All posts by Dr. Chris

Pediatrician trained at University of Michigan Medical School, University of Hawaii and University of Chicago for residencies. Spent 20 years at the Commonwealth Health Center in Saipan, CNMI, before establishing Ebert Children's later Ebert Family Clinic in Frisco, CO in 2000. Published in the Journal of High Altitude Medicine and Biology
Altitude Science, COVID-19, Doc Talk, Health, High Altitude, Medicine, Pandemic

COVID VS HAPE: Experts Analyze Effect on Lungs

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Dr. Chris with Dr. Eric Swenson from the University of Washington

An article published yesterday, April 13, 2020 in the Journal of High Altitude Medicine and Biology clarifies misconceptions in the media comparing high altitude pulmonary edema (HAPE)and COVID lung injury. The six authors include two critical care pulmonologists from the University of Washington: Andrew Luk MD and Eric Swenson MD, as well as Peter Hackett MD of the Hypoxia Institute in Telluride and the University of Colorado Altitude Research Center. Dr. Swenson is the editor of the journal and has given presentations in Summit County on altitude. Both Dr. Hackett and Dr. Swenson personally communicated with Dr. Chris yesterday.

Dr. Chris with Dr. Peter Hackett of the Hypoxia Institute in Telluride, CO

Severe viral pneumonia, as seen in COVID-19, can cause Adult Respiratory Distress Syndrome (ARDS) leading to respiratory failure and the need for ventilator support. As with HAPE, this is a form of non-cardiogenic pulmonary edema, where the air sacs in the lung fill with fluid due to conditions not related to heart failure, the most common cause of pulmonary edema. Other causes include bacterial pneumonia, near-drowning, nervous system conditions, re-expansion, and negative pressure edema. Radiographic findings are similar in all these cases with diffuse bilateral densities in the lungs. All these patients have severe hypoxia.

At altitude, hypoxia can lead to uneven pulmonary vascular constriction, (hypoxic pulmonary vasoconstriction or HPV). In the areas with the highest pressure, fluid leaks from capillaries into the alveoli. With COVID, alveolar inflammation reduces the protein surfactant that maintains expansion of the alveoli. The alveolar collapse causes hypoxemia, low blood oxygen. Severe viral and bacterial infections also cause inflammation in other organs, such as the liver, kidneys, and brain, which is not seen with HAPE.

Medications used to treat HAPE are not likely to be useful in treating COVID pneumonia and may have harmful effects such as increasing perfusion to damaged areas of the lung that are not oxygenated.

Both these conditions likely have large numbers of patients with mild symptoms who recover without seeing a medical provider. However, both HAPE and COVID can cause a sudden, rapid deterioration with severe hypoxia and death.

ACCESS TO A PULSE OXIMETER TO TRACK OXYGEN SATURATION IS VITAL.

Oxygen levels below 90% merit medical attention. Pulse oximeters can be purchased online, at drug stores, or at Ebert Family Clinic.

Acclimation, Altitude Science, Child Growth & Development, Doc Talk, Genetics, Health, High Altitude, Medicine

Doc Talk with Cardiologist Dr. Pete Lemis

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Dr. Peter Lemis is a cardiologist in Summit County, CO. He sat down with us in December to share his experience treating heart patients in the mountains.

Summit County cardiologist Dr. Pete Lemis

I graduated medical school in ‘77, practiced internal medicine in New Rochelle, New York, the first county just north of the Bronx. Then I went to New Hampshire for three years. I was reading the New England Journal and saw an unexpected cardiology opening at Henry Ford Hospital in Detroit. Next I was in Pittsburg for 26 years practicing cardiology. Decided I wanted to retire to Colorado, so I built a vacation home here only to discover I didn’t have to wait to retire to move here, so I came five years ago. 

What is it about high altitude and the heart that makes it healthy for heart patients?

Summit is the fifth highest county in the US with the highest population of those counties. The 21 highest are all in Colorado. Lower air pressure means that although there is 21% oxygen in the atmosphere, there are fewer oxygen molecules. So every breath we take is giving us less oxygen, unless we breathe faster and deeper to make up for it, a natural tendency for people. They don’t even think about it. Some people have hypoxia without shortness of breath. Every once in a while, I’ll see a patient who moved to altitude for work or something, and they’re hypoxic. It is probably genetic that some people have a decreased central respiratory drive. 

