How to Thru-Hike with Type 1 Diabetes
I hiked the PCT last year with Type 1 Diabetes and I am here to impart some of the lessons that I learned along the way. Diabetes was definitely an extra challenge that brought with it extra supplies (and thus extra pack weight/volume), more complicated resupplies, additional anxiety, and a host of other things that made a hard thing even harder, but I will forever be grateful that I did it. I hope that some of these tips that I learned the hard way can help other T1D hikers live their best dirtbag lives despite never being able to quit the forever job of being their own pancreas.
Resupply is a complicated topic, even if you’re not Diabetic. When it came to food, we decided to send resupply boxes to the smaller towns where we heard grocery stores were either incredibly expensive, had limited options, or were not there all together. I think that for the most part this worked out pretty well. I made sure to always throw in some alcohol swabs and plenty of low snacks (more on that later) into each mailed box.
For Diabetes supplies, here’s how I handled things. You may think of a completely different strategy that works best for you, and that’s great! I’m just here to give you some ideas.
I started the trail with the insulin that would get me through to Kennedy Meadows, since I knew that I would likely be coming home at that point. When we flipped to Chester, I then carried insulin that would get me close to Washington. My husband ended up meeting us in Bend, Oregon for some days off, so I had him bring me a new vial to add in at that point. I swapped out the unused long-acting insulin pen (brought in case of a huge pod failure) for a fresh one when I went home at Kennedy Meadows.
As I’ll explain more later, I tried my best to keep my insulin at happy temperatures (aided by the pictured Frio case) and this ended up working just fine for me! It was a relief to not have to figure out pharmacies along the way for refilling insulin. If you don’t have the luxury of having someone meet you at some point to bring some fresh vials, there are plenty of towns with pharmacies that you could plan ahead on calling your prescription into. You could also risk it and bring the whole trail’s worth of insulin from the start.
- Omnipod pods
I made sure to start the trail with 5 pods (15 days) and had my husband stick in subsequent pods in resupply boxes. I usually did not carry more than 5 pods at a time and tried to avoid getting down to only 1 pod margin. You have to determine what your own fault tolerance and margin policy are (can you tell I’m an engineer?), and trade that off with weight. I was happy with this strategy.
- Dexcom sensors and transmitter
I started the trail with two Dexcom sensors (20 days) and an extra transmitter (3 months). I followed a similar strategy as the pods for resupplying the sensors. I never carried more than two at a time (they are large) and my husband brought me a new transmitter when he came to Bend, Oregon.
- Nasal glucagon
I carried my one Basqimi for the entire trail in my fanny pack and never had to use it. I highly recommend that you carry some form of glucagon and, just as importantly, make sure that your hiking partner(s) or friends on trail know what it is and how to use it. This can be the difference between life and death in the case of a bad low.
- Backup supplies
I carried a manual tester set (tester, lancet, strips, extra battery) for the entire trail and did use it many times when my sensor had issues or was in warmup periods after changing it. I also carried 5 syringes (in case of pod failure) and 10 pen needles (in case of pod failure and needing to use the long acting insulin pen). I never needed to use the long acting insulin but did use a couple of syringes when having pod issues.
A quick warning on the Omnipod controller (and other pump controllers): Do not have blind faith that your technology will not fail. My omnipod controller had a memory failure in the desert section by Deep Creek Hot Springs. I was INCREDIBLY lucky in that it happened when my husband had decided to surprise us with some trail magic at a road crossing. The controller rebooted and to reset all of the settings, and it required a wifi connection (which luckily my husband was able to do with a hotspot on his phone). If I had been out of cell service on trail, I would have definitely needed to convert to injections. Keep this in mind when planning your backup supplies!
Lows Will Happen – Be Very Prepared
I don’t care how nuanced you are with bolusing, or how perfectly you structure your nutrition – you will go low. And it will often happen when it least convenient, i.e. in the middle of a steep climb, on a part of trail with nowhere to sit for a break, in a shade-less stretch with nowhere to sit out of the sun, or in the middle of a sub-freezing storm that will take a toe if you stop hiking.
Always carry your low snacks where you can easily access them without stopping or taking off your pack or jacket. Stuff your shirt or shorts pockets, your fanny pack, or pockets on your pack straps. I was usually able to keep on trucking when I went low and just downed a bunch of gummies as I continued to hike, stopping only for those really bad lows that make your knees wobbly.
Add margin upon margin
Pack more low snacks than you think you’ll need. There was a stretch in Oregon during which my blood sugars just would not stop going low. I would hike with my pump in “activity” mode and wouldn’t bolus for snacks or meals but the high temperatures, climbs, and longer hiking days just really dragged my sugars down. I went through so many gummies that I had to bum some candy from another hiker to make sure that I had enough margin for the last couple of days. Yes it’s a drag to carry extra candy that you may not end up eating, but you never know when your body is just going to go through a different set of behaviors when you’re hiking such extremes every day so pack extra, then pack some more!
Think about the temperatures that you’re going to be hiking in. If you’re a low gummy person, know which gummies melt in hotter temperatures (I learned the hard way climbing out of Walker Pass in California that Haribo frogs quickly melt into an unmanageable mess) and which become un-chewable in cold temperatures (no one wants to break a tooth on a Haribo gummy bear in a snow storm with their sugars at 64 with two arrows going down). In hot temperatures, candies that have a slightly harder coating (think jelly beans) tend to be the most robust and in cold temperatures, really squishy gummies will fair well (like Trader Joes scandinavian swimmers).
