20 December 2007

Scuba Diving and Diabetes -- My Approach

(Editors note: This was my first post about my experiences with diving with diabetes. I have completed several dives since this post and have adjusted my approach to diving. I encourage you to take a look at my other posts on scuba diving: Scuba Diving and Diabetes - Redux and Scuba Diving and Diabetes: The Live-aboard Experience.)

The biggest risk associated with scuba diving and diabetes is if a person who is taking blood sugar lowering medicine (ie insulin) has a severe low blood sugar event while underwater that could result in losing consciousness which in turn could lead to drowning. Diving is also a physical activity and can be strenuous depending on the conditions and like any other type of exercise, the physical activity itself can lower blood sugar in addition to the insulin.

Yeah, that sounds pretty damn scary, but my view is that if you can manage your blood sugar day to day and are comfortable in the way you manage it, your chances of becoming impaired while diving because of low blood sugar are pretty low. We have to manage our blood sugar for exercise so it doesn't drop to low during a workout, same thing for getting behind the wheel of a car. In my opinion, its the same thing for scuba diving.

In 2005, the Diver's Alert Network (DAN) along with the Undersea and Hyperbaric Medical Society (UHMS) established guidelines for recreational diving and diabetes. These guidelines have also been endorsed by the Recreational Scuba Training Council. In summary the guidelines recommend that a diver with diabetes be in overall good physical health (this is important for anyone who wants to dive, not just those with diabetes), an A1C under 9 and no significant complications from diabetes. The guidelines also recommend that your blood sugar be steady or rising before you enter the water and that you have a fast acting glucose source on hand, just in case.

With this info in mind, my husband and I headed to Belize for my first dive trip with diabetes and if I can toot my own horn a bit, I think my blood sugar control was perfect! My blood sugars were higher than I prefer them to be when I'm at home, but that was my lifestyle decision -- to be able to pursue an activity that I enjoy and to do it safely. I did not experience one low blood sugar episode during any of my dives and we did 16 of them, including a night dive. Here was my approach:
  1. I lowered my basal insulin doses both in the morning and before bedtime. I lowered my bed time dose by 1 unit and my morning dose by 2 units. I have to admit that these were kinda arbitrary values. Part of my thinking was that in doing 2-3 dives a day while there, I would be getting some exercise out of that activity which would help lower my blood sugar in and of itself.
  2. When there were dives scheduled right after meals, I opted to eat very low carb and not take any insulin with those meals. My thinking being that I didn't want my rapid acting insulin to be peaking while underwater, which coupled with the activity of the diving itself, could risk sending my blood sugar too low.
  3. I checked my blood sugar at least 3 times before each dive to be sure it wasn't going down. "Steady or rising" was my pre-dive BG mantra for the week.
  4. Both my husband and I carried glucose gels with us during our dives. I also had a water tight plastic box on the dive boat that held my meter and its accessories, another glucose gel, glucose tabs and a snack bar or two.

I found that my BG was in the 180 - 220 mg/dl range before each of my dives. I also checked my BG after each dive and found that the diving tended to lower my BG 50-80 pts, which most of the time put me right in the normal range. I kept my dive times were right around 60 minutes, but I have to admit that I did go beyond one of the DAN guidelines which recommends no dives greater than 100ft. One of the more famous dive sites in the world is the Belize Blue Hole. The main attraction of this site are some huge stalactites that start right around 100ft. I had to check them out so my maximum depth for that dive ended up being 123ft. Thats my deepest dive ever and I really can't get much deeper than that -- 130ft is the recreational limit. I also hit another milestone on this trip -- I completed my 100th dive!

One of the main challenges I encountered on the trip was checking my blood sugar after my dives. After spending 60 minutes in the water, my finger tips were so wrinkly it was hard getting a decent drop of blood that could be sucked up by the test strip -- when I pricked my finger the blood would disperse through the many little channels created by the wrinkles on my finger tips.

The staff at the resort took alot of interest in how I managed my diabetes for diving. I think part of their interest was because they hadn't encountered someone like me before and wanted to learn more in the event they had future divers with diabetes. One of the things they mentioned and that I was not aware of was that some dive operators won't let a person with diabetes dive unless they have a note from their doctor. This kinda bugs me because I believe that it is my decision to undertake the risks associated with diving and that by signing those liability forms you always have to sign before going on a dive, I believe I should be able to do what I damn well please. But, it is definitely something to keep in mind for my next trip and if a note from my doctor is necessary, so be it.

All in all it was great week of diving -- I was so happy to be able to do something I enjoy despite having diabetes.


B Jahnke said...

