#8 Altitude Distress (May 2013)

Acute Mountain Sickness is generally associated with elevations over 8,200' (2,500 meters) though Bill experienced it at 7,000' when in the Grand Canyon last year (read more about his hair-raising experience: "Fitness Focus #3, Walking Out"). But as Bill has repeatedly demonstrated, he can be miserable at 7,000' without actually having the all of the symptoms of acute mountain sickness like: sleep disturbance; sore throat & cough; irregular breathing; lethargy; and decreased performance, especially cognitive.

Bill has learned much over the last several years about what we call his 'altitude distress' and is slowly learning how to manage it. Below are our suggestions for coping with the problem should you know his pain.

"Ta-Da." 8750' at Guadalupe Peak, TX & smiling.
Manage the Weight
Bill can sit around at 10,000' and feel fine if he isn't or hasn't been exerting, so it's not just the altitude that bothers him at 7,000-10,000', it takes exertion to trigger the dizziness, the headaches, the slightly ill feelings. One way to reduce the level of exertion is by decreasing the weight you haul up the mountain. For Bill, that knowledge motivates him to keep his body weight down because even 5 extra pounds can make a big difference in the energy output when going uphill.

In addition to containing your body weight, scrutinize the contents of your pack looking for opportunities to shave a few more ounces or pounds. Perhaps a lighter weight, less heavily engineered pack would help. We forfeit the handy pockets, zippers, flaps, and padded straps on our packs to decrease the weight that we feel with every step. And sort through your pack's contents carefully, looking for duplicated items or items that can be eliminated or replaced with lighter versions. Replacing cameras and flashlights with newer, lighter models creates a significant opportunity to trim the weight, as well as going with lighter jackets and rain gear. Keep in mind however that both the actual temperature and wind-chilled temperature will drop the higher you go.

And re-evaluate your footwear for weight. There can be a significant weight difference between different pairs of shoes and boots--consider going lighter instead of sticking with what you've always worn to decrease your accumulated energy output.

Food & Fluids
On the Trail
Drink, drink, drink is the professional advise to avoid adverse altitude effects and Bill, the reluctant hydrator, has learned the hard way that he must apply himself to keep his hydration level up. But the pay-offs can be rapid if he gets short on fluids and chugs some water. Starting well hydrated is a good habit too and means you won't have to carry quite as much water on the trail..

If you are huffing and puffing at moderate elevations and feel like you are depleted, try eating your lunch early or having a substantial snack of over 200 calories. We find that one's need for additional calories can defy logic when exerting, but if you are hungry or dragging, you need more to fuel the exertion. Note what you find most palatable when feeling depleted. Sugary foods are often appealing but we've found that when we are the most needy that we really prefer bland foods like bread or canned garbanzo beans (an acquired taste). Having an assortment of foods to choose from helps too, like bread, cheese, chocolate, nuts, and dried fruit.

The nitrates/nitrites in cured meats give Bill a "hot dog headache".
Long-Term Perspective
One of the many lessons Bill learned the hard way about his altitude distress was that he is subject to "hot dog headaches" without eating hotdogs. The fun phrase describes the headache that some people get from eating nitrates/nitrites. Interestingly, Bill is borderline enough that he only gets the headaches when he eats nitrates and exerts at altitude.

The cosmic joke on Bill was that about the only time he ate nitrates was when we were in the Alps and he treated himself to the cured meats of Austria and Italy. Some nice tasty morsels at the B&B'a breakfast buffet would be followed by biking over a pass or hiking a peak and Bill would disintegrate in distress on the way up, barely making it and feeling absolutely miserable. Once he eliminated the nitrates/nitrates, that particular pattern of distress completely evaporated. Read the labels, but nitrates/nitrites are generally in cured or preserved meats, though are occasionally added to cheeses and other foods. They were originally used as preservatives but now are largely used as flavor enhancers.

In January of 2013 we switched to a gluten-free diet on a trial basis and it took all of about 48 hours for us both to conclude that the trial was over, we had officially switched to gluten free. We became increasingly convinced over the weeks and months as our own patterns of cranky-guts improved. In addition, Bill noticed a number of other improvements, including increased tolerance for exerting at elevation. Go figure….. Our guess is that by removing the irritant from his body that his body became more resilient in many ways, elevation stresses being one of them.

Moderating Output
Bill learned when hiking in the Alps around 9,000-11,000' last summer that he could safely make it up to those high points on the trails if he carefully managed his level of output. Early in the summer of that year (2012) we discovered that our 15 year old Suunto sports watch with altimeter had a feet/minute reading. We switched from tracking our heart rates on other devices to seeing how high we could push the feet/minute rate on "Al" our altimeter.

Summiting on this 10,700' peak near Soelden, IT took careful pacing on Bill's part.
We quickly learned from staring at Al as we cheered ourselves on that 33-36 '/min was a robust rate (our gauge reports in "three's"). Once in a while if the footing was excellent on a really steep slope and we were feeling spry, we could touch 42 or 45 whereas on well-graded trails we might max out at 18. When Bill was bumping up against his physiological limits at altitude, 21 '/min was the magic number. His willfulness and strength made it easy to go much faster, but higher rates weren't sustainable for the comfort of his brain at elevation. But if he reigned himself in when hiking and kept his rate of gain at 21'/min or less, he could cruise up to the higher peaks with relative comfort and safety.

There are several prescription medications for preventing or minimizing elevation un-wellness but of course, they have some nasty side effects that made Bill less than enthusiastic about trying them. In 2012, the same year that his doc gave him a prescription for one of the drugs, I read about a small study using ibuprofen for altitude adjustment and the study demonstrated that ibuprofen was as effective as the common prescription medications.

