Is acute mountain sickness related to hyponatremia?

[Diane “Piper” Soini]

I spent 6 weeks hiking the Colorado CDT. Over time I believed I was suffering from the altitude. I had a persistent headache and at night I gasped for air. I had to pee up to 6 times at night. I had no appetite for food or water so I would force myself to drink about 500 ml twice a day. The rest of the time I’d sip from a bottle about a liter or two during a 20+ mile day. I didn’t always have electrolyte drinks but I usually had crackers for salty food. Overall I would say the food I ate was not very salty.

I noticed I had better nights of sleep without waking up gasping for air on days when I got some salty restaurant food.  That link seemed even clearer when I got home and watched my videos. Even when a trail angel gave me a bratwurst one day I slept better that night.

I wonder if my problem was too little salt in my diet, too much water, or altitude, or if actually all those things are sort of the same problem. Does altitude over time cause problems managing sodium in the body?

Has anyone else experienced anything similar? I am not as young as I used to be. Altitude has never bothered me before. I am 59 now and a woman and I only take HRT for menopause, nothing else. I went up gradually enough and then stayed above 10,000 feet for about a month. I felt fine until gradually I felt terrible. I finished the last 100 miles on roads to avoid as much high altitude as I could.

[Paul McLaughlin]

I would be surprised if your issues were altitude related, given the duration of your trip, and the fact that your issues began later in the trip rather than at the beginning. As to whether altitude issues are related somehow to getting too much water or not enough salt, I do not know. I have read quite a number of articles and discussion of altitude related issues, and have never seen either of those mentioned. Your description of the amount of water you were drinking does not  sound like too much water. I might say not enough except for how often you got up at night. It’s not easy to drink too much water day after day while backpacking – one day is one thing, but day after day, you’d have to make an effort to do that I think. From everything I have read it is unlikely (but not impossible) that your salt intake was too low, unless you prepare all of your own food and do not eat anything commercially made – BUT – you could very easily have been not getting enough potassium or magnesium. I make a point of taking dried bananas on all my backpacking trips for the potassium, plus I drink a vitamin mix every day just to kind of cover myself for whatever vitamin deficiencies my backpacking menu may have. Over a period of 6 weeks there could be other dietary deficiencies that might cause issues – it’s not easy to eat a healthy, balanced diet on the trail. Seems to me from reading other posts of yours that this was not your first long hike by any means – did you eat different stuff this time? Also, the symptoms usually connected with altitude sickness are all things that are individually, and sometimes collectively, associated with other conditions that may be unrelated and yet simultaneous. And of course, it is possible that if you were experiencing dietary deficiencies, then being at altitude could make that situation worse. But I would strongly suspect that your issues were dietary to begin with, and look for a solution there. I would also suggest talking to a doctor. We here on the forum may have plenty of experience on the trail at altitude – I do, over many years – but I am not a doctor, and there may be something obvious about your symptoms that I am completely missing due to my lack of medical knowledge.

[Steve S]

Consider the possibility of an acute anemia occasioned by your body’s attempts to recruit extra red blood cells.

In many trips to altitude from sea level ,I have had trouble only on a few trips that were years apart. Always on day two or 3. Different symptoms each time.

After the last event, I thought of acute anemia as a cause and, assuming it was a borderline effect caused by being barely in the healthy range at home due to normal variation, I began taking the lowest dose iron supplement tablet I could find. 1 tablet the morning before 3 or more day excursions above 5000 feet. No other supplementation. I experienced no untoward altitude events after that.

[Dan]

It would have been interesting to get tested for iron, ferritin, etc.

[Steve S]

The symptoms always disappeared upon descent, so I would expect to be in the normal range by the time I could be tested. Also. medicine uses guidelines based on extremes and averages. Anyone in good shape suddenly failing upon entering thin air was in the area of the poorly understood margin before, and probably during, the inconvenient altitude event.

[Jerry Adams]

When I go above 10,000 feet I pretty quickly get severe headache which pretty quickly goes away when I go back down below 10,000 feet, which doesn’t match your problem.

You said restaurant food and bratwurst made you feel better.  That would be salt.  Take some salt tablets or some table salt.  Put 1/2 teaspoon in your drinking water.  Maybe twice a day.

If you need potassium also, use “lite” salt which is 50% sodium chloride and 50% potassium chloride.

