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DEEP LIVED MEDICINE. EXPEDITIONS – 1.
ISLET. International Snow Leopard Expedition Tipe 1 Diabetes.

The American Diabetes Association states that all levels of physical activity can be performed by people with type 1 diabetes who do not have complications and are in good blood glucose control. 

Pels col·legues interessats en les aventures de la Medicina de Muntanya. Ja podeu veure alhora el FILM i llegir el diari d'expedició (PART 1 i PART 2) dels metges de l’expedició ISLET al pic Lenin, de 7134 metres d’altitud.

Aquesta expedició va sorgir de la il·lusió d’un grup de muntanyencs diabètics de tot el mon. Èren italians, nordamericans i britànics. Aquell grup ja havia anat exitosament a l’Aconcagua i al Cho Oyu. Vistes les experiències d’altres alpinistes diabètics al Kilimanjaro, i a la seva pròpia experiència amb metges més investigadors que assistencials al Cho Oyu, van demanar ajuda al grup mèdic de l’Institut d’Estudis de Medicina de Muntanya de Barcelona. El Dr. J. Admetlla ja els havia assistit a l’Aconcagua, i ja havia treballat i publicat sobre el tema de la diabetis i l’altitud. De manera que cap al Kirguizistan que vàrem anar dos metges muntanyencs a ajudar als diabètics a pujar a un set-mil i a aprendre tant com poguéssim.

El pic Lenin, és situat a la gran serralada del Pamir, al mig de l’Àsia, subserralada Zaalajsk, ó més internacionalment Trans-Alay Range, a la frontera entre el Tadjikistan i el Kirguizistan. El seu nom prové de l’antiga Unió de Repúbliques Socialistes Soviétiques, ja periclitada, que dominava per aquelles terres a principis del segle XX. El nom que li ha posat l’actual govern del Kirguizistan, que ja no obeeix les ordres de l’antic govern de Moscú (o si, però ho disimula), i que té predominància social musulmana, no és el mateix. Avui dia, oficialment és diu pic Ibn Sina (als metges us sonarà; està dedicat al filòsof i metge del segle XI, que va néixer a la zona, i que per aquí en diem Avicena). La realitat actual és que el nom Lenin Peak és encara el més utilitzat i, si no ho veieu clar, navegueu per Internet una estona. Vaja cosa tonta la dels humans. La muntanya no canvia ni gota per com li diguin els governs. Ella ni s’entera. I l’esforç i el risc per pujar-hi és el mateix. El mateix passa amb els altres cims del Pamir. Tots tenen molts noms depenent de qui governi i d’on consultem.
Espero que us agradi el relat i el film d’aquella expedició.

Us afegim bibliografia sobre el tema de la diabetis i l’altitud. Segur que hi ha molt a aprendre encara.

Perqué l’expedició es deia Snow Leopard Expedition Tipe 1 Diabetes?

El nom Expedition Tipe 1 Diabetes és obvi. No insistirem. Però i Snow Leopard? 

El que en anglés s‘anomena snow leopard és un gat gros, originari de les muntanyes centroasiàtiques, amb el nom científic de Panthera uncia ò Uncia uncia depenent d’on consulteu. És una bèstia similar al linx ibèric, però d’un color blanquinós tacat a l’hivern i més fosc a l’estiu. És una espècie declarada en perill d’extinció i, per tant, digne del nostre interès. Un servidor ha vist les petjades a la neu (Karakorum 1988), però mai ha pogut veure l’animal. Deu ser prou prudent per deixar-se veure al mínim pels humans.
La qüestió és que al Pamir hi ha cinc cims de més de 7000 metres. A l’Hindu Kush n’hi ha sis. Qui assoleix els cinc setmils del Pamir, per decisió i estímul turístic dels governs locals, té dret a ser anomenat Snow Leopard. Una cosa similar a “Cavalls del Vent”, “Carros de Foc”, “El camí dels Bons Homes” o el “Camí de Santiago”. Salvant les diferències, és clar. Cosa turísticoeconòmica.
Us afegim els cinc cims del Pamir de més de 7000 metres que aporten el títol de “Snow Leopard” pels qui hi creguin: 
1- Kongur, 7649 m. Sinkiang xinés. 2- Muztagh Ata, 7509 m. Sinkiang xinés. 3- Ismoil Somoni, Kommunism o Stalin peak depenent de la nomenclatura, 7497 m. Tadjikistan. 4- Lenin Peak, Abu Ali Ibn Sino o Kaufmann peak, 7132 m. Kirguizistan. 5- Korzhenevskaya. 7105 m. Tadjikistan.