Bill tried the ibuprofen approach once later in 2012, was unimpressed, and didn't try it again. In the spring of 2013 after spending about a month living in the SW at 6,000-7,000' and still having altitude challenges, he tried the ibuprofen strategy again and Bingo! it worked like a charm. Why the difference? Who knows but perhaps having eliminated some of his general health problems by being gluten free had created space for the ibuprofen benefits to register for him.

If you want to know more about using ibuprofen, the study was reported in the March 22, 2012 edition of the Annals of Internal Medicine. Briefly, the study looked at the effect of using 600mg ibuprofen (usually 3 standard tablets) in 4 intervals, taken every 6 hours. The study was done using subjects that were unacclimated and were rapidly going from 4,000' to 12,000' by car. The study found that the use of the ibuprofen resulted in a decreased incidence and decreased severity of altitude effects. The efficacy of the ibuprofen regime was similar to that of the 2 prescription drugs, acetazolamide and dexamethasone, and it was safer than both of those products.

Bill has found that he gets sufficient relief from his symptoms by using 400 mg or 2 regular tablets of ibuprofen 3 or 4 times a day, though he hasn't tried 1 or 3 tablets at a time. He takes 2 tablets at bedtime the night before a high elevation activity; 2 when he gets up in the morning; 2 more at noon; and the last 2 around dinner or bedtime. If it's a single event, he takes a total of 4 doses with one being post-activity to help him avoid feeling off the next day. If we are exerting at elevation day after day, he takes 3 doses per day, combining the current day's post-activity dose with the next day's 'night-before' dose. He is pleased to be taking half the total recommended amount of ibuprofen as generally 'less is better' when taking medications (antibiotics of course are a major exception to that rule).

Quite unexpectedly, Bill even benefitted from taking a first dose of ibuprofen well into a day's activity when he had been feeling bad for several hours. We were biking from Bandelier to Los Alamos, New Mexico, which was around 8,000' high and he was dying. He felt miserable, had no energy, had to snack often, and had stop to rest frequently on the 10 mile course. At lunchtime, he popped 2 ibuprofen and when he hopped on the bike for the return trip 2 hours later, he was a rocket going up the steep hill at the beginning of our ride. On the way out to Los Alamos, I had to pedal slowly and pause often to stay with him; on the trip home, he left me in the dust--a stunning different from taking 2 ibuprofen after already being in distress.

Nutritional Supplements & Nutrients
CoenzymeQ10 is a vitamin-like substance available on nutrition department shelves that Dr Andrew Weil recommends taking in advance of activity at elevation to aid in acclimation. He recommends 100 mg/day of CoQ10 for 2 weeks before reaching higher elevations and continuing to take it during the stay. I've hiked several summers in the Alps while taking CoQ10 year round and as well as last summer when I was not taking it and I didn't notice any performance difference between the summers, though I seem to have an average tolerance for altitude. Bill hasn't tried using CoQ10 for dealing with his altitude distress so doesn't know if it would help him or not.

Getting the sodium right keeps him smiling & safe on the high trails (Zion).
Salt (sodium) intake is never mentioned as a factor in acute mountain sickness and Bill hasn't found it to be an element in his altitude distress but for both of us, it's important to monitor our sodium intake when engaged in dangerous activities, like hiking the peaks. Our lifestyle choices that include a 'downward pressure' on sodium have landed us in the realm of dangerously low levels of sodium several times, which makes us unsteady on our feet. And we've learned the hard way that untangling the symptoms caused by being low in sodium from those of being hungry, weary, or ill from altitude or a virus can be daunting, especially when you don't feel well.

After a long, nasty, episode of headaches, malaise, and dizziness in late 2010 from diligently complying with the DASH diet recommendation that everyone limit their sodium intake to 1500mg/day, we determined that we each needed somewhere between 2,000-2,500 mg of sodium or more per day. Unfortunately, I inadvertently and unwittingly ran that experiment again in 2013. Decreased levels of salt snuck into our meals while shifting to a gluten-free diet in the spring of 2013 and it took over a month of feeling nasty for me to recognize what had happened. That episode was a good reminder that if you are like us and rarely eat out and eat very little processed food, that your sodium levels can dip unexpectedly low. (It was lower sodium content in the canned beans we bought on the road compared with those that we bought at home and a small change in cooking routines that caused my intake to dip below 2 g/day.)

The low sodium symptoms we each develop are slightly different; aren't the ones you read about in the first aid literature; and they mimic mild viral infections as well as being under hydrated or short on calories, which makes for a difficult diagnosis. The symptoms come and go on a given day but persist day after day after day, making them all the harder to interpret. Being low in salt makes us unsafe in traffic on our bikes and unsafe on the trails. And once the low sodium symptoms set in, it can take weeks to fully re-stabilize our levels. If your sodium intake runs on the low side, you may want to do as we do and carry a baggy of salt when hiking at altitude so you can treat it promptly if you think low sodium might be a source of your distress.

The State of His Art
That's it for what Bill has learned about overcoming his body's resistance to exerting at altitude. Of course the advise of the ER doctors in Flagstaff who thought he was having a heart attack at the Grand Canyon in 2012 was to avoid altitude. But we love being in the peaks and hiking and biking above tree line so he has been motivated to find remedies and coping strategies for dealing with his altitude distress. Each year Bill has been able to push the altitude at which he can exert comfortably a little higher; maybe he'll conquer 12,000' in 2013.