Patrick Cody, from Cuenca Holistic Wellness Center, addresses in this in-depth article one of the most common health issues facing Expats living in the Ecuadorian Sierras, high elevation. Learn how barometric pressure, altitude sickness and hypoxic conditions can affect your expat experience “Living at Elevation.”
If you are thinking of moving to a community that is significantly higher in elevation than you are used to, there is a lot to consider. Health issues for ‘lowlanders’ are going to be very different than for those people who grew up at elevation. The good news is that most of us adapt well (in time), and there are even some advantages to living at altitude. For those with pre-existing health conditions, however, it can put additional stress on the body. Consequently, if you are thinking of relocating to a community that is high up in the mountains, careful considerations should be made.
Barometric Pressure and Oxygen
When trying to understand how altitude affects us we first need to understand atmospheric pressure, also called barometric pressure. This is the force that air exerts against a surface (measured with a barometer). When we live at sea level, we have the greatest volume of air above us, and this means we have the greatest atmospheric pressure or air density on us. At higher elevations there is less pressure. As a result, there are fewer molecules in a given space of air. The percentage of oxygen in the atmosphere is always the same (roughly 21 percent), but at elevation the molecules are more dispersed, less dense. This means that each breath delivers less oxygen to the body. The primary cause of altitude sickness is this lack of oxygen or hypoxia. How important is hypoxia? Dr. Chris Astill-Smith, D.O. has been a brilliant clinician and instructor for over 40 years. He is most famous for his lecture on hypoxia called “Oxygen – The Ultimate Nutrient.” In this lecture series, he explains why hypoxia is at the root of most disease states. Dr. Otto Heinrich Warburg, PhD, won the 1931 Nobel Prize in Physiology for his work in understanding the real cause of cancer. As the Director of the Max Planck Institute for Cell Physiology in Germany, he was considered one of the twentieth century’s greatest biochemists. His Nobel Prize was awarded for proving that the cause of cancer is hypoxia. There are many different reasons for insufficient oxygen. What is important to understand is that no matter what the source, hypoxia impairs the capacity of cells to utilize nutrients and remove waste. This in turn adversely affects tissue integrity and can result in disease, as well as making existing conditions worse.
We live in the city of Cuenca Ecuador, which is located about 8366 feet (2550 meters) above sea level. This puts Cuenca on a short list of large cities at the highest elevations on Earth. Mountain medicine recognizes three altitude regions that reflect lowered amounts of oxygen in the atmosphere. Between 5,000 and 11,500 feet (1,500 and 3,500 meters) above sea level is considered high altitude. Above this there is very high altitude (11,500 – 18,000 feet) and extreme altitude (above 18,000 feet). For some people, altitude sickness can occur at as low as 8,000 feet, but serious symptoms do not usually appear until over 12,000 feet. Children can experience all forms of altitude sickness at lower levels than adults.
We Adjust Automatically
At sea level the standard barometric pressure is 101 kPa. This means that 100% of the oxygen is available to us. According to Altitude.org’s spiffy calculator, if we are at 2550 meters above sea level the standard barometric pressure is 76 kPa. This means that in Cuenca, Ecuador, we have only 75 percent of the oxygen that is available at sea level. Luckily, we are highly adaptive and are able to acclimatize to this rather significant 25 percent drop in available oxygen. The body does this in a number of ways, including:
- Causing us to take deeper breaths – thereby increasing the amount of oxygen into the lungs and utilizing unused portions of the lungs.
- Increasing heart rate, so that more volume of blood (and oxygen) is pumped throughout the tissues.
- Increasing the number of red blood cells (and therefore hemoglobin) in the blood. Hemoglobin is the protein inside red blood cells that carries oxygen. More red blood cells usually translates into more oxygen getting to tissues. (This is normally a good thing, but in chronic forms of altitude sickness this can become a concern, as too much hemoglobin can cause the blood to become sticky and viscous, which is harder to pump).
- Producing and enzyme called Citrate Synthase, which helps in hemoglobin/oxygen transportation.
So, while we have these automatic mechanisms that kick in when we are at elevation, if the altitude is too high or the higher elevation is reached too quickly, the adjustment can be impaired and/or difficult. For those who are already having health challenges and/or taking prescription medication this can also make the acclimatization process challenging or can cause it to be incomplete.
