How does living at high altitude affect the human body? It’s a complicated question that researchers have been trying to answer for years.
It takes two things to grow: adequate nutrition and the body’s ability to convert calories into energy. Observations over 20 years at the Ebert Family Clinic suggest that the decreased oxygen levels at altitude may interfere with optimal utilization of calories or decrease appetite and intake in small children.
After opening her pediatric clinic in Frisco, CO in 2000, Dr. Christine Ebert-Santos noticed that children living at high altitude are smaller than average. Dr. Chris and Meredith Caines Pollaro, an occupational therapist with expertise in feeding and growth in children, organized a group for parents of underweight children but did not find any consistent abnormalities. After this, Dr. Chris decided that smaller growth might be a normal pattern for little ones at altitude. The children were otherwise healthy, with nutritional analysis showing adequate intake, and no signs of endocrine or gastrointestinal problems.
Graduate student Aaron Clark reviewing high altitude growth charts with PA student Laura Van Steyn and Dr. Christine Ebert-Santos.
Research on growth in children at altitude is sparse. So, in 2009, Dr. Chris recruited her daughter Anicia Santos to launch a detailed data analysis. Anicia worked with one of her math professors at the University of Colorado to convert the data into a unique growth chart for altitude which demonstrated the downward shift. Twice the number of infants and toddlers had weights below the 3rd percentile of the World Health Organization growth charts than at lower altitudes. Heights were also decreased. After years of gathering data, Dr. Chris and Anicia are getting ready to share their findings with the help of Logan Spector, PhD and graduate student Aaron Clark.
Spector, chairman of the department of epidemiology at the University of Minnesota, was concerned about his two nieces who lived in Summit County who were not fitting into the “normal” growth pattern. This sparked his interest in Dr. Chris’ research. He was able to recruit Clark to take on the project.
In the first study of its kind in North America, the growth charts of 970 kids living in Colorado’s high country are analyzed. With over 9,000 pieces of data, one thing is clear. From birth to 18 months of age, children living at altitude weigh much less than the average child. Length is also considerably decreased, though the weight discrepancies are more drastic. These findings were studied extensively and found to be statistically significant. Using the generalized estimating equation (GEE), Clark was able to analyze the data in a non-linear way. This compensates for correlated data. Clark created density graphs for both male and female children to depict these findings (see figures). When the graph line is fairly close to 1 on the y-axis, or a straight line across the top, this means there is little difference from the standard growth chart (age 2-18). The farther away from 1 on the y-axis, the more significant difference there is compared to standard growth charts (age 0-2).
There is no denying that something is causing these high-altitude children to fall off of the growth charts. The next logical question would be, what are the effects of this smaller growth rate? Initial research shows that children at altitude are catching up on the growth curve by age two. There does not appear to be any long-lasting deficits from the initial smaller growth.
After combing through research articles, a new study from Ladakh, India also displayed a correlation between children living at high altitude and smaller size. Specifically in Colorado, another study shows lower birth weights at high altitude, however, it does not follow the growth patterns of the children over time.
From what this research shows, a unique growth chart for children living at high altitude would be helpful. A new growth chart would account for the variations in size seen at altitude. This could save thousands of dollars in unnecessary testing looking for underlying disease or endocrine deficiencies as well as the anxiety for parents being told that their child has failure to thrive or is not being fed. Instead of being concerned when a child falls low on the growth chart, one might expect to see smaller children at altitude.
There is still much research to be done in this field. Hopefully, this study will serve as fuel for future studies.
Laura Van Steyn is a 3rd year Physician Assistant student studying at Midwestern University in Glendale, AZ. She graduated from the University of Colorado in Boulder with a degree in integrative physiology. After that, she worked as a CNA at Littleton Adventist Hospital prior to starting PA school. She hopes to work in women’s health or dermatology after graduating. During her six weeks at Ebert Family Clinic, she has joined Dr. Chris for numerous hikes and has truly enjoyed escaping the Arizona summer heat!
References
Yang, W.-C.; Fu, C.-M.; Su, B.-W.; Ouyang, C.-M.; Yang, K.-C. Child Growth Curves in High-Altitude Ladakh: Results from a Cohort Study. Int. J. Environ. Res. Public Health 2020, 17, 3652.
Bailey, B.; Donnelly, M.; Bol, K.; Moore, L.; Julian, C. High Altitude Continues to Reduce Birth Weights in Colorado. Matern Child Health J 2019, 23(11): 1573-1580
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 airwith 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.
Inflammation and altitude can cause low oxygen. Inflammation is commonly caused by viral infections such as colds or influenza, but can occasionally occur with bacterial infections such as strep throat or pneumonia. Low oxygen, or hypoxia, is the result of fluid collecting in the air sacs of the lungs, called pulmonary edema.
There are three types of high altitude pulmonary edema
(HAPE).
Classic HAPE, recognized for over a century. occurs in visitors to altitudes above 8000 ft (2500m) beginning during the first 48 hours after arrival. Symptoms include cough, congestion, trouble breathing, and fatigue, all worse with activity.
Re-entry HAPE occurs in people who are living at altitude, travel to lower altitude, and develop symptoms during the first 48 hours after returning home
High Altitude Resident Pulmonary Edema (HARPE) is a recently recognized illness that occurs mostly in children who have an underlying respiratory illness and live at altitude, with no recent history of travel. They have oxygen levels below 89 and lower but do not appear toxic. They are fatigued but rarely have increased work of breathing.
Parents are often worried their children won’t wear a canula for oxygen, but they don’t typically mind.
