Diabetes and Diving

[BigTuna]

I was involved in an incident that could have turned serious. A diver panicked at 80 feet as a result of running low on air, and instead of going to the surface he struggled to launch an SMB (which he'd never done before). He made several more errors, including inflating(!) his BCD on the way up. I was positioned to assist, but he wouldn't accept help. [The incident is described more completely here.] At the surface I found out that the diver is a diabetic.

I've been thinking about the incident's possible connection with diabetes, and more generally about diabetes and diving. Here are some questions on which I'd appreciate answers and opinions, especially if you're a diabetic diver.

- Could the diver's panic be attributed to diabetes, or perhaps have been aggravated by his diabetes?

- What kinds of special risks is a diabetic diver exposed to?

- If a new buddy informs me that he's a diabetic, does that imply some different or unusual burden for me? What risks would I be taking if I accept him as a dive buddy?

- Is there some kind of training agency qualification or medical qualification required for a diabetic to dive? Should there be?

 

[baydive20]

One of my dive buddies is insulin dependent. When we go diving, he checks his blood sugar before and after each dive. He does this in the privacy of the head so as not to arouse too much curiosity or strange looks. He said it's almost like he has grown another head when people realize what he is doing. Only his dive buddies know of the diabetes for this very reason. If his numbers are too high or too low, we don't dive until they are just right. We've never had to call a dive due to his diabetes, but equipment failure, that's another story. Just make sure the diver has his numbers under control before the dive and all should go well.

My 2 cents.

 

[BigTuna]

Just make sure the diver has his numbers under control before the dive

How do I do that? Ask for his numbers? Ask if they're OK? What if he's an instabuddy?

Suppose his numbers are out of bounds. What then?

 

[-Phoenix-]

Well the main risk of a diver with diabetes is him/her having a hypoglycaemia. This is a situation where the body is low on sugar (or the diabetic has injected too much insuline) and might result in coma.

Most diabetics are well set up, and know exactly how much medicine/insulin they need for them to be allright. You also mentioned in your other post that your buddy checks before and after the dive which shows he's well aware of the risk and checks to make sure nothing happens.

I wouldn't worry too much.

Also diabetes doesn't make people panic quicker. (unless they feel a hypo is coming and they want to surface quickly)

Hope this helps a bit!

 

[Gene_Hobbs]

I ask what their A1c is but make sure you are familiar enough to know what it means and what can change it. From there I have an idea how well controlled they are. Normal recreational dives do not generally change the blood glucose that much so I gauge what I will do based on their experience and ability to read themselves. (MY personal rule: If the A1c numbers are higher, the less I can trust their ability to gauge)

Read what you can...

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. RRR ID: 5538

 

[-Phoenix-]

Well when diving a higher A1c number might actually be safer... But it also shows that the person in question might not have his disease under controll...

The Hb_A1c shows the average blood glucose level. If the average is high, it means they dont use enough insuline. This is bad for the person in question but also means he or she wont pass out due to low blood sugars.

Usually an A1c of 6ish is wanted in optimal diabetic treatment.

 

[TSandM]

Big Tuna, this is a very good question.

To answer it, I'll start with a very brief description of what diabetes is. Diabetes is a disease where the body is unable to take the sugars absorbed from the foods you eat and transport it into the cells. It becomes more and more concentrated in the blood instead. Although this is an oversimplification, it's a reasonable description. The inability to transport glucose can be due to one of two things: Either the body is not making any insulin, or the cells have become resistant to it. This leads to two very different kinds of diabetes, and they have different implications for divers.

In the insulin-deficient type, patients don't tolerate EITHER low or high glucose levels. They require insulin injections and have to monitor their blood sugar closely. In the insulin-resistant type, most patients will tolerate somewhat high glucoses, although they have the same trouble with low levels. Many such patients are maintained on oral diabetes medication.

The biggest and most immediate danger of diabetes in a diver is low blood sugar. This can lead to lethargy, confusion, unconsciousness, or seizures. The treatment of low blood sugar is oral glucose, followed by food, as well as the possible use of injected glucagon (a hormone that raises blood sugar). Most diabetics carry some sugar source with them (and I understand divers can carry a squeezable source that can be used underwater). Diabetic divers are taught to know their blood sugar patterns well, and to arrange their food intake and medications to err on the high side for blood sugar while diving. (This works fine for the Type II diabetic; it can be much dicier for the insulin-deficient type, which may not tolerate high blood sugar well, either.)

So, to answer your specific questions:

1) Low blood sugar can make people anxious and shaky, and impede their ability to think. So yes, it is possible that low blood sugar was playing a role in your incident, although it is also quite possible that you just had an overwhelmed diver in passive panic.