These patients with low oxygen often are ordered to have an echocardiogram. When they first come up here, they usually won’t have pulmonary hypertension. For some, the decreased central respiratory drive develops not when they first move here, but years after they move here. They become more and more hypoxic without having the feeling of shortness of breath. They have the same physiological response that people with hypoxia get. Their pulmonary vessels are still being constricted, which is reversible if diagnosed and treated with oxygen supplementation during the first few years of high altitude living. If not treated they are likely to get scarring of their pulmonary vessels. The length of time for this to develop is different for different people, and is unpredictable.

For example, I had somebody just this week who’s been here about 2 years who has a resting oxygen saturation of about 82% at 60 years old. 

We can’t tell who is susceptible to this problem. There are likely some genetic factors involved. Dr. Johnson, who recruited me for my job in Summit County, has been here since 2008. He warned me about the issue of high altitude and hypoxia. Most doctors who are unfamiliar with life at high altitude think you adapt and that’s it. Dr. Johnson said to me, “wait three months and test yourself and your wife with an overnight oximetry to see if there’s hypoxia.” Based on that test I started using nocturnal oxygen and I sleep better when I use it. My wife doesn’t need it. Neither does her mother, who is 90 years old. Neither do my sons.

Awake, we’re able to maintain our oxygen levels, but at night when asleep most people who are here in Summit County have low oxygen. Hence my advice is to get a nocturnal pulse oximetry test. Low oxygen for several hours every night over the years can lead to pulmonary hypertension due to the narrowing of the pulmonary arteries. Then there is the question of what is normal: most high altitude studies were done in La Paz with indigenous, adapted populations as opposed to people living in the mountains of Colorado who have been here years or decades. (See what Dr. Chris has written on her collaboration with physicians and scientists in La Paz, Bolivia.)

We asked Dr. Lemis about arrhythmias at altitude. There are two categories-atrial (from the top chamber) and ventricular (from the bottom chamber).

Studies have shown that cardiac arrhythmias are increased initially, but people become acclimated after about 3 – 5 days and the risk returns to baseline. I don’t think these studies have been conducted over enough time. Hypoxia leads to an increase in arrhythmias. I see a lot of atrial fibrillation  and atrial flutter up here; plus, I send three to four patients a month for an electrical procedure to ablate some of the cardiac conduction pathways to get rid of their arrhythmias. Many patients experience relief from atrial arrhythmias when put on nocturnal oxygen.

JB is a 70 year old who has lived at high altitude for 14 years. He experienced atrial fibrillation several times after returning to Summit County from a trip to sea level. He wore a heart monitor for over a month to see how his heart was beating. He felt the atrial fibrillation was related to dehydration and has prevented further episodes, never needing a pacemaker or other treatment. Jim uses a device that monitors his oxygen and heart rate continually while he sleeps, downloading a written report in the morning.

Why do so many people who live up here have bradycardia?

I think because many are athletes. Athletes often have an efficient heart; I see just as many people who have tachycardia because they have low oxygen. Low oxygen causes higher levels of epinephrine. This stimulates their adrenal gland, which can increase their blood pressure. Many people have high blood pressure at high altitude because they have low oxygen. One of my criteria for testing someone for low oxygen at night is if they have high blood pressure.

Many people have central apnea during sleep at altitude caused by the brain’s blunted response to high CO2 and low O2. Similar to obstructive sleep apnea, this central sleep apnea can increase the risk of heart problems. Many people with obstructive sleep apnea here at high altitude need to have oxygen put into their CPAP machine so they get oxygen, rather than just air with continuous positive airway pressure.

There is less fatal ischemic heart disease up here. People tend to be healthier, more athletic. They’ve moved here for an active lifestyle. There’s less cigarette smoking, more exercise, generally better diet (not always), but people up here still have heart attacks. My impression is more of them survive their heart attacks because of their increased physical activity and healthy lifestyle. They have better collateral flow with more capillaries in the heart. They’re protected to some degree. The corollary to this is the fact that when visitors come here and have heart disease, I don’t think that their cardiologist back at low altitude understands high altitude risks and therefore are unable to provide appropriate medical advice. The same amount of exertion here is much harder on the heart, much more stressful to the heart, than it would be at low altitude. There’s something called a double product when you do an exercise test, related to blood pressure and heart rates. You get the same double product causing the same stress on the heart here as at low altitude, but it takes much less exertion to get to a specific double product. 

