Diabetes in Wilderness Athletes: Clinical Practice Guidelines (2019)

Wilderness Medical Society

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

November 27, 2019

In November 2019, the Wilderness Medical Society published evidence-based, clinical practice guidelines for wilderness athletes with type 1 or type 2 diabetes that included recommendations on the recognition, prevention, and treatment of diabetes complications.[1]

Before wilderness travel, a comprehensive cardiovascular disease risk assessment should be undertaken by individuals with diabetes, via their primary care provider and/or endocrinologist.

In asymptomatic wilderness athletes with diabetes, it is not recommended that routine exercise electrocardiography (ECG) be performed to screen for coronary artery disease.

Protection of insulin against environmental extremes—eg, high or low temperatures, light exposure, and physical agitation—is important in the wilderness. Before a method of protecting insulin from physical and/or temperature-related wilderness hazards is employed, this strategy should be evaluated in a low-risk environment. A separate location should be used to store a contingency supply of insulin.

Patients with insulin-dependent diabetes should undergo blood glucose monitoring before, during, and after intense and/or prolonged exercise.

If protocols for glucose monitoring and carbohydrate intake in exercise are planned, the patient should learn to adjust carbohydrate intake based on blood glucose and exercise. The patient’s medical and exercise history, as well as environmental stressors, should be taken into account as a means of individualizing this plan.

Wilderness athletes with type 1 diabetes should learn insulin dose adjustment using either multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII). Medical and exercise history, as well as the patient’s environment, should be used to individualize this adjustment strategy. Before patients engage in wilderness activities, a detailed discussion of insulin adjustment should be undertaken with their primary care provider and/or endocrinologist. Also prior to an expedition, any device being used should be thoroughly explained.

Persons with insulin-dependent diabetes should recognize the signs and symptoms of ketosis, carry a serum and/or urine ketone testing kit, and understand the means of managing ketones during wilderness activities. Carrying both a serum and a urine ketone testing kit may be a good idea, since this provides an alternative assessment method should one fail due to environmental conditions.

Both hyperosmolar hyperglycemic state (HHS) and diabetic ketoacidosis (DKA) should be considered medical emergencies in which the patient must emergently be removed or evacuated to definitive care.

An evacuation plan should exist in case of a hyperglycemic emergency.

Patients with insulin-dependent diabetes should know how, when hyperglycemia arises during activity, to adjust insulin doses. This adjustment strategy should be built around patients’ individual experiences during exercise and training and their previous exposures to environmental stressors. A detailed discussion of the strategy should be undertaken with a patient’s endocrine provider prior to a wilderness adventure.

For more information, please go to Type 1 Diabetes Mellitus and Type 2 Diabetes Mellitus.

For more Clinical Practice Guidelines, please go to Guidelines.


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