Treatment of HAPE is oxygen. There may also be signs of
asthma or pneumonia which are treated with bronchodilators and antibiotics.
Most people with pneumonia at altitude do NOT have hypoxia. All three types of
HAPE can reoccur, but typically not with every arrival at altitude or viral
illness. Many of these patients are told they have pneumonia again and again,
or severe asthma, and are treated with inhalers and steroids. Usually, this
adds nothing to their recovery.
A chest x-ray may show typical infiltrates seen with pulmonary edema, but in mild or early cases, can look normal. There is no blood test for HAPE. Oxygen should be used continuously at a rate that raises the oxygen saturation into the 90’s. Length of treatment may be as short as 2 days or as long as ten days
Most
importantly, owning a pulse oximeter and measuring oxygen levels in anyone at
altitude with symptoms of cough, congestion, fatigue and trouble breathing with
exertion can keep people out of the ER and ICU. HAPE can rapidly progress to
respiratory failure and death if not recognized and treated expediently.
We’ve published a series of accounts from Dr. Chris’s recent attendance at the 7th Annual Chronic Hypoxia conference in La Paz, Bolivia , conducted by Dr. Gustavo Zubieta-Castillo. He is one of the world’s leading experts of altitude medicine and Dr. Chris’s collaboration and contact with him has added literally phenomenal insight into our own high altitude research.
Dr. Chris “en Teleférico” with fellow altitude researchers Vanessa Moncada, Diana Alcantara Zapata, Dzhunusova G. S., Oscar Murillo, and Alex Murillo. Photo courtesty of Dr. Zubieta-Castillo.
There is something literarily romantic about the scientists who are compelled to remind you, “I’m not crazy!” Dr. Zubieta-Castillo has held soccer games at 6,542 m (21,463′), proving the remarkable adaptability of the human body. He maintains a high altitude training lab, called the Chacaltaya Pyramid, at 5,250 m (17,224′). In his recent video (below), he illustrates the connection between longevity and elevation, where citizens of the highest cities in South America live to be well over 100.
It’s notable that a city known for its wine at 2,790 m (9,153′), called Chuquisaca, boasts some of the oldest residents. Not surprisingly, our research has led us to some speculation on the relationship between alcohol and the body at altitude. Additionally affirming is Dr. Zubieta-Castillo’s father, nicknamed “El Guru de la Montaña”, who began his legacy of altitude research and medicine by examining the hearts of dogs at altitude (sound familiar? See our article on Dogs at Altitude), as well as Dr. Zubieta-Castillo’s own testament that asthma can be and has been treated by altitude (see Asthma at Altitude).
His latest correspondence with Dr. Chris and their mutual colleagues reads like letters written by history’s greatest scientists, beginning,
Dear Colleague Scientists:
The 7th Chronic Hypoxia Symposium, thanks to your outstanding participation was a great success !! We shared great scientific, friendship and enthusiasm from 16 countries, along with travel and conferences in fascinating environments, all at high altitude.
The letter ends with an invitation to all colleagues to contribute their own research to the first chronic hypoxia-dedicated issue in a top medical journal, so be on the lookout for Dr. Chris’s contribution (which we will be sure to share here).
The video below is a fascinating look into some of Dr. Zubieta-Castillo’s latest research, including his theories and recommendations on conditioning humans in space with hypoxia, a dissertation that was initially dismissed as irrelevant, then subsequently published. Enjoy!
Roberto Santos is from the remote island of Saipan, in the Commonwealth of the Northern Mariana Islands. He has since lived in Japan and the Hawaiian Islands, and has made Colorado his current home, where he is a web developer, musician, avid outdoorsman and prolific reader. When he is not developing applications and graphics, you can find him performing with the Denver Philharmonic Orchestra, snowboarding Vail or Keystone, soaking in hot springs, or reading non-fiction at a brewery.
The 7th Chronic Hypoxia Symposium was held this year in La Paz, Bolivia, in February and March. La Paz, sitting at 11,942 ft. (3640 m), is home to one of the world’s leading researchers of the effects of chronic hypoxia, Dr. Gustavo Zubieta-Calleja, with whom Colorado’s own Dr. Christine Ebert-Santos was able to meet with during her attendance of the symposium. You can refer to her previous article on the gathering of experts from over 16 countries for her own account of Dr. Zubieta-Calleja’s impressive work.
Below is the renowned Dr. Sanjay Gupta’s own account on video of his introduction to the experience of hypoxia and altitude with Dr. Zubieta-Calleja.
Always keep in mind, there are many physiological reactions going on when your body and brain are at altitude, and the higher the altitude, the more extreme the effects. Benefitting from a hypoxic environment isn’t as simple as staying hydrated. When we talk about chronic hypoxia, we are typically referring to a population who have spent many years in a high altitude environment.
Roberto Santos on an epic powder day at the opening of The Beavers lift at Arapahoe Basin ski area.
Roberto Santos is from the remote island of Saipan, in the Commonwealth of the Northern Mariana Islands. He has since lived in Japan and the Hawaiian Islands, and has made Colorado his current home, where he is a web developer, musician, avid outdoorsman and prolific reader. When he is not developing applications and graphics, you can find him performing with the Denver Philharmonic Orchestra, snowboarding Vail or Keystone, soaking in hot springs, or reading non-fiction at a brewery.
After over a decade of serving pediatric patients in the high country communities of Colorado as Ebert Children’s Clinic, we opened up our health care practice to serve the needs of the adult population several years ago. As Dr. Chris can attest to, the world of health care has grown and evolved incredibly since she first opened up her practice in Colorado in 2000, and we all continue to learn from the providers we welcome to our team as well as the students we mentor.
