• Some factors to consider when choosing a blood glucose meter:

  Weight: Minimizing weight is an important factor on outdoor trips. Blood glucose meters on the market vary between 30 - 150 g (1 - 5 oz) in weight.

  Ease of use in cold, difficult situations: Try to select a meter that doesn’t need a table top to set out all the pieces. You want a meter that can be held in your hands while doing a blood test, so that you’re not fumbling around and running the risk of dropping a test strip or lancing device in the snow. Speed is also important and current meters on the market take 10 - 70 seconds to perform a test. A meter with a longer countdown will increase the risk of the meter and test strip getting too cold to operate.

  Temperature: Some meters are only guaranteed to function down to 18°C (64°F) but others as low as 10°C (50°F).

• All blood glucose meters and their strips deliver accurate results as long as they work and are stored in the desired temperature ranges. For most meters, the temperature ranges are 10 - 35°C (50 - 95°F) so it is important to keep the meter as warm as possible in cold weather. To keep your meter (and all other diabetic supplies) warm and working:

  Keep it close to your body so it won’t freeze (e.g., in an inner, warm and dry pocket, close to your body). A pack, purse, or outer pocket may be too cold. A small fanny pack worn under your jacket at the front, a large money belt worn next to your skin or even a sports bra work well for storing insulin and testing supplies. Be aware that a fanny pack can get cold if you ever remove your jacket.

  If you’re not sure whether the pocket you carry your insulin and meter in is warm enough check the temperature by carrying a small thermometer in your pocket when you are outside in the cold. Make sure you read it quickly since the cold air will quickly cool off the thermometer when it’s outside your pocket! Check the meter and insulin manufacturers for their recommended temperature range.

  To make your pocket warmer you can insulate it. Buy a small piece of flexible aluminum-coated insulation (sold at building supply stores for wrapping around hot water tanks) and cut a piece in the shape of your pocket. Place it in your pocket so that the foam insulation is on the outer side of the pocket and the diabetic supplies are towards the inside of the pocket, between you and the insulation. Your body will act as a heater and the insulation will bounce the heat back into your pocket.

  If you are handy with sewing, you can sew an inside pocket onto your ski pants. Make sure it is easy to reach, such as on the inside of the bib on your ski pants.

  Place the meter in a plastic Ziploc bag to keep it dry.

  If you prefer to keep the blood glucose meter inside your pack, try placing it beside a water bottle filled with hot herbal tea (and preferably stored in an insulated water bottle parka) or try storing the meter inside your day pack, at the section of the pack that lies against your back, where it can be kept warm from your body heat.

• If the meter is still too cold to perform an accurate blood glucose test (or if it just feels a little cold) try warming it up under your arm pit for about 30 seconds prior to doing a test. If the wrapped test strips feel cold, warm them up too by putting them under an arm pit or inside your mouth for about 10 seconds.

• It can be very hard to perform a blood test if one’s hands are cold and numb and the weather is windy and wet. Try to minimize the amount of time that your bare hands and meter are exposed to the cold. When you prepare to take a blood sugar reading, make sure your hands are warm enough to get a drop of blood quickly. To make blood testing easier:

  If the weather is windy, snowing or raining, kneel behind a tree, snowbank or other windbreak and face away from the wind.

  Put the meter inside your half-unzipped jacket, next to your body, to shelter it from any falling snow or rain and to help keep it warm.

  If it is windy and wet, try placing your pack on the ground in front of you, and while kneeling or squatting, take a blood sugar reading with your hands sheltered just inside the pack opening.

  Use a large drop of blood to help keep the test strip warm.

  Cup a bare hand around the meter and test strip to keep them dry and warm. This can help prevent the blood drop from freezing and keep blowing/falling snow off. Holding the strip between two fingers (thumb on top and one finger underneath) while the blood travels down the sensor can also help.

  A pre-loaded blood glucose meter (pre-loaded with test strips) can make testing much easier, not having to peel off the individual wrappers on each test strip. Alternatively, prior to the trip, you could tear your test strips apart (remove the packaging) so that they are easier to use when wearing gloves or mitts or when your hands are frozen.

