a popular activity for patients with diabetes. In Poland, mountain leaders often accompany organized groups to ensure their safety during treks; we aimed to evaluate their competency in caring for diabetic clients by assessing their diabetes-related knowledge. This was a cross-sectional study among Polish, certified, active mountain leaders carried out by means of an anonymous, standardized 41-item questionnaire adapted from a study by Wee et al. It was distributed through e-mail to 500 leaders. A total of 106 (21.2%) mountain leaders completed the questionnaire (males 60.4%) with a mean (standard deviation [SD]) age of 38.6 (13.5) years. Their mean (SD) length of experience acting as a mountain leader was 11.9 (10.2) years. The average score was 72.4% of the maximum possible (29.7 of 41 points). Results varied significantly depending on gender (p = 0.006). The percentage of correct answers among questions in each section varied between 23.6% and 100%. The main sources of diabetes-related knowledge identified by respondents were members of their family and their friends who suffer from diabetes (33%). First aid courses were indicated as sources of information by only 12.6% of the informants. Results of the questionnaire revealed that respondents did have a reasonable level of diabetes-related knowledge. There were topics in which the respondents achieved lower than an average score, demonstrating a need for further education.
Full-text available
Although regular physical activity is encouraged for individuals with diabetes, exercise at high altitude increases risk for a number of potential complications. This review highlights our current understanding of the key physiological and clinical issues that accompany high-altitude travel and proposes basic clinical strategies to help overcome obstacles faced by trekkers with Type 1 or Type 2 diabetes. Although individuals with diabetes have adaptations to the hypoxia of high altitude (increased ventilation, heart rate, blood pressure and hormonal responses), elevated counter-regulatory hormones can impair glycaemic control, particularly if mountain sickness occurs. Moreover, high-altitude-induced anorexia and increased energy expenditure can predispose individuals to dysglycaemia unless careful adjustments in medication are performed. Frequent blood glucose monitoring is imperative, and results must be interpreted with caution because capillary blood glucose meter results may be less accurate at high elevations and low temperatures. It is also important to undergo pre-travel screening to rule out possible contraindications owing to chronic diabetes complications and make well-informed decisions about risks. Despite the risks, healthy, physically fit and well-prepared individuals with Type 1 or Type 2 diabetes who are capable of advanced self-management can be encouraged to participate in these activities and attain their summit goals. Moreover, trekking at high altitude can serve as an effective means to engage in physical activity and to increase confidence with fundamental diabetes self-management skills. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
Full-text available
Safe, very high altitude trekking in subjects with type 1 diabetes requires understanding of glucose regulation at high altitude. We investigated insulin requirements, energy expenditure, and glucose levels at very high altitude in relation to acute mountain sickness (AMS) symptoms in individuals with type 1 diabetes. Eight individuals with complication-free type 1 diabetes took part in a 14-day expedition to Mount Meru (4,562 m) and Mount Kilimanjaro (5,895 m) in Tanzania. Daily insulin doses, glucose levels, energy expenditure, and AMS symptoms were determined. Also, energy expenditure and AMS symptoms were compared with a healthy control group. We found a positive relation between AMS symptoms and insulin requirements (r = 0.78; P = 0.041) and AMS symptoms and glucose levels (r = 0.86; P = 0.014) for Mount Kilimanjaro. Compared with sea level, insulin doses tended to decrease by 14.2% (19.7) (median [interquartile range]) (P = 0.41), whereas glucose levels remained stable up to 5,000 m altitude. However, at altitudes >5,000 m, insulin dose was unchanged (36.8 ± 17 vs. 37.6 ± 19.1 international units [mean ± SD] P = 0.75), but glucose levels (7.5 ± 0.6 vs. 9.5 ± 0.8 mmol/L [mean ± SD] P = 0.067) and AMS scores (1.3 ± 1.6 vs. 4.4 ± 4 points [mean ± SD] P = 0.091) tended to increase. Energy expenditure and AMS symptoms were comparable in both groups (P = 0.84). Our data indicate that in complication-free individuals with type 1 diabetes, insulin requirements tend to increase during altitudes above 5,000 m despite high energy expenditure. This change may be explained, at least partly, by AMS.
Individuals may seek the advice of medical providers when considering travel to high altitude. This article provides a basic framework for counseling and evaluating such patients. After defining "high altitude" and describing the key environmental features at higher elevations, the physiologic changes that occur at high altitude and how these changes are experienced by the traveler are discussed. Clinical features and strategies for prevention and treatment of the main forms of acute altitude illness are outlined, and frameworks for approaching the common clinical scenarios that may be encountered regarding high-altitude travelers are provided.
Physical activity at altitude: Challenges for people with diabetes
  • De Mol
  • De Vries
  • St Eelco
De Mol P, De Vries ST, Eelco JP, et al. Physical activity at altitude: Challenges for people with diabetes. Diabetes Care. 2014; 37: 2404-2413.