Family Nurse Practitioner Tara Taylor.
This past year, we’ve had the pleasure of having Tara Taylor, FNP on our staff. She’s brought a wealth of knowledge and unique experience from having practiced on a medical campus much, much larger than our little mountain clinic, and her insight into everything from patient care to our own high altitude research projects continues to be an invaluable asset to both our practice and our community. She was so gracious one afternoon to have a chat with me between patients:
How did you find yourself in Colorado’s high country health care community?
So, I have actually lived here since 2004, so I’ve lived here 15 years. I came out here for 6 mos to ski, and stayed for 15 years. I found myself loving it, bought my first house and decided to stay out here. I’ve actually commuted down to Denver all this time, because I had originally started in New Jersey in 2002 in Critical Care. So when I moved out here I wanted to be in the mountains, but I also couldn’t do Critical Care up here at that time. So I decided to commute down to Denver for three 12-hours shifts a week, and then live up here four days a week. So I had an apartment in Denver … when I went back to NP school, my goal was to work and live in my own community. I think that’s huge for me … and not only be serving the population of Denver, but to be serving the people of my actual community.
How long had you been practicing in Denver?
Since 2005, because I worked 6 months at Keystone Clinic, so I’ve been in Denver working for 14 years prior to this in the ICU. And I’ve worked at Children’s hospital in the pediatric ICU, burn ICU’s, bone marrow transplant, open-heart surgery, neuro-trauma, multi-system trauma, all of it.
How is it different working up here, for a small clinic, at that?
This is a huge change … I’m still working down there once a month, so I get to go down and play and enjoy that type of intensity. But at the same time, coming back here, I think that the critical care aspect … it still plays a role here. And in my letter, when they said, “Why do you want to go from [being] an ICU nurse to family practice?” … I said for so long, I’ve seen patients in the ICU [whose] admission or … critical portion of their admission could have been avoided if they had better focus on primary care and had their needs met. If they had been on the right medications, if someone had spent the time — and sometimes it’s because of their own compliance — but with adequate primary care, we’re avoided what I was seeing in the ICU.
Now, being in primary care, I get the stimulation I need from the independence of it, making these decisions, and I really enjoy finding out what’s going on with the patient, deciding what tests to run, and getting back these results and being able to properly refer them. I enjoy the time that I’m able to have with those patients here at a private practice. So each patient gets the time that they need to be properly cared for.
And I’m just seeing extremely sick patients. I’m not seeing a lot of sore throats and earaches, unless you’re 2 years old; besides that, the adults have really complex diagnoses that require a lot of thought. And in its own respect, it’s critical to me.
Great segue: what are the greatest challenges you’ve seen practicing up here?
I think some of the biggest challenges that I have seen up here is limitation of services. That’s why this clinic is bringing up Nephrology, … [expanding] mental health services here, and then, to bring in … pain management specialty, and give them a place to practice … It’s really hard for these additional specialties. We have Cardiology up here, we have Pulmonology, but some of the smaller things like Rheumatology for rheumatoid arthritis, for osteoporosis and kidneys … how do you establish your practice up here? So hopefully, as focused as [Ebert Family Clinic] is in the community about being able to provide the care we want for our patients … we’ll be able to get that door open for those specialties and help them establish their practice up here, which is our goal.
How do you get connected to these services like Genomind?
[This patient] came to me with Genomind. I had not heard of that before. He said, “I got on the right medications because this genetic testing gave [Compass Health] the ability to treat me properly.” [Certain health care providers in Denver] require it, almost, for every patient walking in their door as a prerequisite to help them make medication decisions.
Genomind is a swab in the cheek. I think it’s huge, because we’re not able to “draw” neurochemicals. We’re not able to draw your blood and say, “oh, look, you’re deficient in serotonin.” Because that’s not an option, what’s the best way for us to figure out what’s the best medication for you? Because medications are very specific to what they’re treating. So the only thing we’ve been able to do for the last decade is to guess; to put you on something, and if it doesn’t work, then we know that’s not the thing. And that’s a terrible process, because it leads patients to trying five medications, over a ten-year period, and finally we get them on the right thing. But how frustrating that is for patients; they lose confidence in their providers, they lose confidence in the system, they feel neglected, they feel frustrated. And to have that stamina to even go through that process … I think we have a lot of patients drop off. [They] end up saying, “Forget it. Medications don’t work for me.” Then [they] become non-functional … their quality of life is hindered by their [unwillingness] to spend ten years trying five medications.
That is not the best process. And I think the people that went ahead and engineered Genomind said, “What else can we do? What if we went back to genetics? What if we went back to genes?” We can swab a 1-day old infant or a 95-year old man, and we are going to get their genetics. And when they did the Human Genome Project, and we got our entire genetic profile as human beings, the science behind Genomind was they were able to take anyone who’s been diagnosed with schizophrenia, people who are known bipolar, generalized anxiety disorder, major depressive disorder, took their DNA … laid them over each other, and said, “What gene is predominant in all these patients?”
So they were actually able to use hundreds of thousands of mental health patients to establish what genes these were that led to the cause of their mental illness. So now we’re able to send off DNA with a swab in the cheek. It’s not a perfect science, but it’s what we have.
Is this better than nothing? There’s so much controversy about this test. How can you think this is controversial when you come from a science background as a provider, as a physician. You’ve got this, or you have nothing to guide you for the mental health of these patients. If we have this over nothing, I will take this.
