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Diving With Diabetes Here's an updated and expanded version of a piece that appeared in my "Dive Workshop" column in "Rodale's Scuba Diving:” Diabetes, along with asthma & seizure disorder, ranks among the most controversial medical conditions affecting divers. Diabetes was considered by many in the medical & dive community as a contraindication to scuba until opinion began to change in the early & mid-1990s, a change that is consistent with recent research (1,2). At present DAN, the Undersea & Hyperbaric Medical Society, the British Sub-Aqua Club and the YMCA have protocols for approving diabetic divers. In addition, there is an outstanding dive program for diabetics age 17 and older, Camp DAVI (Diabetes Association of the Virgin Islands) located on St. John. It is operated by the University of the Virgin Islands and has diving diabetologists on staff, some of whom have the condition themselves. The body uses the sugar glucose for fuel, and the hormone insulin is necessary for cells to metabolize it. In diabetes, the pancreas fails to secrete enough insulin, or the body's cells resist entry of insulin, and glucose builds to dangerous levels in the blood. The immediate result is cells are temporarily starved for energy, while over time damage to the eyes, kidneys, heart or peripheral nerves can occur. Signs and symptoms of diabetes can include intense hunger, thirst and tiredness, as well as weight loss, frequent urination, blurred vision, and even seizures and coma. For the diabetic diver, the most worrisome immediate risk is blood glucose falling to a level where hypoglycemia, or low blood sugar, is precipitated. This can result from events such as too much insulin, alcohol or exercise, or too little or improper eating. An episode can cause weakness, tremor, sweatiness or chilling, irritability, alterations or loss of consciousness, and convulsions. The diabetic must also be aware of the possibility of hyperglycemia occurring when insulin runs low enough that the body breaks down stored fat for energy. This process can eventuate in breathing difficulty, alterations or loss of consciousness & shock. If left untreated, both hypo & hyperglycemia can result in death. While the criteria for clearance to dive differ among agencies (3,4,5), they generally include such things as a demonstrated understanding of diabetes, awareness of when a hypoglycemic episode is imminent, good control of the disease with no severe episodes within the past year, and no related abnormalities of the eyes, kidneys, heart or nerves which pose an additional risk. Some protocols include depth limitations to those above which nitrogen narcosis is likely to occur so as to avoid confusion of this phenomenon with a life-threatening hypoglycemic episode. As for diving with an insulin pump, all manufacturers of which I am aware indicate that their units are not designed to be used while diving. Even those who have designed their systems to be waterproof only test and approve them to ~10-15 feet. I have heard several stories of pumps falling apart at depths in the 20-30 foot range. Moreover, even given a system that could withstand significant depths there are other issues. Divers I know who are on pumps disconnect and leave them topside while diving. "The Un-Tethered Regimen" http://www.diabetes123.com/clinic/untethered.htm, written by a well-known diabetologist who has the condition himself, provides a protocol for controlling BG while diving, amongst other physical activities. Clearly it is unwise to deny or minimize this condition to yourself, or hide it from your instructor or the ops with which you dive. If you have diabetes and want to dive, or are already diving without medical clearance, it is critical that you consult a physician to obtain an appropriate medical work up & permission to dive. Even after clearance to dive, it is prudent to carefully monitor blood glucose throughout the course of the dive trip, especially prior to a dive. Measurements at 1hr, 30min & 5-10min prior to a dive would not be excessive. Finally, bring on board whatever substances you use for controlling abnormal glucose levels, and make sure your dive buddy also carries & knows how to use them." 1. "Undersea Hyperb Med. 2004 Fall;31(3):291-301. Plasma glucose responses in recreational divers with insulin-requiring diabetes. Dear Gde L, Pollock NW, Uguccioni DM, Dovenbarger J, Feinglos MN, Moon RE. Dept. of Anesthesiology, Center for Hyperbaric Medicine and Environmental Physiology, Duke University Medical Center, Durham, NC 27710, USA. Insulin-requiring diabetes mellitus (IRDM) is commonly described as an absolute contraindication to scuba diving. A 1993 Divers Alert Network survey, however, identified many active IRDM divers. We report on the plasma glucose response to recreational diving in IRDM divers. Plasma glucose values were collected before and after diving in IRDM and healthy control divers. Time/depth profiles of 555 dives in IRDM divers were recorded. IRDM divers had been diving for a mean of almost nine years and had diabetes for a mean of over 15 years. No symptoms or complications related to hypoglycemia were reported (or observed). Post-dive plasma glucose fell below 70 mg x dL(-1) in 7% (37/555) of the IRDM group dives compared to 1% (6/504) of the controls (p<0.05). Moderate levels of hyperglycemia were also noted in 23 divers with IRDM on 84 occasions. While large plasma glucose swings from pre-dive to post-dive were noted, our observations indicate that plasma glucose levels, in moderately-controlled IRDM, can be managed to avoid hypoglycemia during routine recreational dives under ordinary environmental conditions and low risk decompression profiles." 2. "Undersea Hyperb Med. 2005 Jan-Feb;32(1):27-37. Scuba diving with diabetes mellitus--the UK experience 1991-2001. Edge CJ, St Leger Dowse M, Bryson P. OBJECTIVES: To survey the outcomes and practises of divers with diabetes mellitus. METHODS: Diabetic persons wishing to learn to scuba-dive or established divers who have diabetes mellitus in the UK are requested to fill in a detailed questionnaire annually. Divers are asked to provide basic epidemiological information and general diving history. Data provided by the diver's diabetic physician provided independent evidence of the diver's medical status. These data are recorded and analysed. RESULTS: Data have been gathered from 323 diabetic divers (269 male, 54 female) and 8,760 dives have been recorded over 11 years. Two fatalities were reported, both in non-insulin dependent divers. One incident of hypoglycaemia underwater in an insulin dependent diabetic diver has been reported. CONCLUSIONS: This survey showed that in the group of well-controlled diabetic divers studied, there were no serious problems due to hypoglycaemia when they dived. Long-term complications of diabetes must be excluded before a diabetic diver may be permitted to dive." 3. The YMCA diabetic protocol can be viewed here---> http://www.chesapeakebaydiving.com/Documents/diabetic_protocol.pdf 4. BSAC guidelines can be viewed here---->http://www.scuba-doc.com/endmet.html#Diabetes_and_Diving 5. DAN guidelines, "Diabetes and Recreational Diving:
Guidelines for the Future (2005)," can be found here
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