2) Special risks of diabetic divers are primarily low blood sugar, which is a risk because there is no feedback mechanism operating to ameliorate the effects of anti-diabetic medications in the event of someone not eating enough to balance them. Insulin deficient diabetics can also go into a condition called diabetic ketoacidosis if their blood sugar becomes too high. This condition is marked by rapid breathing, breathlessness and anxiety, sometimes abdominal pain, and dehydration. It can be fatal without treatment.

3) If a new buddy says he's diabetic, the first question is to ask him if he is Type I (insulin deficient) or Type II (insulin resistant). The next question is to ask him what kind of routine he's using to ensure that his blood sugar will remain acceptable during the dive, and also ask if he's carrying a glucose source, and if so, where and how it works. You are accepting the risk that he might develop low blood sugar during the dive, and require your assistance to ingest his sugar, or that he might lose consciousness or seize. Well controlled and insightful diabetic divers have a low risk of this.

4) In the US, there is no specific medical endorsement or clearance required in order for a diabetic to dive. DAN has published some guidelines on what a diabetic should know and be able to accomplish in order to dive safely.

 

[616fun]

A little intro. I'm diabetic. I have been for 25 years. I found out when I was 8 years old. I attempted to get certified when I was 19 and the industry would not touch me. I finally got certified 9 years later, at the age of 28.

I am a diabetic diver who has yet to have an issue while diving. I follow a routine similar to DANs (I made mine up as DAN didn't provide guidelines when I started diving). I know where my blood sugar is heading when I splash and I know where I intend it to be when I come out. I also use an insulin pump that I remove prior to splashing. Heck - I've actually worn the pump in my drysuit on a few dives.

Understand that A1C levels are a test defining the general control of the disease over a period of time. It has NOTHING to do with the state of control the disease is in prior to, during, or after a dive. I have an A1C of 6.1. Any doctor can tell you that's an excellent A1C. But again, that doesn't help define if I'm capable of diving at a specific time point. That's all about using protocols like those outlined by DAN

I don't hide checking my blood sugar, I don't hide it from the crew if I'm on a boat, I don't hide it from other divers. I've never found it to be a situation of people thinking I've 'grown a second head.' I do get questions which I am happy to answer, because the more informed people are about the disease, the more prepared they can be to help a diabetic in an emergency (diving or otherwise). I guess some find the disease something to be ashamed of, or are afraid that people still view it as a total contraindication to SCUBA. They lie on their medical waiver because they are afraid to go talk to their doctor about diabetes and diving. These are the people that really scare me. How can you expect to get help when no one will know what's wrong?

Sure, I do get some people that tell me that they won't dive with me because I'm diabetic. I don't care. I don't want to dive with them either. I have plenty of buddies I've educated about my situation and I am very comfortable that if the situation arises they would be able to assist.

That said, in 4 years of diving I've yet to experience a problem due to diabetes. I'm anal about it and it help me overcome one more challenge in my life.

Sorry for the long post. Diabetes is something I'm passionate about

 

[Hickdive]

Diabetic divers may wish to participate in this long term study;

UKSDMC diver information- diabetes and diving study

 

[ToddK]

I became Type 1 diabetic in 2003, after already having about 80 dives. I stayed away from diving for about the first year, until seeing some threads on Scubaboard from other diabetics describing how they manage diabetes and diving. I really have to credit those threads for changing my perception that diabetes wasn't a "contraindication for SCUBA" to quote 616fun.

Since starting to dive again post diabetes, I've done ~150 dives, with only one incident where I could feel my blood sugar was a little low. As it happened that time, I was very close to the end of the dive, so I just boarded the boat, rather than going for one of my gel packs as back up (see below).

My own routine includes monitoring my blood sugar predive, and then also assessing how cold the water temperature is. What I've noticed personally is that in cold water, I need to back off on the slow acting insulin the night before, and/or take less fast acting insulin when I eat during the day of diving. Also from the board, I learned that the PowerBar electrolyte gels are a great source of sugar underwater, and carry very nicely. I practice a couple times a year with grabbing a pack out of my drysuit pocket, taking my reg out and getting some of the gel into my mouth, reg back in, and then swallow after I've breathed once or twice. My buddy and I also have a special signal that indicates I'm feeling low on sugar, though I've never had to use it when diving with him.

Diving with diabetes requires good blood sugar control as stated above and good predive procedures. The way I look at it is: when anyone goes for a dive, they have a finite air supply, that needs to be monitored, and they need to have backup plans in case of emergency. Having diabetes introduces blood sugar as something else that has to be monitored, with agreed upon and practiced backup plans prior to the dive.

If you are diving with a diabetic, I think it is a fine thing to talk about it predive, to discuss emergency plans and signals. To answer the original poster's question, it sounds like the guy had a bad day and didn't do things right. As far as whether it was due to diabetes or not, you'd have to ask the guy. It might be due to being low on blood sugar, and then again, it may not have been.