[Genomind testing] is not only [about] mental health disorders, but also [for] people [suffering from] eating disorders, difficulty losing weight, ADHD, alcohol addiction and propensity for opioid addiction. It would identify what patients we may never want to start on narcotics if at all possible. It tells us, “Don’t start this patient on this particular drug because they’re at risk for gaining weight with this drug, like as an atypical antipsychotic.” It would tell us which medications an alcoholic would respond to best, if they were wanting to quit drinking and needed medication assistance. We have a lot of kids who seem like they’re ADHD, but really they have signs of anxiety and depression as well. And it’s our job to distinguish [whether] it’s the ADHD that’s causing the depression and anxiety, or it’s the depression and anxiety that’s causing the inability to focus? It’s absolutely fascinating! I want the community to know that we’re offering that here at the clinic.
Is Genomind available to children?
We can test anyone of any age. We can swab the cheek of a one-day old. I actually had a mom in here that said she was tested positive for both genes for the lack of ability to metabolize L-methylfolate, which causes bipolar disorder or mood instability. She came in here with her 4-month old son and said, “When can I get him tested to know?”
So I actually asked Genomind, and Genomind said you could test a brand new newborn baby, which at some point may be the standard of practice!
But at this point, it’s hard to want to test that child, because we’re not able to treat that child [without symptoms]. Once that child becomes 6 or 8 years old, and they are having mood instability, they are showing signs of some sort of mental illness, we do realize we are able to identify this in children. We don’t need to wait until people are 18 to say they must have a mental illness. We are identifying that in the behavior of hyperactive two and three year olds, and we’re seeing them grow up to be bipolar adults. So we are seeing early signs and symptoms of mental illness in these children.
Could we test a 6-year old who is showing signs of something and have them be positive for these genes and be able to supplement them with L-methylfolate or an approved psychiatric medication in the pediatric population based on their genetics? This is absolutely going in that direction. Genomind said they’re 100% approved for adult and pediatric testing.
How do you find balance for yourself and maintain a healthy lifestyle?
Tara with Dr. Chris (center) and Kristen Duffy, A/GNP, at Ebert Family Clinic.
Working at this clinic actually provides me with the exact hours I need to have good work-life balance. That’s extremely important to Dr. Chris Ebert-Santos. When I started working here, she said, “What are your husband’s days off?” And I said, “Sunday-Monday,” she said, “Okay, well you’re not working Sunday-Monday then.” I just honestly couldn’t believe it, that my happiness was that important to her. I work reasonable hours. [Dr. Chris] provides me with the days off that will match my husband’s. I have great quality of life due to my husband. He’s an amazing person, wonderful and spirited, and we get along great. So we have that, and we have our two dogs, and we live a comfortable life up here. We love to do all the great stuff that Summit Countiers do: snowboarding, hiking, biking, camping, just getting outside in general together and playing with our dogs. And that’s what’s most important.
What have been your greatest takeaways from working in Summit County so far?
I think it’s running into that patient at the supermarket who, I know in the back of my head I have their diabetes controlled. To know that I’m specifically helping patients in my community. That I’m doing yoga next to someone [whose] blood pressure is controlled now because of me. I think that’s something really special and it’s not something that I had before when I worked in Denver, and I would come home and I would never see those people again. And then, having the opportunity in this clinic to deal with so many pediatric patients, since this was originally a pediatric clinic [before] expanding to adult services as well, which is amazing. But the amount of pediatrics in this clinic really improves both my exposure to every age group. I love kids. To have patients hug me in this office who have had a very challenging diagnosis … that “thank you” from patients is something I cannot replace.
Tara continues to be a passionate advocate for mental, women’s and sexual health, and a valuable resource as a health care practitioner. Ebert Family Clinic is proud to have her.
Roberto Santos on an epic powder day at the opening of The Beavers lift at Arapahoe Basin ski area.
Roberto Santos is from the remote island of Saipan, in the Commonwealth of the Northern Mariana Islands. He has since lived in Japan and the Hawaiian Islands, and has made Colorado his current home, where he is a web developer, musician, avid outdoorsman and prolific reader. When he is not developing applications and graphics, you can find him performing with the Denver Philharmonic Orchestra, snowboarding Vail or Keystone, soaking in hot springs, or reading non-fiction at a brewery.
A 2009 study from Switzerland found a 12% decrease in risk of death from stroke at 6430 ft. compared to 850 ft. This result was more pronounced in men than women. Since men are more physically active than women in Switzerland, it was thought the exercise at the more hypoxic conditions of higher altitude may benefit them more than for women. The study also noted that being born at a higher altitude had a protective effect on death from cardiovascular disease1.
Strokes occur when blood flow to parts of the brain is cut off causing neurons and other brain cells to die within minutes. Strokes can either be ischemic or hemorrhagic. 80-87% of strokes are ischemic, which means that blood flow to the brain is cut off from a blood clot or other blockage of a blood vessel going to or in the brain. Hemorrhagic strokes are caused by bleeding within the brain (intracerebral space) or in the space surrounding the brain filled with cerebrospinal fluid (subarachnoid space). Risk of stroke is higher in individuals with previous transient ischemic attack (TIA), high blood pressure, previous heart attack, atrial fibrillation, enlarged left atria of the heart, smoking, heavy alcohol use, diabetes, obesity, high cholesterol, and stenosis of the carotid artery2.
