Sugar Rush



Posted by Jeremy Windsor on Apr 09, 2021

Jerry Gore was diagnosed with type 1 diabetes mellitus in 2001 and through his charity Action4Diabetics has done much to raise money to support youngsters diagnosed with the condition. In the 2020 Alpine Journal he wrote an extraordinary article describing a speed ascent of the 1938 Route on the Eiger's north face. Here’s an extract…

 

 “The alarm rang seemingly before I had set it and we were soon up and running. At 1.22am my blood sugars were at 60mg/dL (3.3mmol/l): that meant it was time to eat a lot! I have seldom been first out of the tent or snow cave. I’m always frantically scrambling to get all my bits and pieces together to avoid embarrassment. This time was no different. I hurriedly tested my blood once more at 2.26am: 75mg/dL (4.2mmol/l). This was still a little low but it was rising fast and I knew my carb-rich breakfast would counter the effect of the intensive exercise coming up. I injected myself with 2 units, 2 tiny drops of fast-acting insulin, slammed the refuge door behind me and ran into the night after my partner, Calum, who was already ahead of me, striding against the frozen blackness.

 

 The 1938 Route on the Eiger (3970m)


The black sky was a million tiny shards of light and I gulped it in as we raced across the base of the beast. It was cold, around -10 degrees C, but already our hearts were beating quickly. The lower snow slopes seemed to pass in an instant. We arrived at the Difficult Crack to find it empty and inviting. Soon we were pulling ourselves across the legendary Hinterstoisser Traverse and I saw the sun for the first time: a smoky yellow ball hanging low on the horizon. Freed from the bubble of light of my headlamp, I no longer felt the unreality of moving through the dark wrapped in layers. I understood this was really happening. We were on the Eiger. We climbed on, swapping leads, racing past the Death Bivouac and soon we were into The Ramp. Unluckily for us its magic veneer of ice had gone and we were forced to take turnsdry tooling technical sections of blank rock, pulling hard on ice axes hooked on millimetres of crumbly limestone. I loved this section the most since it reminded me of mixed climbs in Scotland. At the top of the Ramp I led the Ice Chimney. This overhanging slot rears up at you and was totally dry, devoid of all ice. The steep corner became a balancing act, each crampon claw scraping frantically against the smooth vertical sides. I had to take off my gloves so I could rock climb in places where I couldn’t find purchase with my ice axes. Having always been more of a rock climber than an ice merchant, the smooth, slightly crumbly surface of the rock felt good underneath my fingers and I felt agile, loving the movement over cold stone.


Whilst training for his Eiger climb Jerry wrote, "Usually I take 5 units of fast acting insulin before each meal and 11 units of slow acting insulin, with a 12 hour profile, before bed. When training I can drop these quantities by as much as 70%. Furthermore, the effect on my body after a big vertical run is greatest during the second night after the activity, not the first. So I am almost constantly in a state of forward planning with my insulin and if I get it wrong by just a few drops, I can find myself semi conscious at 3am with the bed soaked in sweat and my wife Jackie patiently coaxing me to eat a honey sandwich, her day having already well and truly started"

 

I emerged panting in dry air and suddenly felt a little weird. Normally that’s the sign of an approaching hypoglycaemic attack. I tested my blood: 70mg/dL (3.9mmol/l). My instinct was right. I immediately chomped down a Lion Bar and then a small fruit bar. I had 12 cereal bars for the entire climb and hoped I wouldn’t need more. I then swallowed a swig of water and carried on taking in the rope. Calum passed me with a grunt of acknowledgement.

 “Good lead Jerry; Brittle Ledges now.” Why did he always make me feel like he was the adult and I was the kid? So annoying. We climbed together up easy snow slopes that lead to the flat plates of decomposing cat litter that make up this feature. Calum led this, running around to the Traverse of the Gods. Things were going well but I needed to maintain focus. We were already into mid morning and I could feel the temperature beginning to rise. I led round quickly into the bottom of the White Spider and suddenly felt immersed in a time warp. So many climbers have written about this ragged white carpet, tilted at 65 degrees and littered with small black grenades. We were climbing together now, with no protection between us. If either of us had been hit or fallen, we would have pulled the other off.

