Back on the Appalachian Trail with Type 1 Diabetes

Back on the Appalachian Trail with Type 1 Diabetes


In July we profiled the amazing Mike Joyce, who got his Type 1 diabetes under control – and lost 100 pounds! – when he switched to a low-carbohydrate diet. The first time we spoke, he was about to embark on the adventure of a lifetime, a Southbound thru-hike of the 2,200 mile Appalachian Trail.

Mike has been on the trail ever since, 5 months of walking, over mountains and through valleys, in rain and shine and snow. When we spoke Mike was nearing mile number 2,000, in the home stretch, with Georgia practically in sight. We thought it was a great time to catch up and see how things were going. We ended up having a long talk about the trials and tribulations of the very low-carb hiker, and what it’s like to tackle such a feat of endurance as the Appalachian Trail with Type 1 diabetes.

I asked Mike if he has had to accept a lower level of glycemic control on his journey. We all know that exercise can make tight control tricky, so one can only guess what 150 days of sunup to sundown exercise might do.

“I think my A1C is probably going to go up into the low-6’s, from being in the mid- to low-5’s. I don’t make all of the same micro-adjustments I do when I’m at home. Sometimes I have to make the decision to let my blood sugar stay a little higher than I’d like it to be, just because I don’t want it to drop below where I feel comfortable hiking

“You know, if I’m at 150 [mg/dL], I could take insulin and possibly plummet into the 60s or even 50s, and then I’m struggling to just walk. Or, I could let it ride just see happens during the next climb. Maybe I’ll drop a little.”

“And I don’t have any insulin resistance when I’m hiking. So it’s almost scary how much more insulin brings my blood sugar down than when I’m sitting in a cubicle. Especially when I’m climbing uphill, I feel like insulin is almost twice as effective as normal.”

Mike actually runs his basal a little bit higher than he would off the trail, and “feeds” it in a calculated way. When he’s on the move he’s almost continually snacking on protein bars and other keto treats, which results in a long, slow and persistent glucose rise that can’t be easily combatted with rapid insulin. “The little extra basal will help knock it down.”

Mike sticks to low-carb as well as he can on the hike, and is usually able to limit his consumption to 40-50g per day. For snacks, he relies heavily on Keto Bars and Just the Cheese bars. He prepared most of his dinners himself in the months before he set foot on the trail, purchasing dehydrated meat and veggies in bulk and building just-add-water meals according to his own preferences. These are part of the resupply packages he picks up at post offices and hiker wayposts when the trail dips down between mountains and touches civilization.

Other thru-hikers tend to have legendarily terrible diets. Starchy junk food is cheap, calorically dense, shelf-stable and easily available even at the remote gas stations and tiny shops within a short walk of the trail, making it an almost inevitable choice for the average trekker. And sometimes even the dedicated keto hiker finds the junk food unavoidable.

We discussed perhaps the most iconic thru-hiking breakfast, the Pop-Tart. Pop-Tarts, of course, are an absolute whammy of ill health – a single pouch with two pastries has about 75 grams of carbohydrates, exclusively of the highly processed starches and sugars that are the stuff of diabetes nightmares. But it’s a lot of energy in a small package, and on the Appalachian Trail they’re de rigueur for breakfasts on the go.  Mike never wanted to eat Pop-Tarts, but he ran out of his homemade breakfasts some time ago, and he has found it necessary from time to time to partake. What he has found, to his (and my) amazement, is that his body is burning through energy so voraciously, and is so insulin-sensitive, that it only takes “a really small dose” of rapid insulin to eat a Pop-Tart, and he sees hardly any blood glucose spike at all.

Another often carby pitfall is the phenomenon known as “Trail Magic.” Generous locals will often ply hikers with surprise snacks, and these are very rarely of the low-carbohydrate variety. Just imagine how cruel a temptation a cooler full of chilled Snickers bars would be to the weary and famished keto hiker after a long hot day. Recently Mike found it impossible to resist the offer of a fresh-baked, still-warm, homemade blueberry muffin:

“I’m not gonna say ‘no’ to free food at this point. ‘Yes.’ Yes, I will eat that. And again, I can’t stress any more how amazing Afrezza is, because I can react to my blood sugar going up from these foods.”