People who are accustomed to a certain work load at home come up here and try to do the same amount of exertion. If they have coronary artery disease, suddenly there is a middle aged guy with coronary disease having a cardiac ischemic event, perhaps even sudden cardiac death. 

Another important point is that people with known heart disease who live at low altitude, if they’re unstable at all, they shouldn’t be up here within three to six weeks of a heart attack. They should be able to pass a stress test at low altitude before coming to high altitude to visit.

Valvular heart disease patients who have not been treated with surgery, who don’t already live up here, shouldn’t come up here from lower altitude. People with heart failure can come up here if the failure is compensated.

For people who have trouble acclimating to high altitude in the short term, Diamox is quite useful. Using oxygen at night helps you acclimate as well. Diamox makes your blood a little acidotic which increases your respiratory drive.

Avoid alcohol when you first come to high altitude. Unfortunately people on vacation don’t do that. Alcohol is a respiratory suppressant. At high altitude the hypoxia and cold promotes diuresis, so people tend to get dehydrated. Anti-inflammatory drugs are useful in treating the acute altitude sickness for some people. During the first two or three days, try not to push your physical activity to the limits. Try to get a good amount of sleep.

I would say that I have way fewer heart failure patients [up here]. Because patients who develop advanced heart failure really do not do well here, so they tend to move away to lower altitude before that happens. I have younger patients as compared with my former Pittsburgh practice. I also have way fewer patients with COPD. Anything that causes chronic respiratory difficulties you will find a lot less of that up here. Plus, I’m working in an environment where there are less consultants. 

Back in Pittsburg, two thirds of my practice was taking care of patients in the hospital, so I would deal with patients who would come in with a heart attack, with a heart failure exacerbation, or other acute cardiac problem. Here in Summit County, those severely ill patients get transferred down to Denver, so I provide more in-office preventive or post-illness follow-up than I do care in the hospital. My patients who need advanced procedures (e.g. heart catheters, ablation for arrhythmias), I generally send them down to our sister hospital (St. Anthony in Lakewood). 

The cardiac surgeon who will do the bypass surgery usually knows that the patient returning to the mountains will have to be on oxygen for two weeks after surgery.


COVID-19, Doc Talk, Health, High Altitude, Mental Health, Pandemic

Gone, Gaper, Gone:COVID-19 April 3, 2020

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April 1 is traditionally celebrated in Colorado’s mountain resort communities as “Gaper Day.” Locals dress in their finest 70’s and 80’s outdoor fashions and commemorate the tourists who stop in the middle of the mountain to stare at the beauty that surrounds us. This year travel is discouraged, so the tourists are gone. Here are some local updates on the pandemic to reinforce these directives from Governor Jared Polis.

One day this week, several residents were intubated and transferred to intensive care in Denver. Physicians at St. Anthony Summit Medical Center have access to an ICU and ventilators, but patients with severe respiratory symptoms and hypoxia have a better chance at lower altitude. Let’s hope the day doesn’t come when the Denver hospitals are full, leaving us no choice but to provide this care locally in our low-oxygen environment.

As of April 3, 29 people in have been hospitalized with COVID illnesses, ranging in ages from 20’s to 60’s. There have been 43 confirmed cases in Summit County, according to the Summit Daily News.   It’s here, it’s real, it’s dangerous to all.

Follow the footprints of the fox.

EVERYONE LIVING AT ALTITUDE SHOULD HAVE ACCESS TO A PULSE OXIMETER. You can buy this simple instrument at the pharmacies or call Ebert Family Clinic. You don’t need to go to the hospital if you are breathing normally and your oxygen is above 88%. You can call your doctor or the Ebert Family Clinic for a Telehealth assessment and advice. Our nurse practitioner Tara Taylor will be available 7 days a week between 9 am and 5 pm and Dr. Chris will answer calls and texts for parents and children 24/7. We all know to keep washing our hands: the Corona virus hates soap. Don’t touch your face.

And now I’m going to endorse recommendations from New York and other hard-hit locations: wear a mask and gloves when you go shopping. A bandana, ski mask, surgical mask, anything that reduces the spray of droplets from your mouth and the chance you will inhale these from others.  We are all wearing gloves to keep our hands warm this time of year anyways.

For your mental and physical health, get outside every day. Walk around your neighborhood. Exercise stimulates the immune system. Sunlight helps prevent depression. Look up at the mountains. Gaze at the stars. Let us all be gapers.