To better understand these issues let us start with the most common symptoms of altitude sickness. These include headaches, dizziness, insomnia, muscle twitching, edema, fatigue, and/or disorientation. These symptoms are usually experienced to some degree within 48 to 72 hours of rapidly ascending from sea level to higher elevation. This form of oxygen deprivation is referred to as acute mountain sickness, or AMS. The symptoms of AMS are generally worse at night. This is due to the fact that our respiratory rate decreases during sleep and results in less oxygen intake than when we are awake.
While this form of altitude sickness is quite common, there are more serious issues one should also be aware of. These are quite rare and usually experienced only by mountain climbers, but it is good to know just in case. The first is called high-altitude pulmonary edema (HAPE).It is most often seen when someone ascends too quickly (within 24 hours) from sea level to altitudes of over 10,000 feet. HAPE symptoms include fluid in the lungs, severe cough, rapid heart rate, and heavy/labored breathing. Men are five times more likely than women to develop HAPE.
The same circumstances can also cause high-altitude cerebral edema (HACE). Symptoms of HACE include visual disturbances, disorientation, confusion, severe loss of coordination, and extreme fatigue. The only remedies for both of these forms of altitude sickness are to quickly descend to lower altitude or use supplemental oxygen.
Those with Elevated Risk
Some people are more susceptible to health challenges at elevation. If you have significant health issues it may take much longer to acclimatize to elevation. It should also be noted that the higher the altitude, the greater the risk. Dr Alistair Simpson, one of the world’s leading authorities on altitude sickness, indicates that the following risk factors are most significant:
- Abuse of alcohol or narcotics
- Being overweight
- Chronic diseases
- Fatigue/overwork in physical activities or athletic training
- Certain medications
There are clearly some people more at risk than others. There are also some conditions or issues that should be of particular interest to anyone thinking of moving to (or who have already started living at) higher elevation. These include:
- High Blood Pressure (HBP): It is not unusual for people moving to elevation above 8000 feet to experience temporary high blood pressure until they acclimatize. For those with a pre-existing condition this may require closer attention and monitoring.
- Premature Ventricular Contractions (PVC) occurs frequently at altitude. This is a type of heart arrhythmia where the heart throws in an extra beat every so often. This is not considered a significant condition, but it can be uncomfortable.
- Congenital Heart Problems: Anyone born with heart issues could experience increased symptoms at higher altitude.
- Other Heart Conditions: Oftentimes people with certain heart conditions don’t know they have them until they get into trouble at altitude.
- Pulmonary Hypertension: High blood pressure in the lungs is a main issue that can lead to HAPE. Those persons with pulmonary hypertension are at much higher risk of developing HAPE while at elevation.
- COPD/Emphysema: Anyone experiencing a chronic lung disease will have more difficulty transporting oxygen from their lungs to their blood stream while at altitude. Those persons experiencing chronic lung or heart diseases may before affected by elevation due to the heart having to work harder.
- Periodic Breathing: This usually occurs at night. It is a cycle of decreased breathing followed by a complete absence of breathing for up to 15 seconds (apnea or near-apnea). Periodic breathing is more common at higher altitudes, as the sleeping body tries to balance oxygen and carbon dioxide levels. Periodic breathing can leave some people feeling unrested upon waking.
- Sleep disturbances: Due to decreased barometric pressure, continuous positive airway pressure (CPAP) machines used for sleep apnea and heavy snorers may need to have a pressure-compensating feature to allow them to work properly at altitude.
- Eye Issues: The cornea swells mildly in response to low oxygen. The medical literature shows that retinal hemorrhages, corneal edema, and even cerebral edema, are more prevalent for those moving to elevation.
- Sunburn: Remember that the atmosphere is thinner at altitude. This allows more harmful UV rays through, which can more easily burn your skin and your eyes (sometimes called snow blindness).
- Blood Issues: People who have sickle cell disease can precipitate a crisis in a high altitude setting due to the low oxygen levels. Similarly, if you have polycythemia (too many red blood cells) it can cause blood clots at altitude.
- Delayed Wound Healing: Wounds tend to get more infected at elevation, and they tend to heal more slowly.It is believed that increased stress hormones and decreased oxygen delivery are responsible for this occurring.