 

Getting the right dose of insulin can be a challenge in the mountains. On a previous attempt to climb the Eiger, Jerry wrote, "The alarm went at 5am. We brewed up, gulped down muesli and packed the last remaining items. I had one last task to check off: my insulin injections. I normally inject both the slow-acting type and the fast-acting at 7.30am during breakfast. Now I decided to inject 75% of my normal slow-acting dose and just 60% of my fast acting. I should have spent more time researching and testing these doses because unfortunately for me I had guessed badly. We shut the door to the refuge quietly behind us and climbed towards the dark shape above us. We moved quickly and unroped up the initial 45 degree snow slopes but within 2 hours of leaving the hut I knew I was low on blood sugar. I stumbled upwards..."

 

Calum was suddenly struggling and after shouting down I realized he had a nosebleed. I headed for a rock cleft at the side of the Spider and clipped a piton or nail hammered deep into the crack. He joined me and I asked if he was OK. Just that once, for a tiny instant, Calum acted his real age with a dismissive shrug, as if to say, “It’s only a nosebleed. What’s the problem old man?” I asked him if it was OK if I led up the Quartz Crack just above us. This is the final barrier before the summit ridge, right at the top when it really is the last thing you want after all that precarious and mentally exhausting climing. It’s technical and smooth and your crampons are skittering on blank rock. I led round to a block and then had to wait with another team as a slow climber struggled above us. I could see the ice melting above me and knew each climber would take more of it away. When my turn eventually came the black crack was bare and I was forced to hook my way up, precariously fighting the cramp in my calves.

 

Ueli Steck setting a speed record on the Eiger of 2 hours 22 minutes 50 seconds in November 2015


We were now above the technical difficulties. All that remained were a few hundred metres of steep ice that fell back in angle as we moved up it until we popped out onto the summit ridge. We were now in the sun and it was still early afternoon. We knew we had time. At the summit Calum looked like he had just got out of bed. I looked like I had just done 15 rounds with Mike Tyson. But it didn’t matter. We were a team. Our time up the face was 7h 56m. It wasn’t a world record; it wasn’t even close. That didn’t matter either. We took a selfie and I tested my blood sugar again: 132mg/dL (7.3mmol/l). Perfect!"

 

Jerry, many thanks for giving us permission to publish an excerpt from "Sugar Rush" and agreeing to answer our questions. Can we start by taking you right back and asking you how were you first diagnosed with type I diabetes mellitus and the challenges you initially faced?

I was diagnosed 30th Jan 2001 aged 40. A day I remember well and a lovely 40th birthday present! Honestly! My diagnosis was the catalyst for our family move to the French Alps and a life of alpine happiness! When first diagnosed, as now, I did not see challenges. I never do. My attitude to life is always to look for and focus on the positives. Never look back only forward. Try and appreciate and enjoy every second of every day. Oh, and finally never, ever give up! Back to the question, I guess all I wanted to find out was would my condition stop me from enjoying my fast-paced action lifestyle of consultancy work, family life, lots of sports like rock climbing and mountain biking, and a new route expedition every year. The other (big!) challenge was finding different sponsors to support my expeditions. The day-to-day challenges of controlling my T1DM were easy for the first 2-5 years as I was in a long honeymoon period which I did not understand at the time but which I did make full use of. I learnt two important things pretty early on. Firstly, I learnt the most about managing my condition from other mountain mad T1’s. And secondly, I accepted almost intuitively that the patient has to become his/her own doctor asap, and that self-management is the ONLY long-term solution. I always knew that the only thing that really stops anyone is themselves. But my condition really hammered this important lesson home to me. Finally, I learnt that exercise (that makes your heart beat faster) is essential each day to maintain good glycaemic control. A minimum of 30 minutes a day.


Your extraordinary accomplishments on rock and ice may make it appear to those looking on that your diabetes hasn't held you back, but what have been the greatest hurdles you've had to overcome?

Not many to be fair so far. I found out from others with T1 about keeping your glucometer in a self-test bag round your neck – always warm and always accessible. And that I needed an insulated pen pouch to keep my insulin from freezing – thanks to my new sponsor Lifesystems I have a great set up for both. Finding accessible flesh for a jab in -20 degrees C conditions can be a bit of a shocker but you just learn to deal with it. On my 24hr endurance challenges I exist very happily on reducing my basal and bolus units by as much as 85% and eat cereal bars throughout the day, the number depending on the intensity of the activity. I will revert to this question again later, but I think doctors are wrong when they think the body cannot process sugars on low levels of insulin. I certainly can and many T1’s I know can. And to me that makes sense biologically. I am sure your pancreas produces far smaller amounts of insulin for a given amount of carbs when exercising hard. A matter of debate and research clearly. 