  Try wearing fingerless gloves to do blood glucose tests or inject insulin if your hands get very cold.

  If you have problems getting blood out of your fingers, windmill (swing) your arm to get blood into your finger tips before testing.

  Retracting one finger inside your glove and pressing it against your palm for about five minutes before you test can help the blood flow more easily.

  If you cannot do an accurate blood test and are feeling slightly odd or light-headed, assume that your blood sugar is low and treat for a reaction. If you are wrong, it's better to have a high blood sugar for a short period of time than to go low.

  Remember that if it gets dark early, you will need a flashlight to read your meter and write a record in your blood glucose log book. Put a pencil rather than a pen in with your log book as the ink in pens sometimes freezes.

• Be prepared for an emergency and always have a back-up: Ensure that you have enough diabetic supplies for an extra day or two, remembering that you will be doing extra blood tests and will probably have to treat more than one low blood sugar. Take your insulin and syringes even if you plan to be out for less than one day. Consider taking regular syringes and visual test strips as a back-up (in case the meter doesn’t work) even if you use a blood glucose meter and an insulin pen or pump.
• Hypoglycemia: The symptoms of hypoglycemia are easily recognized by diabetics at rest or during quiet activity. However, in the back country it can often be difficult for a diabetic to decide whether the pounding heart, sweating and trembling is caused by fear, hypoglycemia or a strenuous workout. The same hormones that produce the symptoms of hypoglycemia (adrenaline) are released by fear. Also, one tends to associate thirst with high blood sugar levels, but when doing outdoor activity, one can easily be thirsty and experiencing hypoglycemia. One risk of hypoglycemia is that it may lead to falling off something, getting confused or getting lost. Any diabetics new to cold weather outdoor activities should be aware that symptoms can be quite different in the winter and in the outdoors.

Insulin Therapy

• Insulin storage: The ideal storage temperature for insulin is 2 - 8°C (36 - 46°F). If your insulin freezes, a significant decrease in its potency must be expected. This is particularly true for the long-acting insulins (the large aggregates become no longer soluble and they can consequently block the needle).
• Keep all your insulin close to your body (e.g., in the same place as your blood glucose meter) or very well-insulated in the middle of your backpack (if on a short trip) so it won’t freeze. An inner pocket in your clothing works well. Consider storing extra insulin vials in a fleece pouch around your neck under your upper clothing.
• If you usually mix two insulins together, giving yourself two separate shots may be easier and a good compromise in cold, windy conditions. Using an insulin pen or having some pre-measured insulin doses, already loaded in syringes (with the option to empty some of the insulin out if one doesn’t need the entire dosage), can also simplify the process of giving oneself insulin in cold conditions.
• Insulin infusion pump: An insulin pump can be great for cold weather activities since one does not have to bare skin or an insulin vial to the elements to give an injection. Since an insulin infusion pump is typically worn close to the body, it usually stays warm enough and the insulin doesn’t freeze.

  Keep the insulin pump warm by keeping it immediately adjacent to your body and covered by clothing. Make sure the infusion set tubing does not get exposed to the cold since it can freeze very quickly.

  The insulin pump can be placed in a plastic case (Sport Guard) to protect it against falls, however, this means that the pump is not easily accessible to give a quick "bolus".

  The latest models of the pump have a screen that lights up and can be used as a mini flashlight…this can be a great help for doing a blood test in the dark!

