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Finding the sweet spot

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June 2023 Issue

People with diabetes face extra challenges when they go tramping but with a few considerations, no trip is beyond reach.

“Nature has a way of distracting you from the daily grind of diabetes, but food and blood sugar levels are often on my mind while out tramping,” says Rebecca Ryan. She was diagnosed with Type 1 diabetes 13 years ago, but this hasn’t curtailed her love for the great outdoors. “I love day trips, but the best adventures are always the longer ones. When I’m out walking long distances, days at a time, I’ve got to keep a close eye on my blood sugar levels and adjust my insulin. But I know my body pretty well and mostly how it will respond to walking long distances.”

More than 250,000 people in New Zealand have diabetes. This chronic disease affects blood glucose levels and occurs when the pancreas is unable to produce insulin or when the body can’t use the insulin it makes. Insulin is the molecule that enables glucose (from carbohydrate-based foods) to  enter body cells to provide energy. 

Sports dietitian Conrad Goodhew describes insulin as being like a key. “In Type 1 diabetes, sufferers don’t have the key to unlock the door into cells,” he says. “Type 2 is where the lock is a bit jammed so despite there being a key (usually) the door struggles to open. Type 1 is an autoimmune disease and Type 2 is generally more to do with lifestyle.” 

If insulin can’t be produced or used effectively, blood glucose levels increase. This is called hyperglycaemia and it can lead to organ failure. People with Type 1 diabetes need to inject insulin to prevent this occurring.    

At the opposite end, low blood sugar or hypoglycaemia occurs when too much insulin is taken. Among a multitude of causes can be low food intake and intense exercise. Reactions include an accelerated heart rate, dizziness, confusion and, potentially, seizures or loss of consciousness. In the backcountry, such reactions could be problematic. 

Dr Rosemary Hall says diabetic trampers need to know how to manage the unexpected

In May 2012 David Charles Palmer, an experienced tramper with Type 1 diabetes, went for a solo day hike in the Ahuriri Valley in North Otago. The 53-year-old Dunedinite didn’t come home. Two weeks after he had gone missing, Palmer’s body was found in a creek bed. A coroner later ruled he had died within the first 24 hours from exposure complicated by multiple injuries sustained in a fall. The coroner also noted that Palmer’s diabetes was likely to have reduced his survivability.

Palmer was one of the unlucky ones. According to the NZ Mountain Safety Council’s most recent search and rescue data, few search and rescue incidents have been caused by someone becoming hypoglycaemic.

“The more common scenario is that a person with Type 1 diabetes goes out for what they intend to be a short walk without carrying their medication or their food – but they get delayed and become anxious that their sugar levels will fall, so they call for assistance,” says operations manager Nathan Watson. “This happens a few times a year.”

Even with medication and food on hand, a blood sugar low can happen on a tramp.

“I’ve had plenty of hypos [become hypoglycaemic] while tramping, but nothing too serious and nothing an extended rest stop and snacks couldn’t fix,” says Ryan. “My insulin pump once alarmed for a low during the night in a hut with lots of other trampers. But it was a quick fix with Mentos and, after apologising for waking up the others, it was an opportunity to discuss hiking with Type 1 diabetes at breakfast the next morning.”That’s the good news – diabetes needn’t stop a wilderness lover getting into the hills. It just requires more thought and planning, says Dr Rosemary Hall, endocrinologist at Wellington Hospital and president of the New Zealand Society for the Study of Diabetes. “Anyone going tramping should know they are fit enough and prepared with the right gear, know their boots are comfy and their pack fits. It’s the same for people with diabetes. But in addition to the tramping gear, people need to know how to manage the unexpected from their diabetes.”

For people with Type 2 diabetes who don’t require insulin or other diabetes medications, exercise is important in managing blood glucose levels. But for people with Type 1 diabetes, managing blood glucose levels during exercise can be challenging, says Cushla Holdaway, a sports dietitian. This is especially so as glucose levels fluctuate throughout the day. Responses will be individual and depend on various factors, from stress and temperature to food eaten and the amount of exertion.

In general, aerobic activities such as hiking reduce blood sugar levels because more glucose is used by muscles for energy. Holdaway says that the body becomes more sensitive to insulin, meaning less insulin is required to get sufficient glucose: “After about 30 minutes of moderate hiking, the supply of glucose from the bloodstream and stored reserves starts to reduce causing blood glucose levels (BGLs) to drop. Non-diabetics can continue to hike without consideration as the body has a backup system that tightly controls BGLs. With Type 1 diabetes these back-up systems don’t work effectively and maintaining BGLs within a normal range can be more challenging.”

