Often, at high altitude we hear complaints of gas pain and increased flatus in our infant population. Parents often wonder, are we doing something wrong? Is my child reacting to breastmilk, or showing an intolerance to certain foods? Actually there is another explanation for increased flatus and gas pain in the high-altitude region of Colorado.
The term HAFE was coined by Dr. Paul Auerbach and Dr. York Miller and published in the Western Journal of Medicine in 1981. Their discovery began In the summer of 1980, when the two doctors were hiking in the San Juan Mountains of Colorado on a quest to summit three 14ers. During their ascent they noticed that something didn’t smell right! As the pair continued to emit noxious fumes, they began to put their scientific brains to work and discovered HAFE. The symptoms include an increase in frequency and volume of flatus, or in other terms an increase in toots! We all have familiarity in watching our bag of potato chips blow up when reaching altitude or our water bottle expanding as we head into the mountains. This reaction is due to a decrease in barometric pressure. Based on Boyle’s law, decreased barometric pressure causes the intestinal gas volume to expand, thus causing HAFE (Skinner & Rawal, 2019).
To my surprise, a gas bubble the size of a walnut in Denver, Colorado (5280 ft) would be the size of a grapefruit in the mountain region of Summit County, CO (8000+ ft)! Trapped gas is known to lead to discomfort and pain. The use of simethicone may have merit in mitigating the effects of HAFE. Simethicone works by changing the surface tension of gas bubbles, allowing easier elimination of gas. This medication, while benign, can be found over the counter and does not appear to be absorbed by the GI tract (Ingold, C. J., & Akhondi, H., 2022).
While this phenomenon may not be as debilitating as high-altitude pulmonary edema (HAPE), it deserves recognition, as it can cause a significant inconvenience and discomfort to those it inflicts. As the Radiolab podcast explained in their episode The Flight Before Christmas , expelled gas in a plane or car when driving up to the mountains can be embarrassing. While HAFE can be inconvenient, it is a benign condition and a matter of pressure changes rather than a disease or pathological process. We would love to talk more about HAFE at Ebert Family Clinic if you have any questions or concerns!
A bald eagle flies toward its nest atop a bare lodgepole pine.
As always, stay happy, safe, and healthy 😊
Taylor Hollingsworth is finishing her final semester as a family nurse practitioner (FNP) student at Georgetown University. Originally from the east coast, Taylor plans to start her FNP career in North Carolina close to family. She has a passion for pediatric and family wellness and has worked as a pediatric intensive care unit nurse for 6 years! In her free time, Taylor loves to hike, fly fish, run, and spend time with her fiancé Logan.
References
Auerbach, P. & Miller, Y. (1981). High altitude flatus expulsion. The Western Journal of Medicine, 134(2), 173-174.
From backpacking and camping to skiing and snowboarding, there are plenty of activities outdoors in the Colorado high country. If you find yourself wandering around and lost without food in the mountains, there are several wild plants that you can eat.
However, before you consume the delectable greens, there are a few precautions to take.
Moose shopping
Do not eat any wild plants unless you can positively identify them. There are iOS and Android apps that you can download prior to your hike to help distinguish plants, such as PictureThis and NatureID.
Be aware of environmental factors such as pollution or animal waste. Avoid popular wild animal gathering areas.
Make sure you’re not allergic to the plant by rubbing it against your skin and observing for a reaction. If so, do not eat the plant. Before ingesting a large quantity, eat a small amount and check for a reaction.
It may be difficult to cook if you did not come prepared with a portable stove, pots, and water, which could limit ways to enjoy vegetation. Here is a list of edible plants, how to identify them, where can they be found, and which part you can eat.
Wild plants
Dandelions (Taraxacum officinale): yellow ray florets that spread outward from center with toothy, deep-notched, hairless basal leaves and hollow stems. They can be found everywhere and anywhere. Every part of the dandelion plant is edible including the leaves and roots.
Pineapple Weed/ Wild Chamomile (Matricaria discoidea): the flower heads are cone-shaped and yellowish-green and do not have petals. Often found near walking paths and roadsides, harvest away from disturbed, polluted areas. If you’re feeling anxious about being lost, pineapple weed promotes relaxation and sleep and serves as a digestive aid.
Fireweed (Epilobium angustifolium): vibrant fuchsia flowers. Grows in disturbed areas and near recent burn zones. Eat the leaves when they are young as adult leaves can stupefy you. Young shoot tips and roots are also edible.