Interestingly, on initial exposure to hypoxia at high altitude, blood flow to the brain increases which is split equally between gray and white matter. After 4 to 5 days, blood flow to the brain decreases but is still 13% greater than at sea level. The increased blood flow is needed to maintain adequate delivery of oxygen when the oxygen content of the blood is lower during hypoxia, until other acclimation mechanisms take effect3.
As noted in previous blog posts in response to hypoxia, erythropoietin (EPO) is also released, which increases the production of red blood cells to increase the oxygen-carrying capacity of our blood. Other studies have found that EPO also has a protective effect on neurons. Cerebrovascular endothelial cells have been found to have receptors for EPO and are thus able respond to EPO. Other studies have found that EPO is also involved in brain development of a fetus in utero. Animal studies suggest EPO not only protects neurons from cell death but may enable their regeneration as well. If this translates into humans, it is an important effect for those at risk for stroke4.
In a small clinical trial, patients with middle cerebral artery stroke received IV EPO daily for 3 days after their stroke. These patients had better neurological outcomes with increased physical functioning and independence as measured by Barthel index test results. Following the EPO doses, the size of the cerebral infarct, the damaged area of the brain from blood being cut off during the stroke, was reduced as well4.
Based on this research, Ismailov hypothesized that in the United States, geographic variation in levels of EPO from altitude differences may account for the differences in risk of death from stroke. He termed it the “stroke belt” in the Southeast, with higher rates of death from stroke compared to the Mountain states.
The states in the “stroke belt” are Louisiana (LA), Mississippi (MI), South Carolina (SC), Alabama (AL), Georgia (GA), Arkansas (AK), Indiana (IN), North Carolina (NC), Kentucky (KY), Tennessee (TN), and Virginia (VA), and all are at lower altitude. The mountain states have higher altitude and are North Dakota (ND), Kansas (KS), Nebraska (NE), Arizona (AZ), New Mexico (NM), Wyoming (WY), and Colorado (CO).
Louisiana and Mississippi’s average altitudes are 100 and 300 ft. compared to Colorado and Wyoming with average altitudes of 6800 and 6700 ft4. Since there is increased EPO released in individuals living at higher altitudes, perhaps there is more of a neuroprotective effect at higher altitudes, contributing to the observed lower risk of death from stroke seen in the Swiss study.
Symptoms of Stroke5
Think F.A.S.T
Other signs are sudden
Numbness of face, arm, or leg and particularly numbness on one side of body
Confusion
Difficulty seeing out of one or both eyes
Difficulty walking
Feeling of dizziness, loss of balance, or coordination
Stephanie Schick is a Physician Assistant student at Rocky Vista University in Parker, CO. She is born and raised in Fort Collins, CO. She started off her clinical year working in pediatrics with Dr. Chris at Ebert Family Clinic. The remainder of her clinical year will be spent closer to home in northern Colorado. In her free time she enjoys spending time with her husband, friends, and family in the beautiful Colorado sunshine.
We’ve learned a lot in the high country this season! For example, it isn’t too late or too warm for a snowstorm. We’ve conducted several interviews with professional, high-altitude athletes, athletic and tourism organizations in Summit County, physicians, podcasters, interns, and a local brewer. They’ve shed so much light on fitness, health, child growth & development, and acclimation at elevation, it warrants a re-cap:
8,000 ft. seems to be the pivotal elevation at which the body starts to experience a significant deficit in the oxygen and water it needs to function, affecting everything from sleep to metabolism.
A plant-based lifestyle has benefitted athletes under extreme training and competitive conditions at altitude.
Training at altitude significantly reduces your ability to reach cardiovascular and strength goals, even while preparing your respiratory and circulatory systems for the severe decrease in oxygen. “Live High, Train Low” is an effective strategy more and more athletes are advocating for.
Preparation for backcountry excursions is as much mental as physical.
Foods high in nitrates (like red beets, red bell peppers and arugula) can facilitate acclimation and recovery.
Oily foods may inhibit your body’s ability to cope with a significant increase in altitude.
We metabolize and experience the effects of alcohol differently at altitude.
Current research suggests some people suffering from Parkinsons disease may experience some relieve from symptoms at higher elevation.
Increased muscle mass requires increased oxygen. Being an athlete does not necessarily mean you will have an easier time acclimating.
As always, the best way to facilitate acclimation and deal with symptoms of altitude sickness is to drink plenty of water, allow yourself ample rest, and monitor your blood oxygen saturation levels with a pulse oximeter.
Be sure to subscribe to keep up with what this summer has in store for your elevated experiences at altitude! And if you have any questions or are eager to read more about a particular topic, let us know in a comment!
Living in Summit County, Colorado has its perks – residents are within a 20 to 40 minute drive to five world class ski resorts, and some of the most beautiful Rocky Mountain trail systems are accessible right out our back door. With the endless opportunities drawing residents outdoors to partake in physical activity, it comes as no surprise that Summit County is considered one of the healthiest communities in the country. However, there may be more than meets the eye when it comes to explaining this, as it also has something to do with the thin air.
As a Summit County native, you have likely heard the term “hypoxia” or “hypoxemia” mentioned a time or two. So what does this mean? Simply put, these words describe the physiological condition that occurs when there is a deficiency in the amount of oxygen in the blood, resulting in decreased oxygen supply to the body’s tissues. When this occurs in the acute setting, it may result in symptoms such as headache, fatigue, nausea, and vomiting. These are common symptoms experienced by those with altitude illness, also known as acute mountain sickness. While these symptoms can cause extreme discomfort and may put a huge damper on a mountain vacation, they are not usually life threatening. However, in a small number of people, development of more serious conditions such as a high altitude pulmonary edema (HAPE) and high altitude cerebral edema (HACE) can occur. The treatment for all conditions related to altitude illness is oxygen, whether via return to lower elevations or by a portable oxygen concentrator that allows you to stay where you are. While altitude illness generally affects those who rapidly travel from sea level to our elevation, it has also been known to affect residents returning home to altitude, usually after a period of two or more weeks away. In a very small subset it can occur after a period of only a day or two. This generally occurs in those with a preexisting illness, where altitude exacerbates the condition.