First tracks on the track.
Mountaineering

A Sea-Level Dweller Climbs Cotopaxi

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During the winter of 2018, the Little Rock Climbing Center Alpine team ventured south to Ecuador for a mountaineering expedition. However, poor weather and high avalanche risk thwarted our summit attempts of Cayambe (18,996’, 5789 m) and Cotopaxi (19,347’, 5896 m). This winter (2019), we returned to Ecuador to attempt to summit Cotopaxi again, with a new and improved acclimatization plan and high hopes for better weather. Little Rock, AR sits at a mere 335 ft (102 m) above sea level … but we are lucky to have Pinnacle Mountain, with 750’ (228 m) of elevation gain to train on. A small mountain is better than no mountain!  My training plan entailed hiking Pinnacle Mtn 2-3 times during the week, and then hiking or mountain biking on the weekend for approximately 3 months. I also rock climbed at the climbing gym 2 days a week, but Cotopaxi is not a technical climb, so that was mostly for fun.  I took a week-long trip out to Colorado in September to reassess how my body reacts to high altitude.  During this week we rock climbed in Boulder Canyon, Idaho Falls, and climbed the first and second Flat Irons, as well as hiked up to Sky Pond at Rocky Mountain National Park, hiked Mt. Bierstadt, and hiked out to Crystal Mill with Dr. Chris. I chose not to run too much this year for training because I have a meniscal tear in my left knee that gets aggravated on long runs. 

We arrived in Quito, the capitol of Ecuador on December 30. Quito sits at 9,350’ (2849 m), so we took our first day pretty easy, and walked from our hotel to the older part of town with historic churches and cathedrals. Walking up the many flights of stairs in the Basilica del Voto Nacional got my heart pumping and legs and lungs burning! New Year’s Eve in the La Mariscal area of Quito was quite entertaining and a little rowdy, with fireworks, burning of effigies, and jumping over the fires. Our first day hike was up Rucu Pichincha (15,413’, 4697 m), a stratovolcano right in Quito! The TeleferiQo (a gondola) brings you up to 12,943’ (3945 m) where you begin the hike. The hike up Rucu Pichincha starts out mellow, on smooth trail with short steep, punchy climbs. Once you near the top, the steepness increases and the last few hundred feet involve very easy scrambling on sharp volcanic rock. The winter in Ecuador is typically the rainy season, so scattered showers and electrical storms are very common. However, we lucked out with perfect weather on Rucu Pichincha, and fantastic views of the big mountains – Cotopaxi, Antisana, and Chimborazo. The next day we drove to the base of the Ilinizas, and just missed the horse that was supposed to carry our packs up to the refugio. It was about a 3,000’ (914 m) climb up to Refugio Nuevos Horizontes, in relentless wind and dense fog. About half way up to the refugio, a lone figure emerged out of the fog. The horse that was supposed to carry out gear was carefully making his way down the mountain, such a surreal sight! We spent the night sharing bunk beds, packed like sardines in the tiny refugio (15, 696’, 4784 m). The next morning, the wind hadn’t let up, and the fog was still suffocatingly thick. A few groups had attempted an early morning ascent of Iliniza Norte, but said it was too icy and windy to summit. Our mountain guide, Alejo, suggested we traverse around the backside of Iliniza Norte to avoid the worst of the wind, and his advice was on point. The wind was whipping so hard at the summit (16,818’, 5126 m), we spent less than 5 minutes on top before beginning our decent back to the car. The wind was so strong on our descent (upwards of 60mph!), it knocked me off my feet several times. Next time I will use my hiking poles when it is so windy! We spent the next day resting and recuperating at Los Mortinos Hacienda, a cozy B&B at the edge of Cotopaxi National Park where we watched llamas graze, went horseback riding, and dined on fresh trout from a nearby river. 