Many reading this extract will be surprised at how much insulin requirements change with exercise. Getting on top of this has clearly been an enormous challenge. What advice would you give to young athletes with diabetes when it comes to managing their insulin?

Again, like everything I keep it simple. I experiment ... constantly. First off, your condition changes with age and time. So, your units change. But each day I change certainly my bolus units. And often my basal. Just the same as pump users regularly adjust their pump. And actually, pump users start off by constructing a 24hr profile and find out when they are most and least insulin sensitive and program accordingly. This is basic stuff but very important. My activity schedule, and diet and work types change almost daily. Right now, as I write to you, I am sitting in Bedford catching up on admin before Christmas. My only training consists of hikes with a weighted rucksack and muscle maintenance sessions. Soon I will be traveling again to Italy and then France and headlong into intensive pre-expedition training. Each day I could do anything from a day at my desk to an endurance 2000m vertical hike. So, I have to change my dosage accordingly. But again, I think health car professionals must teach their patients to self-mange and work it out for themselves. And if they do T1’s will start to really understand what works for them. And as we all know each Diabetic is different so standard rules are not relevant if you are after good control.


Following your earlier attempt you decided to forgo most of your daily insulin for the climb. Whilst this meant that you avoided episodes of hypoglycaemia you effectively "shut the door" on carbohydrate as a source of energy. Your body would have relied heavily upon fat and protein metabolism to get you through. Clearly this approach worked! But is it sustainable?

Firstly, this question is inaccurate. I always have plenty of insulin to hand to use as and when I need. Running out of insulin on a climb is not an issue as it is light and easily transportable. If there is an issue it is on an alpine style when I might run out of food. Which has happened to me. That said let’s get to an important issue for a climber with T1 and that is the ratio of insulin to carbs for optimal performance when unlimited food quantities are not guaranteed. The body does need insulin to stimulate conversion of glucose into energy for sure. But similarly, I find you can reduce insulin a lot when exercising and still get by fine, especially if you’re reducing carbs too. So, as my good friend and fellow T1 Diana Maynard suggests, I think the question is really, “what’s the minimal amount of insulin you need to stimulate the uptake of carbs?” Or put another way, what’s the minimal insulin-carb ratio needed for this to happen effectively? Diana and I both suspect that this could differ quite a lot amongst T1’s. Especially if you train your body as I have, just as you can train your body to need less water or less food or fewer carbs to function effectively. Bottom Line is I have achieved many alpine and Himalayan routes where I have run out of food but never insulin as I always take plenty of spares. And I have not found I have run out of energy any more than my fellow non-T1’s. In fact, sometimes quite the opposite. On a Sea2Summit 24-hour endurance cycle and mountain climb (7,500m in total elevation and a distance of 250Km) I felt ok at the end whereas my vegan mate who was in the GB Olympic squad and is a 2-meter-tall endurance monster “died” on the final 4,000 mountain climb and could not complete it. He is 25 years younger than me and non T1.

Finally, on the question of sustainability, the longest mountain challenge as a T1 to date was a 4 week Himalayan commercial expedition, when I guided 9 clients to the top of a 6,500m very technical peak in Nepal. By the end because I had lost 4.5Kg. But then so had everyone else and I don’t know any Himalayan climbers who don’t lose weight at altitude. I also felt simply amazing fitness wise by the time we reached Kathmandu.


A few years ago you suffered a serious cycling accident. Could you talk us through your injuries and whether your diabetes had an impact upon your recovery?

In August 2017 I was knocked off my bike by a blind driver. I suffered a broken C6 and lost a lot of the deltoid muscles in my right arm. A year after my accident I completed the above mentioned Sea2Summit challenge raising over USD 100,000 for my charity Action4Diabetics. In brief, my condition had almost zero impact on my recovery as far as I could tell. But it is hard to know as I have only broken my neck once before during a sumo wrestling match at a Christmas party. But that really is another story. 


Could we finish by talking about your charity Action4Diabetics that you set up after your diagnosis. Who are you seeking to help and how is this done?