BIBLIOGRAFIA

1.- Extreme Altitude Mountaineering and Type 1 Diabetes. The Cho Oyu Alpinisti in Alta Quota Expedition. Pavan P, Sarto P, Merlo L, Casara D, Ponchia A, Biasin R, Noventa D, Avogaro A. Diabetes Care. 2003 Nov;26(11):3196-7
Abstract: Extreme altitude mountaineering, defined as climbing at altitudes in excess of 5,000 m, creates physiological demands, especially in type 1 diabetic subjects, who might experience impaired pulmonary function. We present the metabolic control and symptoms of mountain sickness during the 2002 Alpinisti in Alta Quota (ADIQ) Expedition to Cho Oyu, which is the sixth highest Himalayan peak. Six subjects with type 1 diabetes and 10 matched nondiabetic individuals participated in the expedition. The type 1 diabetic subjects were free of long-term diabetes complications and experienced climbers; they were in good metabolic control before the expedition. The glucose profiles at time 08:00, 10:00, 12:00, 14:00, 18:00, 20:00, and 22:00 hours and the insulin requirement were assessed. The 3-hydroxybutyrate concentration on capillary blood was also determined at 08:00 and 20:00. Retinopathy and albumin excretion rate were assessed before and after the expedition. One of 6 type 1 diabetic subjects and 3 of 10 control subjects ascended to the top of Cho Oyu (NS between groups). The Lake Louise Scoring System showed no difference between type 1 diabetic and nondiabetic subjects in their susceptibility to symptoms of altitude sickness. None of the type 1 diabetic subjects developed fresh retinal hemorrhages. No differences were observed in urinary albumin excretion rate. There was a worsening of HbA1c during the expedition in both control and type 1 diabetic subjects (5.4 - 0.1% vs. 7.9 - 06%, P - 0.01). During the ascent to the Cho Oyu, there was a progressive increase in daily insulin requirement (from 38 - 6 units/day at 0 m to 51 - 6 at 4,200 m, P -0,001). A significant rise in the capillary glucose concentration at 0800, 1000, 2000, and 2200 was also observed. On the day the type 1 diabetic subject reached the top of the Chou Oyu, he had an insulin requirement of 56 units/day (34 units/day at sea level) and a mean plasma glucose concentration of 198 mg/dl. No changes in the daily glucose coeficient of variation were observed. No significant changes in the 3-hydroxybutyrate capillary concentration were observed at 0800 or 2000. In conclusion, we found that uncomplicated type 1 diabetic subjects can cope with extreme altitude mountaineering; however, this activity leads to a worsening of metabolic control. Moreover, our results suggest that all diabetic patients who want to deal with this activity need to be extremely trained to handle glucose monitoring and to vary dietary and insulin needs accordingly.

References
1. American Diabetes Association: Diabetes mellitus and exercise. (Position Statement). Diabetes Care 20:1908–1912, 1997
2. Strojek K, Ziora D, Srocynski JW, Oklek K: Pulmonary complications of type 1 (insulin-dependent) diabetic patients. Diabetol 35:1173–1176, 1992
3. Moore K, Vizzard N, Coleman C, McMahon J, Hayes R, Thompson CJ: Extreme altitude mountaineering and type 1 diabetes: the Diabetes Federation of Ireland Kilimanjaro Expedition. Diabet Med 18:749–755, 2001