[Dan]

The symptoms always disappeared upon descent, so I would expect to be in the normal range by the time I could be tested.

@Steve S, I was actually responding to the OP. It can be confusing to high-jack a thread with your story, which may be the same or different as the actual topic at hand, so you might consider starting your own thread.

[Steve S]

Jerry, “restaurant food” probably includes a relatively iron-rich protein source — as does bratwurst. Also, towns are generally at lower altitudes than nearby sections of the CDT, so dropping elevation may also provide relief.

We are discussing what seems to be an altitude-specific matter. Your suggestions are as relevant for symptomatic relief at sea level as at high elevations. If I’m not mistaken, Diane has hiked in a variety of environments without experiencing anything like this problem. So, if her diet was not radically different in this trip, the physiology of adjustment to altitude seems to be the matter at hand. Is any element apart from iron involved?

[Steve S]

Dan, my story was needed to supply context and offer an experimental fix. If she had a blood work-up I suspect it would have been uninteresting, just as mine would likely have been.

BTW, Dan, when you are commenting on a specific post, kindly say so. I did not hijack the thread.

 

[AK Granola]

After so much time above 10k, I wonder if your issue was more related to other nutrition issues, or just not enough rest days? You are doing big mile days each and every day, right? I would wonder about fat and protein too – maybe your body is just depleted overall.

If you figure it out, let us know! Inquiring similarly aged females with AMS want to know.

[Diane “Piper” Soini]

I think it was not enough salt but I don’t know if it was because I did not consume enough salt, too much water or if it was something else causing a severe salt imbalance, perhaps just being at altitude for weeks is enough. Having to pee so much more than usual seemed off. I only drank one Starbuck’s Via packet (with one Breakfast Essentials packet) in the morning each day and no other caffeine was consumed.

I ate mashed potatoes (Idahoans) and cheese or salmon most nights. Sometimes ramen or rice with Japanese rice topping instead of potatoes. I usually had cheese-its or other crackers most days. Cereal/granola and milk, cookies, Emergen-C, peanut butter, dried fruit, various bars were other things I ate. Not super salty but not salt avoidant either.

I live in So Cal. I walked regularly in town from 5-9 miles without carrying any water with me as training beforehand. I also work 2x per week in a Japanese garden pruning trees and I usually don’t consume any water during my time there, usually 4 hours. I’ll drink some water later after my walk or gardening. I’m used to not drinking lots of water. On my hike I drank more water than I wanted and more than I usually do on this trip because I felt bad and thought it would help, and because people say you need more water at altitude, and my own doctor said I don’t drink enough water in my daily life.

It’s hard to believe I did not eat enough because I am somewhat overweight by nature and I didn’t lose much weight at all on this trip of 680 miles. I think I’m just getting old and altitude is too hard to endure for such a long time.

[Steve S]

Diane, I missed your post while doing this research. Iron seems to be recognized as altitude adjustment need for athletes — which it wasn’t as far as I could tell when I last researched the matter. One of the articles mentions some of the ways symptoms are expressed.

A few articles. Each offers different hints on how to proceed, although they overlap. The first article offers what seems to be a supplement formula:

https://www.14ers.org/pumping-iron-blood-health-at-high-altitude/
https://alpinefuelnutrition.com/iron-for-mountain-athletes/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4763841/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10608302/

[Bob K]

A quick search of the PubMed data base found “Exercise-Associated Hyponatremia Masquerading as Acute Mountain Sickness: Are We Missing the Diagnosis?”

Clinical Journal of Sport Medicine 18(5):p 383-386, September 2008. | DOI: 10.1097/JSM.0b013e3181883d2d

 

[Steve S]

Bob K,

At the date of that article iron was yet to be discussed as a supplement when going to altitude. Searching the article for the term “iron” found no hits. No mention of ferrous or ferric either. Have any studies from the last few years to quote?

[Diane “Piper” Soini]

That’s interesting. I suppose you’d need iron if your blood has to make more red blood cells. I think they fortify cereal with iron, but probably not very much. I mixed Grapenuts into my granola.

Also there’s this: Fluid Metabolism at High Altitudes

Thanks for fixing the title on my post.