Wild onions (Allium cernuum): look for pink, lavender to white flowers with a strong scent of onion. They grow in the subalpine terrain and are found on moist hillsides and meadows. Caution: do not confuse with death camas. If it doesn’t smell like an onion and has pink flowers, it is not likely an onion.
Cattails (Typha latifolia or Typha angustifolia): typically 5-10 feet tall. Mature flower stalks resemble the tail of a cat. Grow by creek, river, ponds, and lakes. This whole plant is edible, from the top to the roots. Select from pollution-free areas as it is known to absorb toxins in the surrounding water.
Wild berries:
Wild strawberries (Fragaria virginiana): they are tiny compared to store-bought. Can be identified by their blue-green leaves; small cluster of white flowers with a yellow center; and slightly hairy, long and slender red stems.
Huckleberries (Vaccinium spp): They grow in the high mountain acidic soil and flourish in the forest grounds underneath small, oval-shaped, pointed leaves. They resemble blueberries and have a distinguishable “crown” structure at the bottom of the berry. They can be red, maroon, dark blue, powder-blue, or purple-blue to almost black, and they range from translucent to opaque.
Oregon grapes (Mahonia aquifolium): powder-blue berries, resembling juniper berries or blueberries, with spiny leaves similar to hollies that may have reddish tints.
Fun fact: The roots and bark of the plant contain a compound called berberine. Berberine has antimicrobial, antiviral, antifungal, and antibiotic properties.
Mushrooms
True morels (Morchella spp.): cone-shaped top with lots of deep crevices resembling a sponge. They will be hollow inside. A false morel will have a similar appearance on the outside but will not be hollow on the inside and are toxic. Morels are commonly found at the edge of forested areas where ash, aspen, elm, and oak trees live. Dead trees (forest wildfires) and old apple orchards are prime spots for morels.
Porcini (Boletus edulis): brown-capped mushrooms with thick, white stalks. Found at high elevations of 10,500 and 11,200 ft in areas with monsoon rains and sustained summer heat.
There are many more edible plants, flowers, berries, and mushrooms in the mountains. These are just 10 that can be easily identifiable and common in the Western Colorado landscapes. I recommend trying out the apps listed above and reading “Wild Edible Plants of Colorado” by Charles W. Kane, which includes 58 plants from various regions, each with details of use and preparation. Hopefully this post made you feel more prepared for your next adventure.
Resources:
Davis, E., 2022. Fall plant tour: Frisco, CO | Wild Food Girl. [online] Wildfoodgirl.com. Available at: <https://wildfoodgirl.com/2012/eleven-edible-wild-plants-from-frisco-trailhead/> [Accessed 10 July 2022].
McGuire, P., 2022. 8 Delicious Foods to Forage in Colorado | Wild Berries…. [online] Uncovercolorado.com. Available at: <https://www.uncovercolorado.com/foraging-for-food-in-colorado/> [Accessed 10 July2022].
Rmhp.org. 2022. Edible Plants On The Western Slope | RMHP Blog. [online] Available at: <https://www.rmhp.org/blog/2020/march/foraging-for-edible-plants> [Accessed 10 July 2022].
Lifescapecolorado.com. 2022. [online] Available at: <https://lifescapecolorado.com/2014/01/edible-plants-of-colorado/> [Accessed 10 July 2022].
Pfaf.org. 2022. Plant Search Result. [online] Available at: <https://pfaf.org/user/DatabaseSearhResult.aspx> [Accessed 10 July 2022].
Cindy Hinh is a second-year Physician Assistant student at Red Rocks Community College in Arvada, CO. She grew up in southern Louisiana and received her undergraduate degree in Biology from Louisiana State University. Prior to PA school, she was a medical scribe in the emergency department and an urgent care tech. In her free time, she enjoys baking, cooking, going on food adventures, hiking, and spending time with family and friends.
Acetazolamide is already known for its success with treating Acute Mountain Sickness (AMS) and helping patients with their transition to higher altitudes, but what other options are available? What about those who don’t want a prescription, that are looking for other alternatives to help them with AMS and being at high altitude?
During my time in Frisco, Colorado (9000’/2743 m) I was fortunate enough to interview two resident Naturopathic Doctors. Mountain River Naturopathic Clinic on Main Street of this little mountain town is a wonderful oasis for anyone in Colorado’s Summit County looking for alternative care and treatment for their mind and body.