The next day we drove up to the Cotopaxi parking lot, and slogged up the soft, ashy trail for an hour or so before reaching Refugio Jose Rivas (15,744’, 4798 m) at the base of Cotopaxi. At the refugio we ate some dinner, hydrated, and then tried to rest as much as possible. Alejo woke us up at 10pm and by 11pm we were on our way up the volcano. The skies were finally clear and calm after days of clouds and windy weather, all of the stars were out and we watched an impressive lightning storm down in Quito. We began the trek in mountaineering boots as the glacier starts about two hours uphill. While I felt fine the day before hiking up to the refugio, I had a pretty decent headache when we woke up. My right foot kept falling asleep in my mountaineering boot, and I was starting to overheat because I had too many layers on. This was the first time on the trip that I felt bad, and doubts about a successful summit started to creep in my mind. Alejo asked if I wanted to turn around, but even though I didn’t feel good, I didn’t feel bad enough to turn around. After about two hours of hiking, we reached the glacier and donned our crampons. And then I started to finally feel GOOD! As long as I kept switching my stepping technique, alternating between duck-footing, side-stepping, and French technique, my right foot wouldn’t fall asleep. The higher we climbed, the better I felt! About an hour away from the summit is when it really began to get steep. Alejo said it would be really steep, then a little easier, and then really steep again. We trudged on. And it got steep — really, REALLY steep. Just keep moving. Step up, rest, step up again, rest. Repeat. The mountain seemed to keep going up and up and up. But then around 8am we were at the top of Cotopaxi! I had seen photos of the summit, but seeing smoke coming out of the crater with my own eyes was mind-blowing. We ACTUALLY made it! We waited for Ian and his guide to summit, and then spent the better part of an hour taking photos and enjoying what Alejo said was the nicest weather he’d ever experienced at the summit. 

Ian brought along an Accumed Pulse Oximeter, so being the science nerd that I am, I measured my oxygen saturation percentage at various elevations over the course of the trip. While the percentage of oxygen in the air is the same, the fall in atmospheric pressure at high altitude decreases the driving pressure for gas exchange in the lungs, leading to lower oxygen saturation levels.  I measured my oxygen saturation level on my right index finger after being seated for approximately 5 minutes. The Accumed Pulse Oximeter is a small battery-powered device that measures the ratio of red light and infra-red light that is absorbed through the finger to calculate oxygen saturation levels.

Here is a table of my oxygen saturation levels at various elevations throughout the trip:

Day Location Elevation  (ft/m) O2 saturation (%)
1 Quito 9,350/2849 80
2 Summit of Rucu Pichincha 15,413/4697 75
3 Refugio Nuevos Horizontes 15, 696/4784 74
7 Summit of Cotopaxi 19,347/5896 57

Before reading too much into this very limited data set, there are a number of limitations with these observations I would like to point out. First, sample size is very limited, and I only took one reading at each elevation.  Second, pocket pulse oximeters are not very accurate below oxygen saturation levels of 70%, and ambient light interference (as we experienced at the summits of Rucu Pichincha and Cotopaxi) can interfere with accuracy. Also, the literature suggests that pulse oximetry utility is limited in diagnosis of acute mountain sickness, and that measuring oxygen saturation after light exercise compared to rest may be more predictive of acute mountain sickness. I believe that I did not experience altitude sickness at any point during this trip. I had a mild headache after sleeping above 15,000’ (4572 m), but that resolved once we started hiking up the mountain. We stayed at the summit of Cotopaxi for approximately 1 hr, and while I had a slight headache and was day-dreaming (more than usual), I felt pretty good overall and had no problems on the descent. Pulse oximetry is painless and non-invasive, and can be a useful tool in evaluating respiratory and other complaints at high altitude, but care should be taken to minimize erroneous measurements to avoid misinterpreting the data.

Keshari Thakali, PhD is an Assistant Professor in the Department of Pediatrics at the University of Arkansas for Medical Sciences in Little Rock, AR. She is a cardiovascular pharmacologist by training and her research laboratory studies how maternal obesity during pregnancy programs cardiovascular disease in offspring. When not at work, you can find her mountain biking, rock climbing, hiking or paddling somewhere in The Natural State. She has a long-term career goal of merging her interests in mountaineering with studying cardiovascular adaptations at high altitude, and would appreciate any tips on how to accomplish this!

High Altitude, Medicine, Mountaineering

La Paz: Healthy Living At 12,000 feet

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Dr Gustavo Zubieta-Calleja explains how lessons learned in La Paz can make space exploration easier

