Insulin and snow

Type 1 and LADA
1

This seems like a straightforward question: How do you store insulin when you’re out in the snow? We’re taking our toddler for some snow play this weekend (to call it “skiing” or “snowshoeing” would be a stretch), and while we don’t anticipate being super far from the lodge, it seems prudent to keep insulin with us outdoors. I doubt we will do a site change in a snow drift, but still…

But then, is it a concern that it will freeze? How do you store it for these types of outings?

Also, any tips on how to adjust basal rates would be much appreciated. And do those glucose gummies freeze in the cold?

2

One suggestion I have heard a number of times (haven’t had the need to try it myself–yet), is to carry the insulin in an interior pocket, or at least one sufficiently protected so as to be partly exposed to body heat.

As far as the candy goes, anything containing water will eventually freeze, if exposure is long enough and cold enough.

3

Inner pocket works best for any of that - insulin, meter, food. I don’t keep any of my stuff in the jacket outer pockets. If you don’t have an inner pocket, you can get a spibelt or something that keeps it close to your body, under your coat. Your body will keep it from freezing.

I think playing outside in warm temperature makes it more pronounced than in the cold, BUT you will burn up so much fuel being out in the snow just walking, compared to normal conditions. And there will be much more running than normal - what kid will take a slow leisurely walk when there is snow all around him!? When you add in snowball fights and snowmen, that BG will take a big drop!

4

His endo may help you out with samples of injectable insulin you can carry on an inside pocket - mine even had an extra meter and strips I could carry so my primary equipment and med is safe at home…have fun :blush:

5

I am out in 0-20 degree F weather on a regular basis and an interior pocket seems to work fine. If you are going to do any testing with a meter, your meter and test strips probably need to be kept in an interior pocket too, at least my meters give error messages if they are below 40 or so.

You could also use a frio insulin pouch, which is normally used to keep insulin from getting too hot, but it also works as insulation to help keep insulin from freezing.

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6

UPDATE: Well, the good news is that our insulin did not congeal into frozen crystals. The bad news is that our toddler was very spooked by being out in the snow and seems to equate snow with being abandoned to a cold, lonely death. And our trip ended early when he developed high ketones :fearful:

Our son was running high and getting sick when we got to the mountain town (elevation approximately 8,000 ft), so I had set a sick basal that is higher than his typical by about 15%. That worked for the morning, he didn’t go high, he didn’t go low, despite the higher basal rate and the “activity” in the snow (read: us lugging him up the hill over and over again so he could tube down, because he hated even having to walk in the snow).

I must have jinxed things because I told my husband “well, the trip’s not over but so far it’s been pretty smooth sailing.” He ate dinner, we bolused for only a portion and he peaked at around 144 mg/dL. It was time for a site change so my husband did that…and he stayed between 140 and 120 for most of the night, even briefly dipping down to 85 at his usual time when he tends to dip low.

Then at around 4:30 or 5am he started slooowly drifting low, we gave him a gummy, and that didn’t raise him. So we gave him another and he started skyrocketing from about 68 to 200. At that point, we went to give him a bolus and my husband realized he had never hit ‘OK’ on the last screen on the pump while changing the reservoir, so it was not delivering insulin all night long (NOTE: this seems to be a design defect, because if the pump was suspended it would alarm periodically to warn you, but simply not finishing up a reservoir change apparently never triggers an alarm).

We tested his ketones and they were high at 3.4. So, we slightly panicked, cranked up the insulin, gave him a super carby breakfast, more insulin, more water, and four hours later he was down to trace ketones and a blood sugar of 102. But by then snow play for the day was nixed because we didn’t feel comfortable with him romping about with high ketones.

This whole fiasco has raised so many many questions for me.

  1. If he was generating so many ketones overnight, why was his blood sugar so bloody steady? Was it something to do with the altitude?
  2. OIf zero insulin kept him perfectly steady at his target blood sugar for 10+ hours then would there have been any way for us to have kept him from both going low and free from ketones if he had been connected to the pump?? He had only 20 g of carbs at dinner, but he wasn’t hungry for more.
  3. How can I have any reassurance that he will not go into DKA if he generates ketones at very normal BGs?
    Yesterday was his BEST DAY in 3 months:
    Screen Shot 2016-12-19 at 4.15.02 PM.png984×527 33.1 KB

    When he was at 3.4 I tested his BG by finger prick and it was only 203 – a number we see many times in a week. I’m just super scared at this point that my son is just very prone to spiraling into ketone generation if he has even slightly fewer carbs than normal and has any dearth of insulin. He is too young to understand the symptoms of DKA, but he was complaining of feeling tired and having a tummy ache today. Those, however, are symptoms he has multiple times a day for various reasons.
  4. Does anyone have a more scientific explanation of how altitude changes insulin sensitivity, aerobic respiration, insulin needs, etc? Everyone just told us that their kids tended to run low when in the snow at altitude, but for us that seemed to be only sort of true.
  5. How could he have drifted down to 68 at night when he hadn’t gotten insulin for almost 10 hours?? And yet he was surely and most definitely developing ketones at that time.