• Everyone knows how important food is for us diabetics, so when participating in cold weather sports, it is very important to carry food that does not freeze easily and to keep it in a warm, insulated section of the pack.
• Nutrition and hydration play a large part in the body’s ability to deal with cold (cold weather activities call for high calorie intake of 3500 - 4500 calories/day for moderate activity). Stay well hydrated (clear, pale urine is the goal here) and eat plenty of good food. Take more food than you think you will need and make sure that some of it is fast-acting carbohydrate.
• Liquid intake is crucial for the body’s heat and energy production. Carry a thermos of hot water or soup. If you carry a water bottle, either keep it close to your body and/or store it inside an insulated water bottle parka so it won’t freeze. Drink lots of non-diuretic fluids (avoid tea, coffee, caffeinated pop, chocolate, alcohol) throughout the day. Aim to drink 3 - 4 L of water per person per day and resist the temptation to skimp on liquid intake just to avoid the inconvenient winter calls of nature!
• Always have some high energy snack food/glucose immediately accessible in the pocket of the clothing you’re wearing. This way, if you are afraid of slowing others down or making them stop and are feeling a little "odd" you can just quickly eat something and keep moving along. It helps to store it in a small Ziploc bag if it is only wrapped in paper (since it may get wet).
• Choose food that doesn’t freeze easily in cold temperatures - unless you like biting into food that feels as hard as a rock! Low fat energy bars get very hard and almost impossible to eat when they get cold. Fresh fruit also tends to freeze very rapidly. Food with a higher amount of fat in it appears to work best. Sometimes, in extremely cold temperatures, it is very difficult to want to stop and eat so try to take food that is easy to eat, easy to unwrap and, ideally, food that can be eaten without taking your mitts off (e.g., granola bars, chocolate bars, some dried fruit).
• In ski mountaineering, people are advised to be always extra-warmly dressed or to have a dry hat etc. on hand (in the top pocket of the pack) in case they fall into a crevasse - always having some extra (easily accessible) glucose or food on hand would also be a good habit for diabetics in this scenario. Try to always have some kind of emergency food accessible, so that you could feed yourself some energy if you ended up in a prolonged emergency situation (e.g., an avalanche).
• If camping overnight, meals should be high in complex carbohydrates and approximately 20% fats to sustain one through the night. Take food that will not freeze or spoil.
• 500 ml (2 cup) plastic measuring cups work well as a bowl/plate/cup. They don’t tip over easily and you can see the quantity of food that you are eating at a glance.
• Keep your food organized. Ziplocs (plastic bags), baggies, labels and stuff sacks will help do the job. Pre-measure and label the serving sizes, food exchanges and/or amounts of carbohydrate in the bags to facilitate calculating your insulin dosage.

• Diabetics who have circulatory problems are very prone to infection and the lack of adequate sensation and circulation can lead to difficulties in registering temperature changes. As a result, diabetics are more prone to frostbite, hypothermia and sunburn. Be familiar with cold weather injuries and guard against the onset of frostbite and hypothermia.
• Hypothermia, a condition in which your body temperature drops too low, can mimic the symptoms of hypoglycemia, so make sure that you and your companions know how to recognize and treat both conditions. It is important to keep warm and test your blood often so that you know what your blood sugar levels are doing and which way they are trending.

  A person who is hypoglycemic is very susceptible to the rapid onset of severe hypothermia. As the blood sugar level falls to low levels, the rate of metabolism of sugar into energy also drops. The protective, heat-generating mechanism of shivering (which occurs with the onset of mild hypothermia) is lost, accelerating the drop in the body’s core temperature.

  The priority is to quickly treat the hypoglycemia with fast-acting sugar in order to restore normal metabolic processes. Shivering and metabolic heat production should thus be restored and any necessary treatment of the hypothermia can be started.

  The symptoms of hypothermia and hypoglycemia are similar so if in doubt, treat for hypoglycemia first (^*Exercise and the Curious Diabetic, 1989).

• When dressing for cold weather activities:

  Dress in layers so that you can regulate your body temperature as the weather or your body temperature changes. Wear synthetic (e.g., polyester or polypropylene) long underwear which will wick away perspiration, but still retain its insulating properties. Don’t wear any cotton clothing since cotton will stay wet and draw heat away from your body. Wear a middle insulating layer and a top layer to provide a wind break and add a bit more insulation. If the top layer has zippers for ventilation, it can help get rid of excess moisture.

  Keep as dry as possible. If you are getting too hot on the trail, slow down, remove your hat or open zippers to ventilate, to reduce sweat accumulation and avoid getting too damp and wet from sweat.