Dr. Kimberly Nearpass, ND and Dr. Justin Pollack, ND took the time to educate Dr. Chris Ebert-Santos, my classmate Rachel Mader, and myself about all the naturopathic remedies available for AMS and residents at altitude.
Tell us about Naturopathic medicine and why you picked this path of medicine?
Dr. Kimberly Nearpass: I thought I was going to be an OBGYN and then I did more research. I talked to doctors, midwives and herbalists and found that the Western medicine model didn’t feel right to me. So I thought, “Do I go to medical school and try to operate functionally from the inside or do I find another track?” I did not know about naturopathic medicine until a few years later. I took some time off; I traveled and went to the Peace Corps and then I discovered naturopathic medicine and loved it. I had lived in Ecuador in the rainforest as a naturalist guide so I learned a lot about traditional medicine that way. I learned a lot about traditional medicine when I lived in rural Africa as well. Living in these rural areas and watching the indigenous people — and they certainly use modern medicine — but they did not have a lot of access. Especially in the rainforest, they were using a lot of plants and I was fascinated by that. But I still wanted the medical training. Then I discovered naturopathic school. So, it’s four years of medical school, we get the medical training, but we also have that more holistic, natural, herbal based approach.
What naturopathic remedies are available for acute mountain sickness (AMS)?
Dr. Nearpass: So I will tell you Acli-Mate is our go-to. I’m not tied to this product, a friend of mine, it is her company, she is a naturopathic doctor in Gunnison. She formulated this, she started it out as a high-altitude electrolyte drink. Everybody that comes in our door, we start with this. This stuff works AMAZING. We rarely have to go anywhere else. I think the combination of the electrolytes and that it is hydrating has a great benefit. It helps with the headache and the nausea. For mild to moderate symptoms of AMS it is incredible. What we do is if we have family coming to visit from sea level is we have them start drinking it before they come.
Acli-Mate is found to be highly effective at helping people who are suffering from AMS. The blend includes herbs Ginkgo biloba and Rhodiola, both of which have proven effective in preventing and treating altitude related sickness. Both herbs seem to improve circulation, especially through cerebral vessels, and cellular energy function through improved uptake and utilization of oxygen, reducing toxic brain edema. Ginkgo has also been shown to inhibit platelet clumping, keeping red blood cells evenly dispersed, which improves delivery of oxygen to tissues, while Rhodiola appears to help the body deal with stress.
Nutrients in Acli-Mate: Vitamin C, and many of the B vitamins: thiamin (B1), riboflavin (B2), niacin (B3), pantothene (B5) and cobolamin (B12).
Acli-Mate in a variety of applications.
Have you noticed that when you have patients drink it before they arrive at high altitude, they have a better outcome?
Dr. Nearpass: Yes. And I have a patient who is 70 now and 5-10 years ago she went with some girlfriend to hike Mount Kilimanjaro. She had all her girlfriends take it and emailed me after saying, “We all did great!” And I don’t want to put all my eggs in one basket but this is almost always all we need.
Dr. Justin Pollack: There is something about that blend of Rhodiola, Ginkgo and the B vitamins that seems to work. We’ve had tons of people use it clinically.
Dr. Nearpass: For other options, I think Rhodiola is a good one. It’s interesting to me because Rhodiola grows in Mongolia, it grows in high altitude. One of the things we talk about in herbal medicine is often the plants we need are there. For example, dandelion root grows everywhere and it is good for liver detox and helps with hepatic function. So, it is interesting to me that dandelion is popping up on the side of the highways and in areas that we could probably use a little cleansing and detoxing.
Dr. Chris Ebert-Santos: What about Coca?
Dr. Nearpass: Oh yes! Coca works amazing. It is a plant that grows in the high altitudes of South America and when I was living in Ecuador the folks that live in the Andes drink coca tea all the time. They also take coca leaves and shove a wad in their mouth like chew. While they are doing work, cardiovascular work, they just put it in their mouth and that is their medicine. It gives them more stamina and reduces fatigue. There is not much research on it because you cannot even get it in the states.
Is there a reason you can’t get it here?
Dr. Nearpass: Because it’s the same plant as cocaine. We used to have a homeopathic version of it. Do you know what homeopathic medicine is? You take a remedy and you dilute it until you don’t have any molecules of the original substance but you basically are getting an energetic imprint. For example, Rhus tox, poison ivy, the homeopathic rhus tox is used to treat red itchy inflamed poison ivy type symptoms. But with coca, even homeopathically, the herb is used in concentrated doses to treat high altitude sickness and increase energy and stamina. But because there is such a control over coca, we can’t even get the homeopathic version, which is ridiculous because there is not a single molecule of the plant in the remedy.
