Diabetes and Diving

Diabetes Mellitus: Insulin dependent diabetics represent a gamut of severity; from the more brittle diabetic who should not dive to a less serious one which should not increase the hypoglycemia risk enough to exclude diving. The long-standing diabetic who has lost the normal defense mechanism against hypoglycemia should not dive. Newer methods for testing and steps to regulate blood sugar can eliminate the risk of hypoglycemia. As diabetics are more prone to coronary disease, a good physical examination, and exercise testing when indicated, can reduce the risk for a heart problem while diving.

Guidelines From DAN for Diabetics Who Want to Dive
DAN suggests that some diabetics may dive safely in controlled settings.

• Age ≥18 years (16 years if in special training program)

• Delay diving after start/change in medication
– 3 months with oral hypoglycemic agents (OHA)
– 1 year after initiation of insulin therapy

• No episodes of hypoglycemia or hyperglycemia requiring intervention from a third party for at
least one year

• No history of hypoglycemia unawareness

• HbA1c ≤9% no more than one month prior to initial assessment and at each annual review
– values >9% indicate the need for further evaluation and possible modification of therapy

• No significant secondary complications from diabetes

• Physician/Diabetologist should carry out annual review and determine that diver has good
understanding of disease and effect of exercise
– in consultation with an expert in diving medicine, as required

• Evaluation for silent ischemia for candidates >40 years of age
– after initial evaluation, periodic surveillance for silent ischemia can be in accordance with
accepted local/national guidelines for the evaluation of diabetics

• Candidate documents intent to follow protocol for divers with diabetes and to cease diving and
seek medical review for any adverse events during diving possibly related to diabetes

Scope of Diving
• Diving should be planned to avoid
– depths >100 fsw (30 msw)
– durations >60 minutes
– compulsory decompression stops
– overhead environments (e.g., cave, wreck penetration)
– situations that may exacerbate hypoglycemia (e.g., prolonged cold and arduous dives)

• Dive buddy/leader informed of diver’s condition and steps to follow in case of problem

• Dive buddy should not have diabetes

Glucose Management on the Day of Diving
• General self-assessment of fitness to dive

• Blood glucose (BG) ≥150 mg·dL -1 (8.3 mmol·L -1 ), stable or rising, before entering the water
– complete a minimum of three pre-dive BG tests to evaluate trends
60 minutes, 30 minutes and immediately prior to diving
– alterations in dosage of OHA or insulin on evening prior or day of diving may help

• Delay dive if BG
– <150 mg·dL -1 (8.3 mmol·L -1 ) – >300 mg·dL -1 (16.7 mmol·L -1 )

• Rescue medications
– carry readily accessible oral glucose during all dives
– have parenteral glucagon available at the surface

• If hypoglycemia noticed underwater, the diver should surface (with buddy), establish positive
buoyancy, ingest glucose and leave the water

• Check blood sugar frequently for 12-15 hours after diving

• Ensure adequate hydration on days of diving

• Log all dives (include BG test results and all information pertinent to diabetes management)

For full text see: Pollock NW, Uguccioni DM, Dear GdeL, eds. Diabetes and recreational diving:guidelines for the future. Proceedings of the UHMS/DAN 2005 June 19 Workshop. Durham, NC: Divers Alert Network; 2005.

The Diabetes and Diving Committee of the Council on Exercise of the American Diabetes Association notes that there are currently a substantial number of diabetics, in the United States and elsewhere, who dive.

Criteria for diving include:
good control of blood glucose levels
freedom from severe secondary complications of diabetes (eyes, kidneys, blood vessels)
an understanding of the relationship between the disease and exercise
Diabetics who shouldn’t dive are those who:

have had a serious hypoglycemic episode within the past 12 months
have advanced secondary complications of the disease
have poor control of their blood sugar
are unaware of the early warning signs of hypoglycemia
lack insight into the relationship between diabetes and exercise

UKSDMC recommendations are similar, though more rigorous. A questionnaire must be filled out by the prospective diver, and a separate one completed by the diver’s physician. In addition, BSAC has developed guidelines concerning what additional gear and supplies diabetic divers should carry, and proposes a pre- and post-dive plan in order to minimize risks.

The YMCA has an extensive protocol for diabetic scuba divers. It carefully differentiates the divers with mild diabetes and those with frequent changes in blood sugar levels and hypoglycemia.

References:
DAN, Blood Glucose Response to Recreational Diving in Insulin-Dependent Diabetics
https://www.diversalertnetwork.org/medical/articles/Blood_Glucose_Response_in_Insulin-Requiring_Diabetics

DAN, Summary Form – Guidelines for Recreational Diving with Diabetes
https://www.diversalertnetwork.org/medical/articles/Summary_Form_Guidelines_for_Recreational_Diving_with_Diabetes

DAN, Diabetes and Diving – Update 2005
https://www.diversalertnetwork.org/medical/articles/Diabetes_and_Diving__Update_2005

AUTHOR

Ernest S. Campbell, M.D., FACS

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