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The effects of alcohol on balance at sea level versus the summit of Mt. Fuji.

Dear Editor:

We often can see the climbers drinking alcohol at the summit of the mountain. But there are a lot of risks in descending the mountain under the influence of intoxicants. In the present report "The effects of alcohol on balance at sea level versus the summit of Mt. Fuji (3776m)", we described alcohol kinetics (the change of the expiration alcohol concentration) and the effect of alcohol on balance in three trekkers. Although a scientific study with many subjects is necessary to demonstrate risks of alcohol at high altitudes clearly, we expected that it should be time consuming, and we felt ethical concern for an independent study forcing enrolled subjects to drink alcohol at a high altitude. Then, we considered that an earlier announcement by a style of case report should be adequate to prevent miserable accidents in the next year at Mt. Fuji, which now attract many foreign tourists having interest in world heritage.

Mountain climbing at moderate altitudes is becoming increasingly popular in developed countries. Previously, highlands were special areas visited only by trained personnel and alpinists who understood the risks associated with high altitude. Today, the development of transportation technologies e.g., by automobile, train, airplane, helicopter, or ropeway, has provided tourists easy access to high-altitude and very-high-altitude environments. However, many tourists are not necessarily trained for high-altitude conditions which includes awareness of the associated risks. For example, many "amateur" trekkers continue to engage in their everyday sea-level behaviors, such as drinking alcohol and smoking cigarettes, even at high altitudes. For example, a previous epidemiological study revealed that more than half of high-altitude tourists ingested alcohol during their first few days at altitude (1). Since Mt. Fuji was registered as a UNESCO World Heritage site in June 2013, this trend will likely continue with increasing numbers of visitors. Here, to inform the risk of drinking alcohol in the mountain, we report the alcohol kinetics measured by breath analyzer and the effect of alcohol on the balance of three trekkers after drinking 500 mL (16.9 ounces) of beer at the summit of Mt. Fuji.

The three male trekkers (Table 1) were office workers with a regular physical exercise regimen, and all of them had experienced the same altitude (3776 m) one month earlier and visited another 1300m peak for training, 2 and 3 weeks earlier. They received a yearly health exam at the office, including chest x-ray, electrocardiography, and blood tests, and none of them had medical ailments such as cardiovascular or pulmonary disease. They were all known to present flushing of the skin every time they consumed alcohol. One week prior to their Mt. Fuji trek, at sea level, each subject consumed 500 mL of beer in 10 minutes. Each subject's breath alcohol concentration was measured using an Alcotest 3300R breath analyzer (Drager Safety Japan, Tokyo), 120 minutes after post consumption. A breath analyzer was used for measuring the physiological alcohol concentration. Although some instruction and preparatory training are necessary for their appropriate use, breath analyzers have been used worldwide with acceptable reliability. Balance was assessed by measuring the length of standing time on one leg with eyes closed prior to and 30min after alcohol ingestion. Breath alcohol concentration usually reaches its maximal value, within 30 minutes of ingestion (2).

One week after the baseline measurement, the subjects were transported by automobile to an altitude of 2400 m. From this point they ascended on foot 1300 m to the summit of Mt. Fuji, each subject carried about 10 kg(22 pounds) backpack. The transportation by automobile from sea level to an altitude of 2400 m took approximately 4 hours. The trekking duration required 4 hours from 2400 m to the summit of Mt. Fuji (Subashiri-Yoshida route; summit, 3720 m). The subjects consumed approximately 1 L of water during the ascent. Upon reaching the summit, the subjects rested for 30 minutes before beginning the study. The time course of drinking and measurement at the summit was identical to baseline measurement at sea level. The barometric pressures at sea level and at the summit of Mt. Fuji, was 760 mm Hg and 480 mm Hg, respectively, as reported by the local meteorological center. Measurement at the summit were performed in wind-scaled structures, and the temperature was at 150C.

Although individual differences were observed, the alcohol concentration profiles at sea level and at the summit of Mt. Fuji were practically identical in all of the three trekkers (See Figure).