I just returned from the “Chronic Hypoxia” conference in La Paz, Bolivia at 12,000 feet elevation (3,640 m). The sponsor and organizers were Drs. Gustavo Zubieta-Calleja and his daughter Natalia Zubieta De Urioste who run the Institute of High Altitude Pulmonology and Pathology there. Presenters and attendees came from 16 countries covering topics ranging from molecular biology to genetics.
Dr. Zubieta previously published a scientific analysis of centenarians living at various altitudes. He compared Santa Cruz, Bolivia, at sea level, with La Paz/El Alto, each with populations of over three million, and found there are eight times more people over 100 years old at high altitude. (BLDE University Journal of Health Sciences, see blog post 1/5/18) Since his father Gustavo Zubieto Castillo founded the institute in 1970, they have been advocates of the health promoting effects of a low oxygen environment.
A presentation on “BioSpaceForming” even identifies chronic hypoxia as a “fundamental tool”, that “gives humans and other species an advantage on earth and beyond.” Dr Zubieta explained that the space station is engineered to have the barometric pressure (760 mmHg) and oxygen content of sea level. When the astronauts change into their space suits to work outside the ship they experience a pressure drop of over 200 mm Hg in a laborious process of donning the suit. Seeing that millions of inhabitants are healthy at 486 mm HG in Bolivia, he advocates that maintaining lower pressures and lower oxygen levels in the space station would be economical and promote the health of the astronauts. Several altitude scientists see this as a future that “uncouples biology and physics.

Acclimation, Medicine

Life Threatening Causes of Low Oxygen At Altitude

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Anyone who travels to areas of high altitude is at risk for high altitude pulmonary edema (HAPE). Classic HAPE symptoms include a worsening cough and shortness of breath with activity leading eventually to trouble breathing at rest. If left untreated, serious complications can occur. Many other conditions can mimic HAPE, and it is crucial for health care professionals to be able to distinguish between HAPE and other disorders. Illnesses that may present similarly to HAPE include pneumonia, a blood clot in the lung (pulmonary embolism), and chronic obstructive pulmonary disease (COPD) or asthma. Health care providers take a thorough history which along with the physical exam, blood tests and imaging help narrow the diagnostic possibilities.

  • Pneumonia: In both HAPE and pneumonia, shortness
    of breath, fast breathing, and a fever occur. Normal oxygen saturations are above 90%. In our experience, patients with pneumonia at altitude do not have low oxygen, unless complicated by HAPE, when it can be as low as 37%. Patients with pneumonia feel a lot worse than those with
    HAPE. HAPE typically responds to high flow oxygen showing rapid improvement over a few hours. Pneumonia with low oxygen saturations will lead to immediate hospitalization.
  • COPD/Asthma: High altitudes may exacerbate COPD or asthma. How providers tell the differences is through something called
    pulmonary function tests. This tests how well your lungs work and involves breathing into a device before and after being given albuterol.
    If the peak flow test improves after the albuterol, then COPD or asthma are the more likely diagnosis. These patients usually improve on medication and do not have to leave the emergency department with oxygen.
    The provider needs to be made aware of any history of COPD , asthma, vaping or smoking.

Miranda Bellantoni, FNP-Student

  1. Luks AM, Swenson ER, Bärtsch P. Acute
    high-altitude sickness. Eur Respir Rev 2017; 26.
  2. UpToDate. Distinguishing HAPE from Pneumonia
    2018.
  3. Brusasco V, Martinez F. Chronic obstructive
    pulmonary disease. Compr Physiol 2014; 4:1.
Acclimation, Health, High Altitude, Mountaineering

Anyone want to learn more about Life at Altitude?

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Dr Christine Ebert-Santos presents to employees of the Town of Breckenridge. Contact Ebert Family Clinic if your organization or group is interested in learning more about living in our hypoxic environment admin@ebertfamilyclinic.com

Child Growth & Development

Newborns at altitude: less breathing problems, higher chance of brain hemorrhage

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The September 2018 issue of the Journal of High Altitude Medicine and Biology has an article reviewing statistics on newborn health in the Mountain Census Division: AZ, CO, ID, MT, NM, NV, UT and WY.  The lead author, Robert Levine and his coauthors found that newborns in this region have “by far the lowest infant mortality rates for respiratory distress.”  Conversely, there is a higher incidence of intraventricular hemorrhage, or bleeding in the brain, not caused by trauma. This can be a complication of prematurity.

The authors analyzed about 70 million births and 12,000 deaths in over 3000 counties between 2007-2015. They compared maternal education, age, and marital status. The mean elevation of the mountain division counties is 5,725 feet, with the mean for the rest of the US being 2,500 ft. Colorado ranges from a low of 3317 ft to 14440 with a mean of 6800 ft. There were 30 counties above 8000 ft.