While the acute effects of altitude can clearly have detrimental effects on one’s physical well-being, there is emerging research demonstrating that chronic hypoxia may actually come with several health benefits. Long time Summit County business owner and community pediatrician, Dr. Chris Ebert-Santos of Ebert Family Clinic in Frisco, has spent quite some time studying the effects of chronic high-altitude exposure, and recently attended and presented at the Chronic Hypoxia Symposium in La Paz, Bolivia, the highest capital city in the world.
It is important to first understand the adaptations that occur in our bodies as a result of long-term hypoxia. The ability to maintain oxygen balance is essential to our survival.
So how do those of us living in a place where each breath we take contains about ⅓ fewer oxygen molecules survive?
Simply put, we beef up our ability to transport oxygen throughout our body. To do this, our bodies, specifically the kidneys, lungs and brain increase their production of a hormone called erythropoietin, commonly known as EPO. This hormone signals the body to increase its production of red blood cells in the bone marrow. Red blood cells contain oxygen binding hemoglobin proteins that deliver oxygen to the body’s tissues. Thus, more red blood cells equal more oxygen-carrying capacity. In addition to increasing the ability to carry oxygen, our bodies also adapt on a cellular level by increasing the efficiency of energy-producing biochemical pathways, and by decreasing the use of oxygen consuming processes2. Furthermore, the response to chronic hypoxia stimulates the production of growth factors in the body that work to improve vascularization2, thus, increased ability for oxygenated blood to reach its destination.
So, how can these things offer health benefit?
To start, it appears that adaptation to continuous hypoxia has cardio-protective effects, conferring defense against lethal myocardial injury caused by acute ischemia (lack of blood flow) and the subsequent injury caused by return of blood to the affected area3. The exact mechanism of how this occurs is not well understood, but it seems that heart tissue adapts to be better able to tolerate episodes of ischemia, making it more resistant to damage that could otherwise be done by decreased blood flow that occurs during what is commonly known as a heart attack. This same principle applied to ischemic brain damage when tested in rat subjects. Compared to their normoxic counterparts, rats pre-conditioned with hypoxia sustained less ischemic brain changes when subjected to carotid artery occlusion, suggesting neuroprotective effects of chronic hypoxia exposure4.
Additionally, it appears that altitude-adapted individuals may be better equipped to combat a pathological process known as endothelial dysfunction5. This process is a driving force in the development of atherosclerotic, coronary, and cerebrovascular artery disease. Altitude induces relative vasodilation of the body’s blood vessels compared to lowlanders2. A relaxing molecule known as nitric oxide, or NO, assists with causing this dilation, and in turn the resultant dilated blood vessels produce more of this compound5. The molecule has protective effects on the inner linings of blood vessels and helps to decrease the production of pro-inflammatory cytokines that damage the endothelium5. This damage is what kickstarts the cascade that leads to atherosclerosis in our arteries. Thus, a constant state of hypoxia-induced vasodilation may in fact decrease one’s risk of developing occlusive vascular disease.
The topics mentioned above highlight a few of the proposed mechanisms by which chronic hypoxia may be beneficial to our health. However, do keep in mind that there are potential detrimental effects, including an increased incidence of pulmonary hypertension as well as exacerbation of preexisting conditions such as COPD, structural heart defects and sleep apnea, to name a few6. Research regarding the effects of chronic hypoxia on the human body is ongoing, and given its significance to those of us living at elevations of 9,000 feet and above, it is important to be aware of the impact our physical environment has on our health. Dr. Ebert-Santos is avidly involved in organizations dedicated to better understanding the health impacts of chronic hypoxia, and has several current research projects of her own that may help us to further understand the underlying science.
Kayla Gray is a medical student at Rocky Vista University in Parker, CO. She grew up in Breckenridge, CO, and spent her third year pediatric clinical rotation with Dr. Chris at Ebert Family Clinic. She plans to specialize in emergency medicine, and hopes to one day end up practicing again in a mountain community. She is an avid skier, backpacker, and traveler, and plans to incorporate global medicine into her future practice.