The standing time on one leg with eyes closed for the three trekkers prior to alcohol drinking (Tl) was within the average range of the corresponding age group at sea level. Balance time decreased at the summit of Mt. Fuji (T3) and after drinking at the summit of Mt. Fuji (T4) was particularly dramatic, and the values of two trekkers were much lower than the average range, indicating that their balance performance was impaired.

In this study, a breath analyzer was used for measuring the physiological alcohol concentration. Razatos et al., reported that a breath analyzer was accurate at 3534 m above sea level (3), and Suzuki et al. demonstrated that exercise did not affect the measurement of breath alcohol concentration (4).

The standing on one leg with eyes closed balance test is commonly used to assess balance in elderly individuals (5). The Japanese government recommends regular assessment with this test to evaluate the risk of falls and bone fracture in the elderly population. All three trekkers in this report showed a decrease in their standing time on one leg with eyes closed at the summit of Mt. Fuji, especially after drinking beer. The average value for this test in subjects in their 30s ranges from 21 to 71 sec, and that in subjects in their 50s ranges from 16 to 49 sec. The values of two of the trekkers after drinking beer at the summit were much lower than the average values for their age group. However, this effect may not have only resulted from alcohol consumption, as muscle tiring after the 1300 m ascent also likely affected the balance of the trekkers. Alcohol drinking may lead to lacking the sense of balance on the summit, therefore more attention is needed for descending the mountain. Though this study is a pilot study as only three subjects in their 30s to 50s participated, alcohol is more risky for older trekkers. Trekkers should thus be advised that combining alcohol consumption with physical exertion at high altitudes extensively impairs balance performance.

Smoking at high altitudes is a risky behavior because of oxygen limitation under hypobaric conditions and poor peripheral circulation in the low- temperature environment. Thus, many guidebooks strongly recommend cessation of smoking prior to and during high-altitude trekking. However, in contrast to smoking, trekkers are typically not notified of the risks of alcohol consumption at high altitudes, even though many people enjoy alcoholic beverages at the completion of their ascent to celebrate their achievement, especially when the summit is well-known and the ascent has been a long time goal. Additionally, few scientific studies have evaluated the effects of alcohol at high altitudes and their results are controversial.

An early study by McFarland found that blood alcohol levels increased more rapidly and reached higher values at high altitudes (6). Roeggla reported that alcohol depressed breathing at high altitudes and impeded high altitude acclimatization (7). Collins found that performance decrements caused by alcohol were exacerbated by an altitude of 3660 m in subjects negatively affected by that altitude without alcohol (8).

In contrast, by using a low barometric chamber, Higgins demonstrated that blood alcohol levels were similar at 392 m and 3660 m (9). Lategola showed that blood alcohol uptake curves were the same at sea level and at 3660 m, and that alcohol and altitude did not interactively affect performance in mathematical tests (10). Freedeman found that alcohol affected auditory evoked potentials to the same extent at the summit of Mt. Evans (4350 m) and in Denver (1609 m), and thus concluded that there was no influence of altitude. The alcohol kinetics in our three trekkers were not influenced by altitude, similar to the findings of Lategola. However, we observed impaired balance similar to the decreased performance observed by Collins.

Although the effects of alcohol at high altitudes may be minor or negligible for Caucasians, Asians including Japanese may show profound effects. Many Japanese have a unique alcohol metabolism compared to the Caucasian population.

The profusion of untrained and inexperienced individuals in high-altitude environments is compounded by recent improvements in public health and the availability of medical services, which continue to increase the life expectancy, and thus the elderly population in a developed country such as Japan. Many middle-aged to elderly people enjoy a quiet environment and moderate exercise, and non-challenging highland trekking has thus become increasingly popular in this population. In particular, many aged people in Japan have the goal of praying at sunrise at the summit of Mt. Fuji once in their life or prior to the end of their life, as Mt. Fuji has been one of the most sacred places in Japan for more than 400 years. Given that balance performance decreases with aging (5) and that alcohol was previously shown to have an increased effect in aged subjects at high altitude, our findings are thus especially given the increasing number of aged untrained trekkers at Mt. Fuji who may wish to celebrate with a drink.

