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Medicine for the Outdoors

Dr. Paul Auerbach is the world's leading outdoor health expert. His blog offers tips on outdoor safety and advice on how to handle wilderness emergencies.

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Diabetes on the Rise

Persons who participate in outdoor activities often have chronic medical conditions. One of the most prevalent of these, particularly in the U.S., is diabetes.

Diabetes mellitus is a disorder in which the pancreas cannot create sufficient insulin (type 1 or insulin-dependent) and/or in which insulin is not effective (type 2 or non–insulin-dependent). Insulin allows the body to use and store sugar; in the diabetic state, the victim suffers from high blood sugar and an array of physiological derangements (kidney failure, skin ulcers, bleeding into the vitreous of the eye) associated with deterioration of small blood vessels. Many diabetics need to take insulin by injection or inhalation to manage the disease; others can control their blood sugar by diet and/or oral medications (hypoglycemic agents). The latter include drugs that stimulate pancreatic cells to produce more insulin, reduce sugar production in the liver, reduce carbohydrate absorption and sugar “peaks” after eating, or reduce insulin resistance in the body. Insulin analogues, such as insulin lispro, are rapidly-acting and when used in conjunction with standard insulins, which have longer onset and duration of action, can allow the outdoor enthusiast who suffers from diabetes to have greater flexibility in the timing of meals, snacks, and exercise. Insulin is available in an inhaled form .

The most common dangerous acute situation incurred by a diabetic is a hypoglycemic reaction (low blood sugar) induced by an inadvertent overdose of insulin, or after a normal dose of insulin or glucose-lowering agent accompanied by extraordinary exercise or insufficient food intake. The manifestations of an insulin reaction are weakness, sweating, hunger, abdominal pain, and altered mental status (which may include confusion, belligerent behavior, fainting, seizures, or coma). The solution is to administer sugar as rapidly as possible. If the victim is unconscious, it is generally prohibited to administer anything by mouth, because of the danger of choking and aspiration of food or fluid into the lungs. However, sugar granules or concentrated glucose gel (Glutose™: one tube contains 25 g) can be inserted under the tongue, to dissolve and be passively swallowed. Otherwise, sterile glucose solution must be injected intravenously, which obviously requires a trained individual. If the victim is awake and capable of swallowing, a naturally sweetened solution (apple or orange juice, sugar-containing soft drink), banana, or candy bar (chocolate, sugar cube) should be eaten. As soon as the victim feels better, he should eat a meal, in order to avoid a recurrence. Glucagon is a hormone that causes the liver to release glucose. In a hypoglycemic emergency, it can be administered into the muscle of the victim to raise the blood glucose level.

Anyone who suffers from diabetes should wear appropriate identification, in case he requires assistance. No one who is insulin dependent should attempt physical exertion in a dangerous environment without adequate glucose intake. Even a person taking an oral hypoglycemic drug should be similarly cautious.

If the blood sugar gets dangerously high, the diabetic may become very ill, because the blood becomes acidotic with the by-products of metabolism (known as ketones), dehydration increases, and body chemistries become unbalanced. Such a patient is confused, combative, or comatose. His breathing rate increases, breathing becomes shallow, and exhaled breaths have a fruity or acetone (like fingernail polish remover) odor. Because of dehydration, the skin is very dry and there is little sweating (dry armpits). Such a clinical picture calls for immediate transport of the victim to the hospital. If he can drink, encourage him to ingest unsweetened fluids. The definitive treatment for ketoacidosis is intravenous fluids and insulin injections, which must be carefully dosed according to the measured blood sugar level.

If you cannot differentiate between an insulin reaction (low blood sugar) and altered mental status due to excessively high blood sugar, you should err on the side of predicting a hypoglycemic episode and give the victim something sweet to eat or drink. If you have guessed correctly, the improvement will be dramatic; if your diagnosis was wrong, the extra sugar will not cause any significant harm. If a diabetic person is carrying a blood glucose monitor (such as FreeStyle Lite™, OneTouch®, or ACCU-CHEK®), be sure you are instructed in its proper use before you need to use it.

All of this information is essential because the prevalence of diabetes is on the rise in the U.S. Nearly a year ago, in October of 2008, the Centers for Disease Control (CDC) informed us about this. In a publication entitled "State-Specific Incidence of Diabetes Among Adults - Participating States, 1995-1997 and 20052007," and as reported by KA Kirtland, PhD, YF Li, MPH, LS Geiss, MA, and TJ Thompson, MS, of the Division of Diabetes Translation from the National Center for Chronic Disease Prevention and Health Promotion, we learned that diabetes is a major cause of morbidity and mortality in the United States, resulting in substantial human and economic costs. National survey data indicate that the incidence of diagnosed diabetes in the United States has increased rapidly and that obesity is a major predictor of diabetes incidence.

However, prior to this reporting, data on diabetes incidence had not been analyzed by state. To assess the geographic distribution of diagnosed diabetes and to examine state-specific changes, the CDC analyzed data from Behavioral Risk Factor Surveillance System surveys for the periods 1995-1997 and 2005-2007. The analysis indicated that, during 2005-2007, the average, annual age-adjusted incidence of diabetes ranged from 5.0 to 12.8 per 1,000 persons among 40 participating states, the District of Columbia, and two territories, with the greatest incidence observed in the South and Puerto Rico. In addition, among 33 participating states with data for both periods, the age-adjusted incidence of diabetes increased 90% from 4.8 per 1,000 in 1995-1997 to 9.1 in 2005-2007. This is a startling increase! While there are some limitations to the data collection method used, and therefore to these conclusions, they are consistent with prevailing opinion, and offer further guidance on what has been recognized as one of the most significant health problems worldwide.

Among persons at risk, diabetes can be prevented or delayed by moderate weight loss and increased physical activity. Development and delivery of interventions that result in weight loss and increased physical activity among those at risk are needed to halt the increasing incidence of diabetes in the U.S. Physical activity programs in the outdoors and promotion of a healthy lifestyle can possibly contribute to improving the situation.

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About the Author

Dr. Paul S. Auerbach is the world’s leading authority on wilderness medicine.