There are a number of things you can do to support wellness when living at elevation. They range from what can be done when you first arrive to what can be done to maximize acclimatization in the long-term. These include:
- Go to higher elevation slowly: One of the best ways to prevent altitude sickness is to take your time going from sea level to high elevation. This is especially important if you have had altitude sickness in the past.
- Increase your consumption of water: The typical low humidity and low air pressure of high altitudes can cause moisture from your skin and lungs to evaporate more quickly. This can be a contributing factor for headaches and dehydration.
- Rest and eat well during the first few days: The body is needing to make more red blood cells and enzymes; it is also working harder (breathing more deeply and more often, the heart is pumping more), so give your body the nutrition and rest it needs to help it do these things well.
- Ensure you are getting enough iron: Your body needs iron to produce hemoglobin. If you are low on iron (iron-deficiency anemia is the most common type of anemia), it will be much more difficult to adjust to elevation. Excellent sources of iron are liver, red meat, and sprouted beans or lentils (especially when combined with vitamin C for better absorption). You can also take a plant based mineral supplement.
- Supplement Ginkgo Biloba: This safe, natural herbal supplement has been shown to reduce or eliminate acute symptoms of altitude sickness in two double-blind, placebo-controlled studies in the Himalayas (Dr. Kirsten Maakestad MD, et al., and Dr. Peter Hackett, MD). Take 80 to 120 mg twice a day five days prior to rapid ascent and continue as long as needed. Two of ginkgo’s most important effects are their ability to improve blood circulation as well as allow the brain to tolerate low oxygen levels. Note: Ginkgo Biloba does thin the blood a bit and should therefore be avoided by those taking anticoagulants.
- Use supplemental oxygen: In many jurisdictions where elevation can be an issue you can access supplemental oxygen at a local clinic, rent, or even purchase an oxygen concentrator. This kind of technology plugs into AC power. It concentrates oxygen from the air. You breath via a plastic tube that fits comfortably into your nose. The equipment we use and recommend (for our clients that need it) is the size of carry-on luggage and comes with wheels for easy movement. Even a few hours a day can dramatically improve energy levels, cognitive function, and reverse all altitude sickness symptoms.
- Supplement mate de coca: In Andean countries like Ecuador and Peru you have easy access to coca tea. Locals have used this natural infusion of coca leaves for thousands of years to support balance at elevation.
Advantages of Living at Elevation
Athletes train at altitude in order to take advantage of this natural form of blood doping (increased oxygen capacity) when they compete at sea level. While this is not necessarily applicable if you stay at elevation, there are other advantages to living high up, including:
- Weight loss: This has certainly been our experience and the experience of many of our clients. According to Robert Roach, director of the Altitude Research Center in Aurora, Colorado (which studies how lack of oxygen affects health and performance), “we’ve known since the 1920s (that) if you go to really high altitudes you will lose weight”. It is well known that obesity can lead to a host of health problems, so this is not an insignificant advantage to living at high altitude. Leptin and other hormones involved in appetite control rise at higher elevation, and this is believed to be at least part of the reason why people report weight loss when they move to high altitude. It is also possible that, at high elevations, our bodies are simply working harder and are therefore burning more calories.
- Reduced incidence of stroke/transient ischemic attack (TIA): Incidence of cerebrovascular disease in those living at altitude appears to be lower, according to surveys from both South America and Asia. While we do not understand the mechanism for this, and the data does not distinguish between those that have grown-up at elevation and those that move there, it is nonetheless encouraging.
- Improved asthmatic symptoms: Contrary to popular belief, there is evidence that those plagued by asthma can do better at high altitude. This appears to be caused by the fact that dust mites, a very common allergen, do not live at high altitude. Pollution may also be less than at sea level.
Anyone can develop altitude sickness but not everyone gets it. Some people adjust to hypoxic conditions better than others, and the effects of altitude can vary from one person to the next. For those wishing to live at higher elevation, the adjustment can be accomplished in a matter of weeks. During this time you may experience some altitude sickness symptoms. However, there is much that can be done to reduce or eliminate these naturally. For those with pre-existing health issues it would be prudent to try to improve your well-being prior to moving to elevation. Before making a decision to move yourself and all your belongings to a new home at high elevation, it would also be sensible to test the waters for a few months, just to make sure you are a good fit for high mountain living.