• Diabetics often have impaired circulation:

  Wear gloves or mittens (mittens are warmer) and make sure you have a spare pair if you will be out for a long time. When you exercise your hands and feet sweat so a dry pair can be very useful. Consider using chemical warmer-packs inside your gloves/mittens.

  Wear a hat or a toque: It is true that most of your heat is lost though your head. You may not want to wear it during exercise but it is invaluable for when you stop. Always be prepared that you may have to keep yourself warm during an emergency that will not allow you to keep warm by exercising. Having an extra (dry) long underwear top to change into at lunch time can be a lifesaver.

• If you get cold feet, wear suitable insulating footwear:

  Wear appropriate socks (i.e., not cotton). Wearing two pairs of socks helps to keep your feet warm. The inner pair should be medium-weight polypropylene liner socks to wick the moisture (sweat) away from your feet, and the second pair should be heavy wool socks.

  Don’t automatically put on extra socks if your feet are cold since they often compound the problem. If the footwear is too tight as a result of wearing two pairs of socks instead of one, one’s circulation can be reduced, resulting in even colder feet.

  Flex your feet - flexing with movement improves blood flow.

  Carry a spare pair of socks in case of an emergency situation, especially if you get cold feet easily.

  Foot insulation/warmth can be impaired by the ingress of snow into the boots that subsequently melts so wear gaiters to keep the snow out of your boots.

  Alcohol and nicotine should be avoided. Alcohol dilates one’s blood vessels and increases the rate at which one loses heat. Nicotine constricts one’s blood vessels and will cause premature cooling of the extremities. You can assist your body’s heat flow by staying well hydrated to maintain blood volume.

• When participating in any outdoor activities, communication with others is very important. Try to make sure that everyone knows you are a diabetic and how to treat a hypoglycemic reaction. It is important for others to understand why you may have to stop and eat and that they should not just go on without you even if it’s -20ºC (~-5ºF) and they want to keep warm! They should also understand how to treat you in an emergency (e.g., if you have an accident all the usual first aid principles apply (ABCs) but your blood glucose levels should be monitored if help is not immediately available).
• If you feel that you are a nuisance to the rest of the group when you need to suddenly stop to test your blood (e.g., especially when you are skiing roped up), try to always do a blood test whenever the whole group stops for a break (even if you feel normal).
• If you are in dangerous terrain where it is not always safe to stop (in high-risk avalanche terrain, underneath falling rocks, etc.) try to plan ahead and stop and test/eat whenever you have an opportunity and are in a safe location. If you know there is a dangerous section ahead, test and eat beforehand.
• On any extended trip give someone else a small package of "essential diabetic supplies" (extra glucose, test strips, spare insulin and some syringes etc.) to keep in an entirely separate place the whole time just in case something happens to the supplies you have (e.g., get lost, frozen, damaged, etc.). Make sure the other person understands that the insulin must NOT be frozen or overheated.
• Glucagon should be carried for injection in the event of hypoglycemic unconsciousness. Other members of the group should already be familiar with this procedure so as not to lose precious time during a diabetic emergency in the backcountry. People need to be aware that the effect is only temporary (the person will need to eat food after regaining consciousness) and that glucagon will only be effective if the glycogen stores have not yet been depleted. If these stores have been reduced by an earlier episode of severe hypoglycemia and the person was treated with glucagon without extra food on recovery, the effects may be less successful.
• Always be prepared for contingencies such as hypoglycemia or ketosis, cold weather injuries (e.g., frostbite or hypothermia), getting lost or delayed, injury or illness.
• Let someone know where you're going and when you expect to return.

• The most important factor to consider when on winter camping trips is preventing the insulin and other diabetic supplies from freezing. When camping, placing the insulin in a location close to the body (for example, in a sleeping bag) can prevent it from freezing.
• One great advantage of camping in the winter is that since the bears are in their deep sleep, it is safe to store food in the tent. It can be very reassuring to be able to have glucose and/or food close at hand in case of a hypoglycemic reaction.