Citations
Theodore, A. (2018). Oxygenation and mechanisms for hypoxemia. In G. Finlay (Ed.), UpToDate. Retrieved May 2, 2019, from https://www-uptodate-com.proxy.rvu.edu/ contents/oxygenation-and-mechanisms-of-hypoxemia?search=hypoxia&source=search_ result&selectedTitle=1~150&usage_type= default&display_rank=1#H467959
Michiels C. (2004). Physiological and pathological responses to hypoxia. The American journal of pathology, 164(6), 1875–1882. doi:10.1016/S0002-9440(10)63747-9. Retrieved May 2, 2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1615763/
Kolar, F. (2019). Molecular mechanism underlying the cardioprotective effects conferred by adaptation to chronic continuous and intermittent hypoxia. 7th Chronic Hypoxia Symposium Abstracts. pg 4. Retrieved May 2, 2019. http://zuniv.net/symposium7/Abstracts7CHS.pdf
Das, K., Biradar, M. (2019). Unilateral common carotid artery occlusion and brain histopathology in rats pre-conditioned with sub chronic hypoxia. 7th Chronic Hypoxia Symposium Abstracts. pg 5. Retrieved May 2, 2019. http://zuniv.net/symposium7/Abstracts7CHS.pdf
Gerstein, W. (2019). Endothelial dysfunction at high altitude. 7th Chronic Hypoxia Symposium Abstracts. pg 11. Retrieved May 7, 2019. http://zuniv.net/symposium7/Abstracts7CHS.pdf
Hypoxemia. Cleveland Clinic. Updated March 7, 2018. Retrieved May 9, 2019. https://my.clevelandclinic.org/health/diseases/17727-hypoxemia
Yuki Ikeda has been a professional cyclist for the past 10 years. He’s won titles in both Japan and the US. Interestingly enough, however, he come to Colorado to study at Metro State in Denver in order to play pro basketball. He is now known as an Ultra Mountain Athlete, not only biking, but running races up to 100 miles at altitudes over 10,000 ft. Over some decaf coffee on a warm Sunday afternoon at Gonzo’s in Frisco, he tells me he tried out every semester for the college team and failed. He had never really explored outdoor recreation growing up in Japan, because he had been so focused on a career in basketball.
He started taking some classes on outdoor sports while he was in Colorado, at Metro and then at Red Rocks Community College: rock climbing, cycling, backpacking, kayaking … He ended up staying in Colorado after graduating from Metro. “At that time, I was so into mountain biking,” he says. “I decided to pursue my career in mountain biking.”
He started racing in 2002. It took him five years to accumulate sponsors and become a full-on pro. “After every season, I sent my resume — racing results and what I do — to so many teams [to see if] they [would] accept me or not.”
Ultra Mountain Athlete Yuki Ikeda
But he started to get burned out. While he was still improving his stats, he was noticing that he couldn’t maintain the lead against some up-and-coming younger racers. “I was mentally very tired the last couple of years. I was kind of frustrated. Last year, after the season, I was so bummed out, I didn’t want to ride my bike, and I didn’t feel like starting training for the next year, so I stayed away from biking. I didn’t even touch my bike for a month.”
“But I still wanted to do some exercise. I just followed my wife, running, then I kind of joined the local trail running community. They showed me where to go and where to run, and I just loved it. I was so into mountain biking only, I thought doing other sports might cause injuries and effect my career. But it was the opposite.”
His new love for running turned his career around. “Physically, I don’t know [if it has improved my biking] yet, but mentally it helped. Now, my training is still 60 – 70% cycling, but not all the time. When I get on the bike, my brain is still fresh. Before, I rode my bike every day, pushing hard every day. It burned me out.”
Last month, he ran his first ultra running race, 50K. “Last October, I got sore from just running only 5K. Now I an run 50K, so that’s awesome.” He won.
Ultra Training at Altitude
I ask him how he trains for these races. Every summer, he comes to Colorado, staying in Frisco or Breckenridge to train in preparation for a series of races at altitude. It usually takes him 10 days to almost 3 weeks before he can do the same workouts he does at sea level in Tokyo.
Threshold power key. Threshold power is the maximum power you can sustain for about 60 minutes. He has a power meter on his bike that measures the power he exerts in watts. Recently, he has also been wearing a similar device on his shoe for when he runs.
“In Tokyo, my number is 310 watts, but here, it’s almost 270 to 280. I just did a threshold test last week. So that’s almost 10 to 12% lower. But still, if it’s within 10 to 15%, that’s very good for this altitude. But I usually take the test after a week or 10 days after I get here. I cannot push myself hard enough [before that]. Even [if] you’ve adjusted to this altitude, your power number is still lower than at sea level. I feel like I’m weak, but you have to accept it. That’s just how it is.”
His next race is part of the Leadman series, consisting of 5 mountain biking and trail running races in Leadville, Colorado. This next one is 42 km. Originally, the trail takes the runners over Mosquito Pass, which is at over 13,000 ft. But this year, there is still so much snow that the trail has been re-routed, so the runners aren’t sure what to expect. But the race starts at over 10,000 ft.
To train for this, he’s been running and biking six days a week. Every morning, he measures his blood oxygen saturation using a pulse oximeter. The first morning he arrived in Frisco, it was at 92. After a couple weeks of acclimation and training, it’s pretty reliably at 96 every morning.
Pacing
Yuki claims the most difficult part about running these long races is pacing. His coach encouraged him to run “negative splits”, increasing his speed toward the end of the race. “At my first 50 km race, even though I won it, I could have paced myself better. I just went too hard at the beginning [to] take the lead and paid for it later in the race. I was so trashed after the race, I couldn’t even stand and walk.”
“My coach is saying to be careful about [hitting the wall] at altitude. It’s so hard to recover. It takes almost five times longer than at sea level. I need to pace myself, especially for running 100 miles,” Yuki says, referencing the Leadville Trail Run in August he is also preparing for: 100 miles at altitude. “I’m so excited, but at the same time, I’m so nervous. Even finishing is questionable at this point.”
Acclimation
His secret to acclimating comfortably and quickly is actually movement. He says he feels the affects of the elevation more when he’s sedentary. In order to get more oxygen to his body, he has to get his circulation going. “The first week, I feel better when I exercise than when I just sit [around]. “
Also, beets. And red bell pepper. And arugula.