Jo Halley says she would have to plan walking Te Araroa differently now that she has been diagnosed with Type 2 diabetes

For Type 1 diabetes sufferers, it can mean there’s a lot to think about when going tramping.

“Blood sugar levels were top of mind when I was in the hills,” says Jim Maxwell. “I had to stop often to do blood tests and my companions would tell me it was time to check my levels when they had a rest. I was testing about every hour when on the move. My biggest fear was having a companion set off their PLB and have me helicoptered home.”

Ryan uses a continuous glucose monitor when tramping to keep her levels in check. But that is only a convenience.

“I like to carry at least double the amount of supplies I would normally need for a multi-day adventure, just to put my mind at ease,” she says. “Vials of fast-acting insulin for my pump, a spare pen, needles and a pen of long-acting insulin in case of a pump failure, pump sites/cartridges/needles, battery packs for charging my pump and phone. I also always carry test strips and a spare blood glucose monitor in case of failures. And double or triple the amount of snacks I would usually have.”

Food on a tramp can be tricky. Jo Halley was diagnosed with Type 2 diabetes when she was 66 shortly after completing the Te Araroa Trail. She now manages her diabetes through diet. That means pasta or noodles, dried fruit and hot chocolate are off the menu, replaced by more fresh fruit, vegetables, and nuts.

While still active, Halley says if she wanted to walk Te Araroa (TA) now she would need to do it differently. “To go tramping means a lot more weight and bulk. Fresh green veggies don’t travel well in a pack. One option would be to walk the TA in sections or to have a support vehicle stocked with fresh food meet me regularly. Another option might be to talk to a nutritionist and devise an adequate diet that could be sent ahead in resupply boxes.”

Goodhew acknowledges the weight of food can be a problem but he says there shouldn’t be much difference between those with or without diabetes. “There’s almost too much emphasis on needing to eat a certain way. It’s more about understanding the process and how you react to food. With tramping, mostly only about 20–30g of carbs per hour are needed, along with a broad range of different nutrients. This can come from nuts, muesli or oat bars with added protein and lighter energy-dense foods that contain protein, fat and quality carbohydrates, rather than focusing on quick-absorbing carbs like lollies, which are better for high-intensity activities.”

Holdaway adds that energy-dense foods with carbohydrates are key. She recommends energy bars, dried fruit and nut mix, cheese on crackers, peanut butter on grainy bread, sandwiches and freeze-dried meals.

Greater consideration is needed for those with Type 1 diabetes, Holdaway says, because the body remains more sensitive to insulin for up to 24 hours after exercise. “So care needs to be taken with food and insulin doses in the meals before, during and after activity … and an extra snack before bedtime might be needed to avoid hypoglycaemia during the night.”

Managing diabetes and tramping can seem like a challenge, but Holdaway says: “Don’t let diabetes stop you from doing what you love.”

Ryan can attest to that. “Tramping really clears the mind and reduces stress. It is such a rewarding pursuit with so many physical and mental benefits. Having Type 1 is part of the challenge. It just makes reaching the summit and making it to the hut at the end of the day all the more satisfying.”

Diabetes need not prevent you from tramping. Here are some top tips for doing it safely.

  • If you’re new to tramping, chat with your diabetes team or a sports nutritionist/dietitian with experience in diabetes to discuss your requirements
  • Start with short walks and monitor how your body responds before taking on challenging trips
  • Carry extra supplies for ‘just in case’ and always carry a personal locator beacon
  • Make sure boots fit well and are broken in – people with diabetes often have reduced sensation in their feet and reduced ability to fight infected blisters
  • Educate your walking companions about diabetes including the warning signs for hypoglycaemia, and have food/medication on hand that companions can access easily
  • Know what to expect regarding a trip’s difficulty and duration and know which foods work best for treating hypoglycaemia when walking
  • Eat regularly and test often – a continuous glucose monitor could be more convenient than finger-prick testing
  • Some diabetes kits and medication are temperature sensitive and may not work accurately when exposed to extreme heat or cold. Keep your kit close to your body to avoid extremes. Some kits, like glucose meters, may also be affected by altitude.

These food snacks contain 20–30g of carbohydrates – the recommended hourly intake to power your tramping

  • Medium banana
  • 3–4 small bliss balls
  • 1 slice of bread with jam
  • 1 small bread roll
  • Oat-based muesli bar
  • 50g slice fruit cake
  • 2–3 gingernut cookies
  • 40g dried fruit and nut mix
  • 4–6 grainy crackers with cheese

– Source: Cushla Holdaway