Their conclusion :”…we believe the most plausible interpretation of the present data is that they raise questions abut whether maternal residnce at high altitude has uniformly adverse health effects on infant mortality.”

In other words, maybe it’s not all that bad to live in the mountains!

Child Growth & Development, Health, High Altitude, Medicine

The Mitochondrial advantage at altitude

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Dr. Deborah Liptzen, pediatric pulmonologist from Children’s Hospital of Colorado,

Presents a talk on high altitude to the Ebert Family Clinic staff

I learned several new facts about adaptation to altitude that make us better athletes. First, our muscles have more capillaries to deliver blood to the cells. Second,  the cells have more mitochondria which are organelles involved in the chemistry of respiration and energy production.

Other ways our bodies respond to altitude include: increased breathing rate (instant), increased red blood cells (peaks in three months), hemoglobin in red cells holds on to more oxygen, and blood vessels in the lungs constrict (immediate).It is this constriction of blood vessels in the lungs that can go haywire putting pressure on the capillaries causing fluid leaks that lead to pulmonary edema or HAPE.

Acclimation, Health, High Altitude, High Altitude Training & Fitness, Mountaineering

Rethinking Your Energy Supply

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On May 27th 2017, Adrian Ballinger summited Mount Everest without supplemental oxygen. This is an accomplishment that less than 200 people have achieved and followed a failure to summit the previous May of 2016. The 41 year old seasoned climber attributed his failures to the cold, which could have been aided by more muscle and fat content, better insulated jacket and gloves, but he wondered why his climbing partner, Cory Richards so easily made it to the top. Ballinger came to realize it that wasn’t his gear or body composition, but it was that Richards had a different approach to training and nutrition that gave him the edge to summit. Richards trained with a organization called Uphill Athlete that trains its athletes to become a fat burners. After hearing of Richard’s training regimen Ballinger was determined to pursue the same for a another summit attempt in 2017. Ballinger was a carb burner, which means he was relying on burning carbohydrates for energy. When he attempted to summit Everest being a carb-burner, he simply ran out of energy to fuel his body through the last grueling stretch. This was due to depleted glycogen levels that a carb-burner relies on. The average human can only contain enough carbohydrates to supply glycogen stores for about 45 minutes. Once your glycogen stores are depleted, you need to refuel, which in Ballinger’s case, would mean pulling a hand out of a mit in the frigid Everest air to replenish his energy every 45 minutes. This is also known as “bunking,” which means completely exhausting your energy supply, which is what happened to Ballinger. Richards on the other hand, was a fat burner. With alterations in Ballinger’s nutrition and training regimen, he was successful in 2017.

But what is a fat burner?

A fat burner is an athlete that primarily uses fat for energy, and this metabolic process is called fat oxidation. When an athlete is exercising on a typical high carb and low fat diet, they are burning about a 50/50 mix of carbs and fats during steady exercise. If that athlete decides to sprint at full speed being a carb burner or a fat burner, they are primarily burning carbohydrates, known as glycogen. This is the body’s evolutionary design to have instant energy to run away from the tiger when it storms your cave. In Ballinger’s scenario, the high intensity of Everest climbing was like a sprint, depleting all of his glycogen stores causing him to “bunk”.

Why is a fat-burning diet better for climbing?

Being a fat burner for a long distance endurance athlete is beneficial because it eliminates the need to refuel every 45 minutes, which is bothersome. Ever wonder why there is a plethora of fancy sugary “sports” drinks, gummies, and energy bars at sporting stores? They are called “energy” foods, because they are loaded with simple carbohydrates and sugar. On the other hand, a fat burner does not need refueling foods or drinks during exercise, but relies on the extensive supply of fat throughout the body. Even the most elite athletes with very low body fat will have enough to supply the body energy for a event. Picture this, there is a giant fuel tanker truck cruising on I-70. The truck has its own fuel tank which sits below the cab of the truck, which will be depleted in a couple hours. What if the truck could access the large tank that it’s hauling? That would give the trucker a enough fuel to drive for days! In the context of nutrition and your body, the small tank is the your glycogen storage and the large tank is fat storage. This is why some people can fast for days without skipping a beat; they have tapped into their fat supply.

What does it take to become a fat burner?