2.- The Practical Aspects of Insulin at High Altitude. Paul Richards and David Hillebrandt. High Alt Med Biol 14:197–204, 2013
Abstract: With the increasing prevalence of diabetes and current social philosophy of enablement, many more diabetics are travelling to high altitude where the rate of AMS in Type 1 diabetic mountaineers is no different than nondiabetics. Numerous effects of exercise, both degree and duration, dietary change, illness, stress, mountain sickness, counter-regulatory hormones, and altitude increased sympathetic output, and catecholamines have led to conflicting accounts of insulin requirement increasing or decreasing at altitude. Overall, it would appear that the effects of diet and exercise outweigh those of altitude. Good control requires continual insulin dose adjustment with frequent feedback from blood sugar testing, but glucometers can over -or under- read at altitude. Additionally, heat or cold exposure can degrade insulin efficacy; strategies for storing insulin are described.
Diabetic patients go to the mountains and some of them go to high altitudes or climb difficult routes and generally they do well. Current recommendations establish that people with type 1 diabetes (DM-1) who do not have complications and are in good blood glucose control can perform all levels of exercise (ADA, 2004) and for these patients sojourning to altitude is not contraindicated (Milledge, 1999). Nevertheless, mountaineering and high altitude present special
challenges to diabetic patients, and they are probably at higher risk of mortality and complications
than nondiabetic climbers. While there is a boom in mountain tourism, no data on the incidence of diabetes mellitus (DM) in altitude trekking or in recreational areas are available. According to diabetic alpinists and the author’s records, over the last dècade around 50 type 1 diabetic climbers have participated in high altitude expeditions above 5500 m; hence the diabetic population going to less extreme altitudes is probably significant.
An extensive search of the literature was carried out in Medline, journals of national mountain medicine societies, and diabetic sport journals. The records of the author and the follow up of Internet forums (Madidea; IDEA 2000; Adiq) have also been taken into account. This paper pays special attention to three expeditions in which most of the members were diabetic and have reported their experience at high altitude in medical papers. Some of these cases are summarized next. In the Kilimanjaro (5700 m) expedition (Moore et al. 2001a, b), 6 out of 15 diabetics and 16 out of 22 nondiabetics reached the summit.


3.- Going high with type 1 diabetes. Conxita Leal. High Alt. Med. Biol. 6:00–00, 2005
Abstract: This review aims to identify the main issues facing a healthy and well-controlled type-1 diabetic mountaineer at high altitude. Most of the problems are self-managed by the diabetic climber although the risk of serious morbidity or even death remains. Given the scarce evidence on diabetes at altitude, an extensive search of the literature, including case reports and anecdotes was carried out to reach the recommendations.


4.- Metabolic and Cardiovascular Parameters in Type 1 Diabetes at Extreme Altitude. Pavani P, Sarto P,  Merlo L, Casara D, Ponchiai A, Biasin R, Noventa D, Avogaro A. Med. Sci. Sports Exerc., Vol. 36, No. 8, pp. 1283–1289, 2004
Abstract: The American Diabetes Association states that physical activity can be performed by individuals with Type 1 diabetes. Nevertheless, extreme altitude mountaineering represents a demanding challenge. We present the metabolic and cardiovascular parameters found in individuals with Type 1 diabetes during the ascent to Cho Oyu located at a height of 8201 m. Methods: Six individuals with Type 1 diabetes and 10 matched controls participated in the expedition. Both groups were evaluated before and after 4 h of trekking for vital indices, blood gases, acute mountain sickness, and metabolic control at 0, 3700, and 5800 m. Results: No difference between the groups was observed in acute mountain sickness scores. There was a progressive elevation in basal heart rates in both groups at increasing altitude while no changes were observed in mean blood pressures. After the 3 h of trekking, a significant increase in heart rate was observed in the controls at 0 m whereas a significant decrease in blood pressure was observed at higher altitude only in controls. HbA1c levels were worse after the expedition in both groups. A progressive increase in insulin requirement was observed in subjects with Type 1 diabetes (38 _ 6 U·d_1 at 0 m to 51 _ 6 at 4200 m, P _ 0.001). At an altitude of 5800 m, there was a significant increase in blood lactate concentration, independently of the activity level in the two groups. Conclusions: At extreme altitude, highly motivated trekkers with Type 1 diabetes but free from long-term complications present metabolic and cardiovascular parameters comparable with those of control subjects despite a worsening in metabolic control. This type of physical activity must be accompanied by careful glucose monitoring.  Exercise, along with diet and medication, is considered one of the cornerstones of diabetes therapy. Regular physical activity is recommended for patients with Type 1 diabetes because it may have beneficial effects on both metabolic control and the development of diabetic complications. Its low cost and nonpharmacological nature of physical activity further enhances its therapeutic appeal. 