If you read our first article on Mike, you’ll remember that he primarily uses Afrezza for his mealtime insulin. Mike finds that this inhaled insulin works so quickly that he doesn’t even bother pre-bolusing for meals; he waits for his Dexcom to show an upward rise, takes a dose of Afrezza in response, and then sees the line bend down again almost immediately. 2,000 challenging miles later, and he’s still a huge Afrezza fan: “I’ll probably never stop using Afrezza, unless they stop making it.” Afrezza has worked both for his regular high-fat, high-protein diet and for those occasional high-carb excursions.

It’s the food off the trail that has actually been more problematic. The greasy spoons of Appalachia are not exactly replete with healthy low-carb options, and I suppose there’s only so many times you can order a cheeseburger with no bun and quadruple meat, hold the fries.

“I haven’t had any really scary lows, except in town, because in town it’s almost impossible to eat low-carb. And I’ve used up so many calories, and with so few options available, I just have to eat whatever calories I can get.”

Nevertheless, when possible Mike puts his own low-carb spin on the town food experience, and his followers on social media have been treated to pics of Mike eating a “burger” made with a monolithic slab of fried bologna, and finishing the half-gallon ice cream challenge by downing four pints of Rebel in one sitting.

Tricky diet aside, Mike obviously doesn’t let his condition drag him down much. I have heard of hikers distributing glucagon and backup insulin stashes to friends, carrying satellite phones and buying medevac insurance, and I wanted to ask Mike what precautions he has taken. Not much, as it turns out. Mike is very confident in his ability to manage his own condition in every circumstance: “In 23 years of using diabetes, I’ve never used glucagon. It just expires in my refrigerator. So I don’t have it with me.” And on the less popular North-to-South route, Mike is often alone for long periods of time, and needs to be totally self-sufficient. He does wear a custom Road ID  medical alert bracelet; he designed it to say “feed me sugar.”

The law of small numbers  works out in the wilderness too, and Mike’s low-carb diet helps ensure that the drops he does experience on the trail are mild: “I might drop down into the 50’s, but it’ll be over half an hour of small drops down from the 80’s or 90’s.” As much as I wanted to hear an exciting story about a bear making off with his stash of glucose tablets, he doesn’t feel as if he’s ever been in danger.

One of the obvious attractions of a long-distance hike is the way in which months in the forest cleanse away the noise and distractions of modern life. But I was sad to learn that the unavoidable misery of diabetes in America – specifically, our reliance on our maddening and byzantine healthcare system – has stubbornly followed Mike into the wilderness. Consider the rigmarole that can accompany something as simple as changing pharmacies and imagine trying to accomplish that repeatedly, arranging for one-time insulin and supply deliveries in a series of one-horse towns, all with inconsistent cellphone reception.

“The hardest thing for me has been dealing with the phone calls that I have to make to advocate for myself. I have to do everything from trail, not just call the pharmacies but the insurance company, the pharmacy benefit companies, my doctor, and follow up with my doctor, and then follow up with the lady that works to file the prior authorizations for my doctor, and follow up with her again because she still hasn’t responded to me … there’s too many hands involved, and sometimes I don’t even know who to call.”

This all turned Kafkaesque when someone in a cubicle somewhere mistakenly identified Mike as having Type 2 diabetes on Dexcom’s internal medical file. Overturning that simple clerical error took nearly a month of back and forth. Mike has also had to change insurance twice during his hike: first, as his work insurance expired on the trail, and second, in anticipation of the new year. At one point he had to rent a car to get to a pharmacy that worked with his insurance.

“Those things have been very hard. Those are the things that have slowed me down, because I have to put so much psychological effort into dealing with them.”

Despite the difficulties, Mike is now only days away from his goal, Georgia’s Springer Mountain. Even if he couldn’t completely escape the stress of life with diabetes, he’s had an extraordinary time, and is already trying to figure out if he’ll be able to walk the Pacific Crest Trail in the coming years. Walking the entirety of the Appalachian Trail is a marvelous feat for anyone – to hike the Appalachian Trail with Type 1 diabetes is truly exceptional.

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