[Jerry Adams]

good points Steve, anemia would make sense – at higher elevation not enough red blood cells would become noticeable

It takes weeks or months to eat more iron and get your body to make more blood cells.  It takes maybe an hour to eat salt and have it take effect

I have borderline anemia.  I tried taking 65 mg iron pills but it made no difference.  I read you have to take it with vitamin C and at a different time you eat calcium/dairy.  That’s what I’m trying.  The next time I get a blood test I’ll find out if this works.

[Brad W]

1L of water for a 20 mile day sounds incredibly low. The headaches, urinating, high pulse rate, lack of enough water to dilute your electrolyte levels-to me sounds like AMS. AMS doesn’t really care about fitness, prior experience at altitude, etc. It can be extremely unpredictable. Could the AMS symptoms be exacerbated by other things-low iron, lack of quality sleep, etc. sure.

Your symptoms mimic mine almost to a T last time I attempted a 14’er in California. All went away once I dropped to about 8k.

[Jerry Adams]

1 liter of water for 20 miles would be okay if it was cold, otherwise yeah, not enough

You can tell by looking at your pee.  If it’s fairly clear, you’re okay.  If it gets very yellow drink more

[Steve S]

Jerry, when you go to altitude your body rushes to increase red blood cells and other aspects of the circulatory system, such as plasma volume. It’s days, not weeks or months, and my experience is that adjustment begins sufficiently within 72 hours to give one acute anemia if one is low enough on iron. One study I found — I think it was from the last couple of years discussed intravenous iron supplementation when someone presents with acute mountain sickness.

[Steve S]

Diane, the book you cited is dated 1996, before the work appeared on the link between iron and AMS. Since the shift to concern about iron by the emergency medical folk, I suspect they treat iron as causal and salt as a symptom.

[Brad W]

@ Jerry -this was interesting-from Hydrapak website:

According to the Wilderness Medical Society, your body loses water through respiration at high altitude twice as fast as it does at sea level. High altitude hiking, running, backpacking, and biking can also make you need to urinate more often and can also stop your thirst response, increasing your risk of dehydration. Remaining hydrated at elevation is a serious task. The Institute for Altitude Medicinerecommends drinking extra water daily when at high altitudes, and if going above 10,000 feet to also increase your intake of carbohydrates.

 

In addition to increased loss of water through respiration, high-altitude areas tend to have very low humidity and be more exposed to elements like sun and wind, so evaporation of water from the body increases as well. When you aren’t soaked in sweat, it’s easy to be tricked into thinking water isn’t being lost—but trust us, it is. In light of these increased risks, how much water should you drink at high altitude?

 The IAM recommends drinking an extra 1-1.5 liters of water daily at high-altitude, for a total of 3-4 liters.  Ideally, those 3-4 liters would contain 2-300 grams of carbohydrates. Supplementing electrolytes is important for any high-output activity, but it becomes crucial at higher altitudes as well. Additionally, whether or not you’ll be encountering exceedingly hot or cold temperatures should factor into your hydration plan.

That would put Diane severely underhydrated.

 

https://hydrapak.com/blogs/beyond-adventure/high-altitude-hydration?srsltid=AfmBOoqPvHgG7PK8ZVvm3BVFh3FgFeoX2O_Y4kBkH2mP-dIMGlTUVKrt

[Diane “Piper” Soini]

I would have drank only 1L if left to my thirst, but because I heard you need more water than normal I would stop at a stream twice a day and try to drink about 16oz and then fill up the 1L bottle I carried. Plus the about 16oz at breakfast and dinner. This is on top of sipping water as I went. I felt like I drank a lot more than I actually wanted. It was pretty cold toward the end of my trip, cold enough I would wear a fleece and gloves at the start of the day, and starting to get noticeably colder at 11,000ft.

[Jerry Adams]

now that you mention it Brad, I remember climbing Cascade volcanoes they recommended taking 2 liters of water.  Even though it’s fairly cold.

Steve, I’m surprised you can respond to iron and produce red blood cells so quickly.  If my red blood cell level increases, I wonder if I’ll notice anything.

[Terran Terran]

Holistically. Increased breathing can lead to dehydration as well as your medication. If you get a headache from dehydration, it’ll be worst if you’re also effected by altitude. If eating more salt helps, i would think, eat more salt. Check with the doctor about your meds. Practice your breathing.

[Brad W]

Diane have you tried Diamox for your higher altitude trips? I have always been against this but the feeling of AMS is so devastating I am considering it.

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