Public announcements should recommend caution regarding alcohol consumption at high altitudes, but not necessarily promote abstinence. Although data regarding the effects of alcohol at high altitudes are limited and the interaction between altitude and alcohol effects remains unclear, individuals who are not tolerant to alcohol should be advised to abstain from drinking during high-altitude trekking.

Masaru Tobe

Department of Anesthesiology

Gunma University Graduate School of Medicine

3-29-22, Showa Machi

Maebashi, 371-8511, JAPAN

+81-27-220-8454 (Telephone)

+81-27-220-8473 (Fax)

Tomonori Takazawa

Gunma University Graduate School of Medicine

3-29-22, Showa Machi

Maebashi, 371-8511, JAPAN

+81-27-220-8454 (Telephone)

+81-27-220-8473 (Fax)

Masafumi Kanamoto

Gunma University Graduate School of Medicine

3-29-22, Showa Machi

Maebashi, 371-8511, JAPAN

+81-27-220-8454 (Telephone)

+81-27-220-8473 (Fax)

ACKNOWLEDGMENT

This report was funded by the Japanese Ministry of Education, Culture, Sports, Science, and Technology with a Japan Society for the Promotion of Science Grant (No. 20659242) to Shigeru Saito.

REFERENCES

Available at: http://jhei.net/exercise/excrcise_f/exercise_ f4.html. accessed Septemer 30, 2013.

Collins WE, Mertens HW, Higgins EA. Some effects of alcohol and simulated altitude on complex performance scores and breathalyzer readings. Aviat Space Environ Med 1987; 58:328-332.

Higgins E, Vaughn J, Funkhauser G. Blood alcohol concentrations as affected by combinations of alcoholic beverage dosages and altitude. Washington, DC: FAA Office of Aviation Medicine; 1970.

Honigman B, Theis MK, Koziol-McLain J, et al: Acute mountain sickness in a general tourist population at moderate altitudes. Ann Intern Med 1993; 118:587-592.

Lategola M, Lyne P, Burr M. Alcohol-induced physiological displacements and their effects on flight-related functions Washington, DC: FAA Office of Aviation Medicine; 1982.

McFarland R, Forbes W. The metabolism of alcohol in man at altitude. Hum Biol 1936: 8:387-398.

Razatos G, Luthi R, Kerrigan S. Evaluation of a portable evidential breath alcohol analyzer. Forensic Science International 2005: 153; 17-21.

Roeggla G, Roeggla H, Roeggla M, Binder M, Laggner AN. Effect of alcohol on acute ventilatory adaptation to mild hypoxia at moderate altitude. Ann Intern Med. 7995;122:925-7.

Shumway-Cook A, Baldwin M, Polissar NL, et al.: Predicting the probability for falls in community-dwelling older adults. Phys Ther 1997: 77; 812-819.

Suzuki S, Higashikawa Y. Effect of exercise on breath alcohol concentration. Japanese Journal of Forensic Toxicology 2005: 23; 104-105.
TABLE
Demographics of each trekker and balance performance measured by
the standing time on one leg with eyes closed. T1 and T2 were
measured as the baseline on one week prior to Mt. Fuji trekking. T3
and T4 were measured at the summit of Mt. Fuji.

The standing time on one leg with eyes closed at the summit of Mt.
Fuji was much lower than the average range in Trekkers 1 and 2.

               Age (years)   Height (cm)   Weight (kg)    Sea level
                                                           before
                                                          drinking
                                                         (sec) (T1)

Trekker 1           38           166            59           25
Trekker 2           37           165            61           49
Trekker 3           51           170            60           55

                Sea level     At the       At the
                  after       summit       summit
                drinking      before        after
               (sec) (T2)    drinking     drinking
                            (sec) (T3)   (sec) (T4)

Trekker 1          12           15            7
Trekker 2          32           14            8
Trekker 3          40           45           32

The range of average values for the standing time on one leg with
eyes closed in individuals in their 30s and 50s is 21-71 sec, and
16-49 sec, respectively.
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Title Annotation:LETTER TO THE EDITOR
Author:Tobe, Masaru; Takazawa, Tomonori; Kanamoto, Masafumi
Publication:Journal of Alcohol & Drug Education
Article Type:Report
Date:Dec 1, 2014
Words:2104
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