If you're diabetic it may seem as if multi-day walks in the wild are a step too far; but don't be deterred, says outdoor instructor and diabetic Ailsa Graham. Here she shares tips for managing the condition out on the trail.

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I was diagnosed with insulin dependent diabetes (I have a very rare form of MODY) in April 2014, and to mark the 10-year anniversary I decided to take on a challenge to prove to myself that diabetes really needn't stop me. I live and work in the mountains as a Mountain Leader and Outdoor Instructor and so am used to managing my diabetes in difficult environments and conditions. But I do very little multi day walking, partly because until now I have been worried about how my blood sugars would react to it, and whether I would be able to maintain good control. Jumping in at the deep end, I decided to take on the Cape Wrath Trail (CWT) and put my doubts to bed once and for all.

Running between Fort William and Cape Wrath in the far northwest, the CWT is widely regarded as the UK's toughest long trek. An informal and unmarked route around 370km long, with a number of variations - all of which involve tough and remote terrain - it's a big step up in commitment from more organised trails such as the Pennine Way, and most walkers can expect to take two to three weeks on it. No easy feat, especially if you add diabetes to the equation.

Before I set my sights on the CWT, the longest I had ever spent in the hills since diagnosis was just three days. This is long enough to start to see some of the challenges that would be faced in a longer walk, but also a short enough period of time that it felt relatively easy to plan how I would manage myself. In this article I'm going to talk about trips that involved being out for four days or more, as that is when I feel management gets a little trickier.

In the couple of weeks before setting off on the Cape Wrath Trail, anxiety reared its head. How was I going to manage the constant demands of the mountains, camping, and diabetes? As it turns out I needn't have worried; walking the CWT was one of the best experiences of my life: Three weeks of almost total immersion in the mountains with only the odd stop to rest and recharge. I loved (almost) every minute of it, even when the rain was coming down too hard to see more than 20m in front of me. The careful planning worked and I was able to manage my diabetes well, proving once and for all that when it comes to it, I won't let it stop me. You don't have to let it stop you either!

Here is what I learned from my three weeks on the trail...

Avoid Hypos

Avoiding hypos (dangerously low blood sugar) is one of the most important parts of managing diabetes in the outdoors. A bad hypo can not only cause big delays to your day, it can bring about more hypos and become a life-threatening event if you are unable to bring your blood sugars back up. For this reason, it is crucial to avoid too many of them. There are a few things that can be done to help with this:

1. For most insulin dependent diabetics, a CGM (continuous glucose monitor) of some description is an important part of the way we manage the condition. These give insight into how blood sugars are trending and allow treatment decisions to be made earlier. I choose to set my low alarm to go off at 5mmol/L as this gives me time to see my blood sugars are dropping before I reach hypo. When out on a multi-day walk, I will treat anything below 5mmol/L as a hypo in terms of eating sugar but will continue walking. I will keep an eye on my numbers if I drop below 5 to make sure I don't reach 4mmol/L or below. By doing this I am able to avoid most hypos from developing.

2. Remember, exercise doesn't just affect you on the day that you do it, and so when you're out for multiple days the effect of exercise is cumulative. This means that insulin requirements are likely to change as you go. For those on a Basal insulin you are likely to need less of it after the first few days of walking (I found after about three days my body stabilised). How much less and how soon the effects will be seen will vary from person to person, but it is something that should be kept in mind as you progress. The carb ratio to short acting insulin will also be affected. If you already have a ratio for walking days, that will work at least to begin with, but it's possible to see a reduction in the amount of insulin needed.

3. What you eat and when you eat it will also have a big impact on chances of hypo. I don't want to tell anyone what to do as we are all different, but for me the chance of a hypo increases massively if I stop for a big lunch that contains carbs and then have to take fast acting insulin to deal with the carbs I have eaten. So, to avoid this I split my food into two groups, carby food and non carby food. If my blood sugars are above about 6.5mmol/L I would avoid eating my carby food and instead snack on low carb trail mix and dried sausages. When my blood sugars dipped below this, I would eat bite sized flapjacks, mini brownies and raw fruit and nut bars in small quantities to avoid needing to take any correction insulin. I drip fed the carbs into myself throughout the day in small quantities with a higher-than-normal basal insulin to help cope with this.