To become a fat burner, it’s quite simple: cut the carbohydrates. Well, I guess some may think it’s not so easy. You have to cut out pizza, bread, candy, tortillas, and all that good tasty stuff. When a person limits their carbohydrate intake to less than 10% of caloric intake, and increase fat consumption to 70% of their intake, their body shifts into a different mode of creating energy, by burning fat instead of carbs. The by-products of fat oxidation are called ketones. When a person converts to being a fat burner, it is called being in ketosis. This process may take a few days to weeks, which varies from person to person.

Is there any research behind this crazy idea of eating all the bacon and butter you can handle?

Yes, yes there is!

In the research article by Volek et al. (2015), the authors wanted compare a low carbohydrate ketogenic diet and a typical high carbohydrate diet in 20 elite endurance athletes. The authors tested the athletes with a 180 minute, moderate intensity (64% VO2 max), treadmill run.

VO2 max is known as the capacity of your cardiovascular system and its ability to distribute oxygen throughout the body. Higher means a stronger cardiovascular system, so 64% of your maximum effort would be considered moderate exercise.

A 64% VO2 max to you or I would be a brisk walk or a slow hike up that beautiful 14’er, but for these Ironman athletes it was an easy run on a treadmill. The authors compared the rate of fat oxidation and carb oxidation between the two diets, as well as their ability to recover and replenish their glycogen stores. The authors found that the fat adapted athletes had 2.7 times the rate of fat oxidation than the high carb diet athletes. The low carb group also had fat oxidation at higher VO2 max, meaning they could go faster without tapping into their precious glycogen stores. The study also found that after the exercise, the athletes in both groups had similar glycogen level in their muscle. This is significant because the classic rule of thumb with exercising is that you need a post-workout shake with protein and carbs to replenish your muscles, or your exercising efforts are gone to waste …

WRONG!

It turns out your body has its own way of replenishing its glycogen stores without the post-workout carb load. That means after you climb that 14’er, you don’t necessarily have to stop at the local brewery for carb-tastic IPA, but I won’t judge you if you do.

In another research article by Hetlelid et al., they wanted to compare the levels of fat and carb oxidation levels between nine well-trained (WT) runners and nine recreationally-trained (RT) runners during a high-intensity interval training session (HIIT). There was no difference in diets amongst the participants in the study. The study found that the WT runners had a three times higher rate of fat oxidation than RT runners and increased performance with higher VO2 max. The author attributed the increased performance due to the higher rates of fat oxidation. These athletes were consuming a normal carb-ful diet, which makes me wonder what the difference would have been if they were fat adapted.  

So, let’s get down to why all this mumbo-jumbo is important to your next trip to the high country. Many outdoor activities that we enjoy in the summer like hiking, biking, climbing, etc. all require significant energy to supply for all day fun. Take climbing a 14’er, for example. You will most likely be climbing for several hours, depleting your energy stores as you climb being on a high carb diet. You have to stop, refuel, start up climbing, stop and repeat. As a fat adapted climber, you could sail past your carb-comrades with ease, not depleting your glycogen stores all day, all while burning some of that winter Christmas cookie belly in the process. As we examined the two research articles, we also found that higher fat oxidation could mean higher VO2 max levels.

What does this mean for your next trip to high altitude?

That’s right, better usage of the less available oxygen in the high country and improving oxygen delivery throughout the body. If you want to be the best Balliger you can be on the mountains this summer, rethink your energy supply and consider life in the fat lane! 

So, here are some personal tips to becoming fat adapted:

-Give your body at least 3 weeks to become adapted before any highly strenuous activity, like climbing a 14’er

-Hydrate, hydrate, hydrate with water, and balance it with electrolytes

-Consult with your physician before drastically changing your diet

-Choose foods high in natural fats (eggs, nuts, olive oils, avocados, meat, fish, dairy) and stay away from unhealthy trans fats

-Intermittent fasting can help you transition into ketosis faster (12-16 hrs)

 

References

Hetlelid, K. J., Plews, D. J., Herold, E., Laursen, P. B., & Seiler, S. (2015). Rethinking the role of fat oxidation: Substrate utilisation during high-intensity interval training in well-trained and recreationally trained runners. BMJ Open Sport & Exercise Medicine, 1(1). doi:10.1136/bmjsem-2015-000047

Volek, J. S., Freidenreich, D. J., Saenz, C., Kunces, L. J., Creighton, B. C., Bartley, J. M., . . . Phinney, S. D. (2016). Metabolic characteristics of keto-adapted ultra-endurance runners. Metabolism, 65(3), 100-110. doi:10.1016/j.metabol.2015.10.028

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