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-By Sam Shelanski, M.D.
I recently
chatted with the sales manager of a West Coast scuba company who confided that
for years he has concealed the fact that he is a diabetic from fellow divers.
Many diabetics, fearing
that they will be told not to dive, hide their disease in order to get
certified. Their fears are well-founded. For many years, physicians have
regarded insulin-managed diabetes to be a contraindication to diving. Both Carl
Edmonds, renowned expert in dive medicine, and Peter Bennett, executive
director of the Divers Alert Network, note in their respective dive medicine
books that the risks involved make a diabetic who requires insulin an unfit
candidate for diving. They both qualify that statement by saying that under
some circumstances, people who control their diabetes through diet and exercise
could be allowed to dive.
Potential Risks | The Ban on Diving Diabetics | Guidelines for Diabetics Who Want to
Dive
The
greatest potential risk to diabetic divers is having a hypoglycemic episode
while under water. Hypoglycemia occurs when the glucose-sugar-in the blood
falls to dangerously low levels. This can be precipitated by too much insulin,
too little food, or a variety of stresses, including exercise. Severe
hypoglycemia can result in weakness, seizures and unconsciousness. These
episodes are extremely unpredictable, even in well-controlled diabetics, and
the early warning signs, such as sweating, nervousness and hunger could be
difficult to detect or interpret correctly while under water. The dangers of a
hypoglycemic episode while diving are obvious.
The other risks diabetic
divers face stem from the secondary complications of diabetes, most notably the
effects on the blood vessels. Diabetics, for reasons that are not completely
clear, develop atherosclerosis much earlier than comparable nondiabetics. This
can affect not only the heart, leading to an increased risk of heart attack,
but also the legs, resulting in early cramping and limited exercise tolerance.
Other complications, such as those involving the eyes and kidneys, may not
directly affect a person's ability to dive, but are indicative of severe,
progressed disease.
As a result
of these potential risks, many doctors feel that diabetics who use insulin
should not dive. In response, many diabetics have hidden their disease and
dived anyway. In recent years, however, there has been a change in the way that
diabetes is viewed by the dive medicine community.
The British Sub-Aqua Club
(BSAC) initially established its ban on diving diabetics in the mid-1970s after
an accident involving a diabetic diver. However, when the case was re-examined
in the early 1990s, it was found that several factors not related to diabetes
contributed to the accident. Around the same time, a survey of diabetics who
continued to dive despite the ban found that none of the participants had
suffered hypoglycemic attacks while diving. With this data in hand, BSAC began
to admit diabetics as members in 1992, as long as certain medical criteria were
met.
As BSAC reconsidered its
position on diabetes, the Diabetic Association of the Virgin Islands and
Stephen Prosterman started Camp DAVI, a program combining exercise-including
active water sports-with education about diabetes.
Prosterman is the president
of DAVI as well as the dive supervisor for the University of the Virgin
Islands. He is also diabetic. In 1995, DAN was invited to observe the camp, and
to gather data on diving and diabetes. DAN is using the data to determine the
risks to diabetics who dive. DAN will also help conduct a pilot field study to
gather further data on certified diabetic divers.
Based on
the preliminary findings from Camp DAVI, DAN suggests that some diabetics may
dive safely in controlled settings. The Diabetes and Diving Committee of the
Council on Exercise of the American Diabetes Association recognizes that there
are currently a substantial number of diabetics, in the United States and
elsewhere, who dive.
The criteria for diving
include:
Diabetics who shouldn't
dive are those who:
BSAC 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.
There are still risks to
diabetic divers that are different from those to most other divers. However, as
more and more data is gathered, the dive medicine community is moving away from
an absolute ban on diabetic divers and toward evaluating each case
individually. This in itself carries some risk. It relies upon the honesty and
compliance of the patient and the judgment of the physician. Hopefully, we will
soon be past the days when diabetics hide their disease in order to dive.
Questions for Dr. Shelanski should be addressed
to RSD, Dive Medicine, 6600 Abercorn St., Suite 208, Savannah, GA 31405;
e-mail: RSDmgzn@aol.com.