Thinking we may really need to set him up with the untethered approach. I’m just too concerned with him developing ketones otherwise.

7

There are so many things at work here.

When your body adjusts to higher altitudes, it can cause your body to release extra cortisol, which is a stress hormone that can help your body cope with the lower oxygen levels that exist at high altitudes. Stress hormones can cause a rise in blood sugar levels.

However, on the opposite side, at a higher altitude our hearts have to beat a little faster, which can lead to more rapid absorption of insulin. And generally, more activity in places like the beach or in the snow would greatly reduce the amount of insulin that is needed. Same type of thing for kids at diabetes camp, they usually advise a reduction in basal for their time when they are at camp because of the activity.

You said:

Again, that type of stress would raise the insulin needed!

So, unfortunately, it’s one of those things that can be totally unpredictable, because you have factors working for both raising and lowering BG. I am sorry about your experience. But as you know, all these things are opportunities to learn and adjust. And of course, in the diabetes world, that’s what we do every day. Hopefully you guys can have a better one next time!

Wishing you the best!

8

[quote=“Tia_G, post:6, topic:58035, full:true”]
5) How could he have drifted down to 68 at night when he hadn’t gotten insulin for almost 10 hours?? And yet he was surely and most definitely developing ketones at that time.
[/quote]The ketone thing is puzzling.

Dropping BG in the absence of insulin isn’t completely nuts, however. There are a variety of tissues in the body that absorb and metabolize glucose without any insulin signaling at all. The CNS comes to mind, for example.

So, coming off a day of significant physical activity it isn’t completely mysterious that he might drift down even without insulin. The fact that you under-bolused at dinner and his BG still stayed pretty tame is a strong sign his metabolism was revved up for hours after the day ended. I’ll bet its nothing more than this.

9

@Dave26, do you happen to know which organs can only transport glucose into the tissue using insulin? It’s my understanding that certain tissue, such as the brain, doesn’t need insulin at all, whereas other types of tissue, such as muscle, usually requires at least some insulin but, during intense aerobic exercise, it can activate certain receptors to help ferry glucose into the cell without insulin.

I’m guessing there’s a very very fine line for my son, where he needs some small but fairly constant amount of insulin for the former type of tissue, and the latter has quite variable needs day-to-day, so maybe when he was somehow up at altitude, his muscles was able to take in a lot of glucose from the blood without insulin while still being in a net deficit for other tissues… I guess knowing exactly how much each of those types of tissues typically needs to function could give a sense of how much insulin needs to be active in his body at any given time to prevent ketones, regardless of his BG.

Still, it’s just scary to me that my son develops ketones in such bizarre circumstances, and seems to be so sensitive to even mild-carb reductions. (of his own choosing!)

10

Tia, unfortunately this isn’t something I’ve looked into in depth, so my knowledge is general. That said, my understanding is that the most insulin-reactive tissues are hepatic (liver), skeletal muscle, and adipose (fat).

As you noted, skeletal muscle has some ability to transport glucose even in the absence of insulin, which in part accounts for the greater “insulin sensitivity” after exercise, and the reduced insulin requirements due to exercise.

11

This book has answers to all your questions.

Biochemistry, 5th edition
Jeremy M Berg, John L Tymoczko, and Lubert Stryer

The whole thing is informative, but your questions are addressed in Section 30 - “The Integration of Metabolism”. And particularly section 30.2 - “Each Organ Has a Unique Metabolic Profile”. All of section 30 is extremely informative.

https://www.amazon.com/Biochemistry-Lecture-Notebook-Tymoczko-Paperback/dp/B011DC00NU/ref=sr_1_1?ie=UTF8&qid=1482291475&sr=8-1&keywords=Cover+of+Biochemistry+Biochemistry%2C+5th+edition++Jeremy+M+Berg%2C+John+L+Tymoczko%2C+and+Lubert+Stryer.

12

You’re overthinking it. There are no easy answers. The whole business of insulin/metabolism is incredibly complex - too complex for simple explanations so the “answers” may not be comprehensible. My advice would be to watch the CGM and just roll with it.

I have become a lot more pro-active in terms of avoiding hypos by temping my basal way down rather than just relying on glucose tabs. If my BG is say 8 and drifting down slowly (flat arrow on the Dexcom) but it has been several hours since I ate, I didn’t eat loads of low GI carbs (e.g. pasta) and there’s more than 2 units IOB showing I will turn my basal down by 90% for an hour. With luck it will flatten out at around 5
It may take time, but eventually you will become a Jedi at this

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