Dr. Pollack: When Kim and I were on our honeymoon, we passed through Bolivia and Peru. In Bolivia in la Paz there was a coca museum. It was really fascinating because something around 1,000lbs of coca leaves must be distilled down into 1 gram to make cocaine. When you make tea out of the raw leaves it seems to have the subtle effect of suppressing appetite and allowing people to do better at altitude. Marijuana has a whole stigma around it, even though it has been legalized, and so the research and researchers are stigmatized, yet there are a lot of useful compound coming out of the plant. So, I’m sure that coca is the same, and hopefully somewhere down the line we will be able to use coca leaf for altitude.
Dr. Nearpass: And certainly, coca is the number one herb in the Andes that people use. You can get it everywhere, it’s like black tea down there.
So because coca is not available for your patients, and if you found Acli-Mate was not successful, what would you recommend?
Dr. Kimberly Nearpass
Dr. Nearpass: This is the thing about naturopathic doctors, we look at each individual. If it’s a resident, per se, we are going to draw blood work. We are going to try to figure out what’s going on, what is the underlying issue. Do you have relative anemia? We will run iron but also ferritin. They may have normal blood cells, normal H&H but their ferritin is a 2. One of the things that is tricky about being a naturopathic doctor is, we will be at a party and someone will ask, “Well what do you do for hypertension?” or “What do you do for digestive issues?” We always say we don’t treat symptoms; we don’t treat disease, we treat people. If someone is having recurrent altitude sickness, we are going to look at the individual and look at what is going on. What’s their diet? Are they hydrated enough? Are they drinking too much alcohol? Do they have subclinical hypothyroidism that might affect their metabolism and their ability to adapt when they get here? Might their ferritin levels be really low? And then we would sit down with the patient and say, “Well what are your symptoms? Is nausea the main symptom? Is headache the main symptom?” And then, what other factors could be contributing to these symptoms? If it’s headache then CoQ10 would be what I would go to.
Dr. Chris Ebert-Santos: And what do you look for on physical exams on residents that are having trouble with altitude?
Dr. Nearpass: On physical exams we are doing the standard physical that you would do but we are also looking at the tongue. I am not a Chinese Medicine doctor but the tongue does give you some insight on what is going on in the digestive tract. If we are seeing inflammation or glossitis or geographic tongue, we are thinking, “Oh, this person may have some underlying digestive issue.” We might look at Arroyo’s sign, it’s a traditional sign when you shine a light on someone’s pupil and most of the time their pupil will constrict, but Arroyo’s sign is both pupils will stay dilated. This is a red light for adrenal issues, for hyper cortisol output or adrenaline output. If someone is in a chronically stressed state, their pupils are going to be dilated all the time. If it looks like someone has chronic stress, it takes you out of the parasympathetic, and so their digestion is going to be weaker. The way we look at it is the body has to prioritize, and there is only so much that one body can do. And I suspect that living at high altitude puts chronic stress on the body. I see this huge lack of libido in the women. I see women in their 20s, 30s, 40s, 50s. But it kind of makes sense right? If the body is chronically stressed, having a baby is a huge energy output for a woman. So, I think we may see the chronic stress impacts of living at high altitude.
Dr. Chris Ebert-Santos: So what do you do for the libido?
Dr. Nearpass: That is one that if I could invent one pill, it would be that one. Libido is really hard, especially in women. Unfortunately, what I see is its one of the first things to go in women and it’s one of the last things to respond. So, my suspicion is that this altitude is another physical stress on our bodies. I think we can see multiple systems being affected by it, maybe not severely but still.
Rachel Mader PA-S: Is there anything for sleep at altitude? I know a lot of people struggle with that.
Dr. Nearpass: Yes, again for us there is no magic bullet. Melatonin is very well known and that can be very helpful for some people, but it sure doesn’t work for everybody. When patients come in and say, “What do you use for sleep?” I want to take every person back and have a conversation with them. Ask, “Are you having a hard time falling asleep? Are you having a hard time staying asleep? Are you waking up to go to the bathroom?” Right? So, there isn’t a magic bullet that will work for everyone. Breaking it down, I think you could have 50 people with altitude sickness and we’re going to do 50 different things. I mean, I would start with Acli-Mate, but every patient will be different.