A4D (Action4Diabetics) is a UK registered charity focused on providing medical care and support to disadvantaged young people with Type 1 Diabetes in South East Asia. Together with my fellow co-founder Charles Toomey, we created A4D in 2014, offering medicinal and educational support to ten children with T1 in Yangon. We now support, via 5 different programs, more than 550 children with T1 aged from 2 to 25 years old. We work with clinics in Vietnam, Malaysia, Thailand, Myanmar, Laos, Indonesia and Cambodia and our organisation includes a strong team of Consultant Endocrinologists and Paediatricians. If you are interested in our work, please contact me at jerry@action4diabetics.org


Thanks Jerry.

We asked Dave Hillebrandt for his thoughts on Jerry's answers. Here’s what he wrote...

“Thanks for asking me to comment on Jerry’s blog comments as a mountaineering doctor with Type Three insulin dependent diabetes (a surgeon removed my pancreas!). It is great to hear from Jerry - I was also impressed when I read the Alpine Journal account of his fast ascent of the 1938 Route on the Eiger. I think the key phrase in his blog article is, “self-management is the ONLY long term solution”. He also makes it quite clear that he learnt more from other insulin dependent diabetic mountaineers than from the medical profession.  He is so right with both these comments and it reflects the need for the medical profession to listen to their patients and to work with them on a journey of mutual discovery when dealing with long term conditions.

I remember having breakfast with Jerry soon after he was diagnosed as a “type 1” and before I became diabetic. He was pondering the effect it might have on his rather unique life style. I would hope that if he was diagnosed today he would have more realistic support and advice from active climbing members of the BMMS. By trial, and a little error, he has obviously found a self-management regime that suits him. We all have to do this and I must admit I would be reluctant to make such marked reductions in my basal long acting insulin but we all have a unique physiology and all have different mountain objectives. His objectives can be fairly extreme compared to my more modest and less physically demanding objectives. I would caution new T1 mountaineers to make adjustments gradually as they build up their experience. 

As a doctor frequently advising diabetic mountaineers I detect two different groups who want advice when going into the hills. One are experienced mountaineers who become diabetic. They already have mountain skills and have to learn to adapt to managing their diabetes in adverse weather with quite extreme physical demands. They are well motivated and learn fast. The second group are non-mountaineers who have developed diabetes and now need to prove they can “conquer” a trophy peak. They have a lot to learn and little insight. Oh, and there's a third group who have even less insight but they just don’t ask for advice...

Whichever group you are advising (or fall into!) I would recommend reading the UIAA medical advice paper which is a free download from High Altitude Medicine and Biology".


Thanks to Jerry, Dave and the team at the Alpine Journal for allowing us to publish an extract from "Sugar Rush".

If you would like to find out more about mountain medicine why not join the British Mountain Medicine Society? See this link for details.

NEW DATE...

The Birmingham Medical Research Expeditionary Society (BMRES) and the British Mountain Medicine Society (BMMS) have joined forces to organise the 2021 Altitude Research Conference. The face-to-face event will take place in Birmingham on the 11th September. Speakers will include Peter Bartsch, Jo Bradwell and Chris Imray. There will also be presentations from members of the UK's leading research groups as well as ample opportunity for researchers, young and old, to present posters and short talks about their work.

Further details can be found here.


1 thought on “Sugar Rush

Robyn Johnston commented 3 weeks, 3 days ago
Always interesting to read of the experiences of those with complex medical conditions in the mountains. I've found as an expedition medic that these mountaineers have a huge amount to teach us as healthcare professionals. As Jerry said, much of it learn through trial and error, and I wish there was a better system of collecting all of this personal knowledge to share around! Two things that went through my mind reading this 1 - I seem to remember from my exercise science days that GLUT4 transport is insulin independent stimulated by exercise so maybe this explains some of the ability to drastically reduce insulin doses that Jerry writes about (I'm sure there's been lots more research on this since I studied!) 2 - Having been on a mountain trip with an experienced mountaineer also diagnosed in adulthood with T1DM, the one thing he pointed out to me was the inaccuracy of his subcutaneous glucose monitor (those magic buttons you scan with your iphone to show your blood sugar without a fingerprick). At one point his read 25mmol/L, which he luckily was sceptical about, and the fingerprick read 12mmol/L. Imagine if he had dosed himself based on this subcut monitor! Something worth being aware of. I imagine it was somehow related to the cold but would love to hear if anyone else has had this experience.

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