Your Devices Will Peel – Be Proactive
Unless you are a human who never sweats, your pump or sensor or both will peel off at some point. Especially when the weather is hot and you’ve got a lot of climbing, your torso will be very MOIST (sorry) and this is not the ideal environment for adhesives.
Several times I had my Omnipod pump start to peel off early in its 3 day life, and whenever the peeling was bad enough for me to slap a bunch of leukotape on tape, I usually had crazy high blood sugars for the next 12+ hours until I gave in and just put a new pump on. Learn from my mistakes – start the hike carrying overpatches (like the Pod Pals for Omnipod) and put those on when you first attach a device. Don’t wait until it starts to peel half off, hope that the canula/wire is still inside of you and cover it in tape that will give you rashes, and then realize after many hours of being 300+ that the device peeled off beyond repair and you have to use another one between resupplies!
Keep Your Insulin Happy
Insulin is a fickle friend. It doesn’t want to be too hot or too cold and it’s stinkin’ expensive.
Keeping it cool
To keep my insulin from going bad, I used a Frio pack to keep it cool in the hotter temperatures. You can submerge the insert in a stream or any water source to activate the gel beads and I found that the insert would stay damp for a couple of days. I also placed my insulin strategically in my pack so that it had the least exposure to the sun’s heat. In addition, I was always mindful of where my pack was in shadeless breaks. I either put my pack in what little shade a bush would offer or would set my sun umbrella up to shade my pack.
Keeping it not too cool
In cool temperatures, you still need to be mindful of that liquid gold. Around San Jacinto and in the later parts of Washington, we hiked and slept in freezing and sometimes below freezing temperatures. Since my insulin lived in the middle of my pack, it was fine during the day but at night I would put it in a jacket pocket to make sure that it didn’t freeze.
Nutrition (or Lack Thereof)
While I did my best in the packed resupply boxes to provide a variety of nutrients and skew my food towards healthier, resupplies in towns definitely skewed towards junky. Even when I was eating better quality food on trail, it was way different macro nutrients than I was used to in normal life. I attempted to supplement with a multi vitamin, some supplements, and occasionally some greens powders and protein powder. Do the best you can!
Sometimes you have an ice cream bar and a diet coke for breakfast and call it a balanced diet. It’s a thru hike after all.
When to Bolus for Food
This was a really hard one for me. I played around a lot over the months of hiking with staying in “activity” mode on my Omnipod 5 for the day (which targets a blood sugar of 150), not being in “activity” mode (and using my normal target ranges), bolusing for everything that I ate, not bolusing for anything that I ate, bolusing for only breakfast…etc. While I don’t have the golden answer for you, I will provide you with some observations.
- Just like in my normal life, I was much more sensitive to carbs in the morning. This meant that I had to give myself SOME insulin for breakfast, but how much really depended on how quickly I was going to start hiking vs. when I ate, if we were starting with a climb or easy flat hiking, what I had packed for breakfast, etc.
- If I stayed in “activity” mode while hiking throughout the day, I couldn’t get away with zero bolusing for meals/snacks. This, however, made things a bit complicated because any insulin that I gave myself for food would be hyperactive in my system the second we started climbing. As a result, it seemed to sometimes work better to not be in “activity” mode while hiking, but stay with my normal blood sugar targets and just not bolus for the majority of what I ate throughout the day. This allowed me to have less chunks of insulin onboard, which seemed to help decrease steep lows.
- Once I got to camp and stopped hiking for the day, my blood sugar would be pretty sensitive to carbs once I ate dinner. It was always a balance between not wanting a huge spike and not wanting to go low at night with my low snacks in my Ursack far away from the tent. Once again, this was not a science and some nights my blood sugar was quite high. A few times I had to pull myself out of my warm quilt and trek over to the Ursack for gummies. Do your best.
Highs in Town – Consider Changing Ratios
You’ve been hiking day after day, climbing thousands of feet carrying a pack and eating whatever you want throughout the day with barely a thought of bolusing, just trying to avoid lows. You stumble into town ravenous for real food and in 10 minutes consume the world’s largest cheeseburger, fries, and a shake to top it off. You give yourself a bolus for it all, but still find yourself that afternoon flying high with sugars that won’t come down. Diabetes on trail is not the same as Diabetes in town!
This one is a do as I say, not as I do. In hindsight, I should have been less scared to really increase my boluses in town because your body is going from constant vigorous exercise to virtually none at all, and with way more calories and carbs than before. It’s hard sometimes to give yourself big boluses that you’re not used to seeing because of the fear of going low, but just expect that you’ll need a lot more insulin in town!
Device Placement on Your Body
You wear your pack for most of the waking day, so it needs to not be sitting on top of or hitting or rubbing against any of your devices. Because I have the Omnipod 5 and the Dexcom G6 (which talk to each other via bluetooth), I have to place them within sight of each other. I find the best placement for me that avoids snagging on branches and clothes the most is around my stomach. For the PCT, I purposefully would place my pump and sensor around my stomach in places that sat between the chest strap and waist strap. This worked great for me!
You Aren’t Going to Have Perfect Sugars
If you’re attempting a thru hike, your sugars are going to often be a bit all over the place and that’s ok. Do the best that you can to set yourself up for success. Then, accept that you’re doing a really hard thing and managing a chronic disease where you are your own pancreas is a separate really hard thing and it’s ok to not do either of those things perfectly. You will have highs, lows, technology failures…and you will see the most beautiful trail views, meet super cool people, learn a lot about yourself, and have a great time. Try not to be too hard on yourself and enjoy the entire experience, Diabetes and all.
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