Do you think there’s benefit to adding Acli-Mate in combination with an Acetazolamide prescription?
Dr. Nearpass: As far as I know, there’s no issue combining the two. Most people that come to us are usually trying to avoid medication, but what I always say to them in that situation is, “Try this other stuff to see if it helps.” But if it’s someone who had trouble in the past with AMS, I’ll say go to your medical doctor and get the prescription so that you have it if you need it. I think another issue is that people fly here right from Texas. They fly to Denver, they get right on the shuttle, and they drive right up here. If they’ve had trouble in the past, they should drive here and take their time. Spend a couple days in Denver if they have to. That does seem to help people.
Thank you so much Dr. Nearpass. Is there anything else about naturopathic medicine and high altitude you would like to share with us?
Dr. Nearpass: I guess I would say again that from a naturopathic perspective it is really about looking at the individual.
Is there anything that could specifically help with nausea symptoms of AMS?
Dr. Nearpass: Ipecacuanha! Ipecac syrup — which in full doses will make you throw up, so the homeopathic Ipecacuanha we use for nausea — that is one I have actually used quite a bit for people who have that aspect of AMS. It is really good for nausea and pregnancy too.
PA student Hannah Addison with Dr. Pollock, Dr. Nearpass and Dr. Chris in front of the Naturopathic clinic and apothecary in Frisco, CO.
The way I see Healthcare is a full spectrum, and on one end you have the brain surgeons and on the other end you have the Reiki energy healers. Then you have everything in between. I see us sitting in the middle. For patients, the best thing is to be aware of where they belong on that spectrum. I’m not going to replace a brain surgeon, but sometimes a little bit of massage and energy can do the trick. It is so great for us as practitioners to be able to talk and converse with the medical doctors. We’ve been really lucky in this community.
Available research articles on Naturopathic Remedies and AMS:
Zhang DX, Zhang YK, Nie HJ, Zhang RJ, Cui JH, Cheng Y, Wang YH, Xiao ZH, Liu JY, Wang H. [Protective effects of new compound codonopsis tablets against acute mountain sickness]. Zhongguo Ying Yong Sheng Li Xue Za Zhi. 2010 May;26(2):148-52. Chinese. PMID: 20684264.
Tsai TY, Wang SH, Lee YK, Su YC. Ginkgo biloba extract for prevention of acute mountain sickness: a systematic review and meta-analysis of randomized controlled trials. BMJ Open. 2018;8(8):e022005. Published 2018 Aug 17. doi:10.1136/bmjopen-2018-022005
Gertsch JH, Basnyat B, Johnson EW, Onopa J, Holck PS. Randomised, double blind, placebo-controlled comparison of ginkgo biloba and acetazolamide for prevention of acute mountain sickness among Himalayan trekkers: the prevention of high-altitude illness trial (PHAIT). BMJ. 2004;328(7443):797. doi:10.1136/bmj.38043.501690.7C
Ke T, Wang J, Swenson ER, et al. Effect of acetazolamide and gingko biloba on the human pulmonary vascular response to an acute altitude ascent. High Alt Med Biol. 2013;14(2):162-167. doi:10.1089/ham.2012.1099
Wang J, Xiong X, Xing Y, et al. Chinese herbal medicine for acute mountain sickness: a systematic review of randomized controlled trials. Evid Based Complement Alternat Med. 2013;2013:732562. doi:10.1155/2013/732562
Lee SY, Li MH, Shi LS, Chu H, Ho CW, Chang TC. Rhodiola crenulata Extract Alleviates Hypoxic Pulmonary Edema in Rats. Evid Based Complement Alternat Med. 2013;2013:718739. doi:10.1155/2013/718739
Hannah Addison, PA-S
Hannah Addison (she, her, hers) is a second-year physician assistant student at Red Rocks Community College Physician Assistant Program in Arvada Colorado. Hannah was born and raised in the South Denver area of Colorado. She spent four years getting her bachelor’s in biomedical science at Colorado State University in Fort Collins, CO where she decided her life career goal was to become a PA. After graduating and while applying for PA programs, Hannah worked at Littleton Adventist Hospital of Centura as a CNA, Telemetry Technician and Unit Clerk. In her free time, Hannah enjoys hiking and discovering all the delicious food and drink Colorado has to offer.