These things together helped me to avoid hypos while walking, and while we are all different the first two will be of benefit to most people. Weather or not you want to follow what I did with eating will be personal choice but if you do struggle with hypos when out it's a method that could be worth considering.

Eat like you normally do!

Ok, so I have just said how I ate during the day was very specific, but for breakfast and dinner I believe the best way to look after yourself on a multi-day hike is to eat how you normally would. Again, this is an area where we are all different, but keeping to your normal eating habits will help you look after yourself and your energy levels. If you are someone who eats normal amounts of carbs in your meals you will find there are loads of options for meals both in dehydrated and wet forms, all with the carbs neatly worked out on the back of the packet for you. But if like me you tend to eat low carb, things can be a bit trickier.

I typically eat all my carbs in the middle of the day as that is when I find my body is most able to deal with them. On the CWT I did this using the method I described above but this meant I needed to find low carb food for breakfast and dinner. This isn't easy to do, there are only a few options commercially. These are normally some form of scrambled egg, and this is what I went with for breakfast. Dinner can be harder to find unless you want scrambled eggs again. I discovered the Firepot foods were able to custom make meals and so I got low carb dinners made by them. This allowed me to eat in the way that my body is used to - low carb breakfasts and dinners with my carb intake centred in the middle of the day.

Insulin

For anyone taking insulin, looking after it on a multi-day walk is something that must be thought about. The air temperature you are walking in must be considered as insulin can start to denature when it reaches 37c and so if you are walking in a hot country this could become an issue. Manufactures recommend that insulin shouldn't be kept out of cold storage for more than 4 weeks, and be kept in temperatures below 30c. Even in the UK this is a temperature that can now be reached in the summer months, especially in the south if less likely up in the Highlands. If you think you are likely to be out in these temperatures then a small heat proof bottle may be needed to carry insulin in. Even in colder climes, don't store it all day in a tent in the sun.

Depending on how long you are walking for and how much insulin you typically use you may find that you need to carry spare insulin with you. If you use a vial of insulin relatively quickly then apart from finding a suitable receptacle to carry it in this may not be an issue (small heat proof bottle again recommended). For those people who use their insulin slower or are out for longer periods of time it can be more of a hassle. Keeping insulin refrigerated when hiking is impossible and even if walking hut to hut or campsite to campsite where there are fridges your insulin will still be spending a large amount of time out of the fridge. In this situation the best solution would be to try to get it sent out to places in advance to be picked up. On the Cape Wrath Trail there are occasional B&Bs and hotels that are happy to receive food parcels, so perhaps they would also be happy to put some insulin in their fridges.

Be Prepared

Having spent the past three years living and working in the mountains I had a very good idea of what my body would need and how my diabetes was likely to react to being out for a prolonged period of time. I would recommend anyone else with diabetes, particularly if they are insulin dependent, also spends a good amount of time in the hills, to learn how their body reacts to walking before setting off on a multi-day walk.

On the CWT I also made sure I took spares and extras just in case. In my pack I had a little diabetes kit containing:

• Spare CGM sensor
• Finger prick meter
• Glucose gel (For severe hypos)
• Haribo
• Carb heavy evening meal

I didn't need to use any of this but as a diabetic it is necessary to carry these things just in case. As someone who eats low carb I knew there was a chance of running out of emergency sugar stores (glycogen) and so I had a carb heavy dinner in case I felt my body was in need of some extra carbs if I'd had a day with lots of hypos.

I also planned all my food in advance to ensure I was getting the same amount of carbs each day so that my insulin needs would hopefully stay consistent. This meant my diet wasn't very varied, but I was able to maintain good blood sugar control throughout the three weeks of my walk.

By being well prepared and looking after my food and insulin intake well I was able to walk for three weeks without my diabetes having much effect on me. I hope you can use what I have learned to enjoy your own multi-day walking adventure.

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