Replay to K. Moore, C. Thompson and R. Hayes. Diabetes and extreme altitude mountaineering. Jordi Admetlla, GP. IEMM. IDEA2000 Expedition Doctor. Conxita Leal, GP. IEMM. Anton Ricart, Intensive Care Medicine. IEMM. Br J Sports Med 2001; 35:83 © 2001 the British Journal of Sports Medicine.
After a long time working with diabetic mountaineers we were pleasantly surprised by the article of K. Moore, C. Thompson and R. Hayes. Diabetes and extreme altitude mountaineering. However we would like to make further suggestions. 
We had the privilege to participate in the IDEA2000  expedition (International Diabetes Expedition to Aconcagua) when 7 of 8 type 1 diabetics reached the top of Cerro Aconcagua (6950 m) on January the 12th 2001 without significant medical problems. The only climber unable to make the summit reached 6700m and decided to go down due to a problem not related with diabetes. His blood sugar at that moment was 194 mg/dl.
The main medical goal of such expedition was to find the correlation, if any, between altitude, exercise, diet, glicaemia and insulin. 
None of the climbers took any drug to prevent Acute Mountain Sickness (AMS), but one during the approach to base camp used acetazolamide, for AMS treatment. We were reluctant to use drugs as acetazolamide or dexametasone in diabetic climbers because of the possible added risks. Some are well known (hyperglicaemia and dexametasone) but might there be a relationship between an acidifying drug as acetazolamide, respiratory alkalosis and ketoacidosis?
Regarding the incidence of AMS in diabetics, no data is available. The majority of IDEA 2000 group were diabetic (8 diabetic and 3 non diabetic), and precautions were taken to avoid AMS with a steady acclimatization. The “feeling” is that AMS incidence might be similar to that of the general population. Above 5000 m some of the diabetic climbers experienced hypoglicaemias after dinner with nocturnal hyperglicaemias. We attributed this fact to a delayed absorption of carbohydrates at altitude and rapid absorption of Lispro Insuline used by the main part of the group. We recommend delaying the administration of insuline until the end of dinner.
There were no problems with glucometers. The devices were protected with self-made bags with a hole for the strip and a plastic window for the screen. They were carried next to the skin.
One of the members of IDEA2000 has meadured his glycaemia as high as 8200m in mount Everest. He had tested the glucometer in hypobaric chamber at 5000m without big diferences with sea level. As expected all members of the team had hypo and hyperglycaemias managed succesfully. Glycaemia was monitored on average 7 times a day. The expedition doctor had to intervine only in one case of medium post-prandial hypoglicaemia at 5000m.
In a previouos enquiry between type I diabetic climbers 15 out of 24 had reached altitudes above 4000 m (15 above 5000 an 3 above 7000m). None of them have reported major complications at altitude nor taken any drugs to prevent AMS. In climbs under 3000 m hyperglaemia related with dehydratation (2 cases) or extensive solar burns have been reported, all of them self-managed and were resolved before reaching hospital. 
An optimal management of the diabetes, together with progressive acclimatization were the key for success. Al the team had good skills at self-monitoring in the worse weather conditions and to calculate insuline and carbohydrates and ability to handle early hyper and hypoglicaemia.
Climbing mountains at high altitude is a risky sport. Diabetic climbers should not avoid going to altitude if they are aware of risks probably increased, of the importance of frequent self-monitoring and are acclimatize slowly enough (with no drugs) to avoid AMS.


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