He eats a limited portion of these every day he’s at altitude. These vegetables provide a lot of nitrates, which your body processes into nitric oxide, facilitating blood circulation. At altitudes over 8000 ft., where you have access to about a third of the oxygen available in the air at sea level, the key to supplementing the oxygen your body requires is increased blood flow. After a certain amount of time, your body starts creating more oxygen-carrying red blood cells to counter the deficit, so getting the blood moving is literally vital.
According to high-altitude growth and development expert Dr. Christine Ebert-Santos, nitric oxide is often the way newborn babies with complications at altitude are treated. Hypoxia (the state of receiving less oxygen than is normal at sea level) causes pulmonary vessels (in the lungs) to constrict. Putting these infants on nitric oxide gas dilates the pulmonary arteries and improves some types of respiratory distress.
There are powders marketed to aid the food version of this nutrition, including BeetElite, Yuki’s product of choice, which he’ll add to his sports drinks in addition to consuming about an ounce of roasted beets. But portion control is also important, as too much nitrate can also have a negative effect on the body.
Running Recovery
Yuki is learning that he has to deal with an interesting phenomenon when it comes to his ultra running races: it’s tough on his guts. When it comes to his diet, he doesn’t typically change anything for recovery after a long event. “But I think my guts are more tired, because your body is bouncing so much from running.”
When running these incredible distances, he fuels his body with an energy gel every 20 to 30 minutes while running. “It usually has about 100 to 120 calories. It’s a dense energy. Then you take them for five hours, continuously, so it also tires out your guts. During the race. You have to maintain your blood sugar and keep your muscles moving. My muscles are tired, but also, my intestine and stomach are tired.”
“Even water is hard on my stomach [after running a race]. I’m kinda worried about running 50 and 100 miles. I’m not only worried about my legs, but even my stomach. I’m not used to [consuming] energy for 20 hours, eating and running at the same time.”
In Japan, hot springs and bathing are also a huge, sacred part of the recovery and health ritual. He takes a hot bath almost every day, “especially in winter,” he says. “It helps me to sleep at night.”
Sleep
The first week he spends at altitude in Colorado, he finds it harder to fall asleep. “I used to take one or two melatonin capsules every night, but it’s hard to tell if it helped. I just go to bed early, like 8 or 9, even if I cannot fall asleep. I just take the time to lay down and recover. [I try to sleep] at least 7 to 8 hours a night, but sometimes it’s hard. If I can’t get that amount of sleep, I usually take a nap after training.”
This may sound obvious, but sleep is when your body does most of its recovery, both mentally and physically. Sleep experts and studies have proven that the body and brain visibly deteriorate after so much sleep deprivation. And at altitude, with less oxygen available to supply a body in constant motion, sleep may be more important than ever.
Plant-based Nutrition
Yuki isn’t the first high-altitude athlete I’ve spoken to who advocates for a plant-based lifestyle. In a recent blog, skier and duathlete Cierra Sullivan also tells us about how a plant-based diet seems to make a big difference.
“When I used to like and eat animal products a lot, my recovery time was slower than now. It was hard to digest animal fats. I believed that they had a lot of good protein, but it was so hard on your body and digestive system,” Yuki says. “It took time to change my diet, but I now feel more comfortable with my plant-based diet, physically and mentally.”
Live High Train Low
Another recurring theme among high-altitude athletes.
“One of my sponsors has an altitude tent. They leased it to me before the competition, so I used it about a month. I slept in the tent, set at about 3000 m, then I train at sea level. I think it helped a bit, but it might be too short to tell. It tired me [out], though. I think I needed to do it longer before the competition, like, two or three months. I couldn’t train well, because I felt tired all the time. But I think for altitude training, I think this elevation is almost too high. Because you cannot push to your maximum potential. For example, for cycling, I can push up to 1000 – 1200 watts at sea level, but I cannot hit that number here, so I cannot train in that range here. I can lose that high power if I stay longer here. But it depends on your [goal]. My [goal] is winning the Leadman series, that’s why I’ve come here to train.”
This is partly why Yuki will lift weights once a week when training at altitude, “to maintain my high power.” With such limited access to oxygen, athletes up here can’t reach the same “punching power” that they can at lower elevations, so lifting may help maintain that power. “Very short, maybe 45 minutes, once a week, just to maintain. Weightlifting is still supplemental for your specific sport, so I don’t want it to affect my training on my bike or running. For race week, I don’t lift weights, because lifting weights takes time to recover.”
Keeping It Fun
“My trick to keep going — the best way to improve yourself,” Yuki adds, in a final reflection, “is to keep it fun. If you’re not having fun, I think that’s not good. Last year, I almost lost my motivation as an athlete. I almost thought about quitting racing, but I still love the sport. Trail running helped me mentally and physically, and my motivation came back, even for cycling. Having fun is the key to keep going.”
Ultra mountain athlete Yuki Ikeda with high-altitude researcher and writer Roberto Santos at Gonzo’s Coffee in Frisco after an insightful afternoon interview.
Thank you, Yuki. I completely agree. And best of luck with that 100-mile trail run at 13,000 ft.! Keep track of Yuki’s race schedule, social media and stats at http://yukiikeda.net/
Roberto Santos on an epic powder day at the opening of The Beavers lift at Arapahoe Basin ski area.
Roberto Santos is from the remote island of Saipan, in the Commonwealth of the Northern Mariana Islands. He has since lived in Japan and the Hawaiian Islands, and has made Colorado his current home, where he is a web developer, musician, avid outdoorsman and prolific reader. When he is not developing applications and graphics, you can find him performing with the Denver Philharmonic Orchestra, snowboarding Vail or Keystone, soaking in hot springs, or reading non-fiction at a brewery.