Thank you for posting this experience. I am from the US, but have just recently moved to Australia. Apart from type-1 diabetes, I am an extremely healthy, active and fit person. Unfortunately, because I do have this, I have been unable to locate a diving center or physician that will fill out the dive medical needed for me to become certified. How/where were you certified? I will be back in the states (near Chicago) in December and am hoping to get certified before returning to Aus. Any suggestions? Thanks!

Melissa said...

B Jahnke - This is a bummer! Sometimes it such a fight to be able to do what we want!

I was certified before I developed diabetes. Since then I've gotten a diving physical from my primary care physician every year as most dive operators require one (if you have diabetes) to allow you to dive with them. I've never had a problem with my doctor approving my medical clearance but I know it is a challenge sometimes to find doctors who will sign off.

Maybe there are dive clubs or something like that where you could get a referral for a doctor who will sign off? I gotta believe you are not the only type 1 down there. You can try searching for a doc in the Chicago area who specializes in diving medicine.

Divers Alert Network (http://www.diversalertnetwork.org/) has done studies on diving and diabetes that show there are no added risks. This might be something you can show to your doctor to try and sway them to your side.

You might want to reach out to the diabetes community down there and see if there are other Type 1 divers who can point you in the right direction to get certified.

Best of luck to you!

Jen said...

Thanks so much for this post, Melissa. I just had a fellow T1 contact my D-organization re: Scuba. She had been denied by the scuba company she had registered to dive with while on a vacation because of her Type 1. We're looking to put together a resource package with information about T1 and D and this blog has provided a lot of great info!

Melissa said...

Jen - I've been fortunate that I've never been prohibited from diving by a dive operator - that would make me so angry! The sticking point may be that some operators require a medical form signed by your doctor before they'll let you dive. I've made it a habit of getting this done every year.

The Diver's Alert Network is a good resource, they have actually done scientific studies that have shown there are no added risks for a diver with diabetes.

Anonymous said...

Good story. I was certified years ago and have only been type 1 for a year. The only thing that keeps me from diving is my ear now. Why in the F*** won't the operators let you dive due to type 1? As long as your buddy knows don't disclose it? it's not their f'ing problem!

Melissa said...

Anonymous - I agree - its not the operator's problem, but there are folks out there who think it is. I sign all the waivers/liability forms. I know how to take care of myself - just let me dive!

Kristen Elaine said...

I'm new at diving,and unfortunatly swimming makes my numbers go down a lot faster. The problem I have is feeling the lows underwater. Do you have any suggestions?

Anonymous said...

When Diver's are on a dive boat, they become the responsibility of the dive operators. If you pass out underwater- who is going to help you, get you back on board and initiate EMS- the dive operator. If you end up drowning and die, who does everyone blame? The dive operator. Even though all Diver's sign waivers and know the inherent risks, it comes down to the operators. If you have a medical condition, the dive operators should know and are being prudent by requiring a clearance from a medical professional. After all, it is their lively hood and an incident because someone had an illness can negatively effect their business. Not to mention the fact that it is a terrible situation to put the crew on board the boat in. Dealing with medical emergencies is horrible. The people that take you out on a dive boat care and will be there to help save your life if something happens. I think it is incredibly selfish to say that you want to do what you want to do and shouldn't have to answer to a dive operator. They have every right to refuse to take someone if they think they are at risk just as you have a right to continue to scuba dive with diabetes. Not everyone regulates themselves the way you do and this puts the dive operator and everyone on board at risk of dealing with a medical emergency. When something goes wrong on a dive because a diver was unsafe, panicked, or runs into problems because of their own illness and predisposing conditions, people blame the dive operator. They never say, oh, that person shouldn't have been diving, they are a diabetic. People naturally try to find fault with the dive operator. They then go online and blog and write reviews in sites and this is the reason why prudent dive operators ask (and should require) a medical release from a doctor. To help cover themselves. The other point to mention is that while you may be very responsible on regulating your blood sugar levels etc. Other people may not be

Melissa said...

Kristen - I have been fortunate to never have experienced a low while I was diving underwater. Factors, such swimming against the current and surge, can cause your blood sugar to go low. Before I enter the water I do three blood sugar checks to ensure that my blood sugar is rising before I get in. If its not, I take some fast acting glucose or eat a snack to get it up. My blood sugar can drop by as much as 100 points during a dive so I like to see it above 180 before I hit the water. This approach has served me well. Best of luck to you!

Bonnie said...

Hey there,
I know I'm late to the party on this post, but I just wanted to thank you for it. I was diagnosed type 1 just about a year ago now and wanted to become scuba certified. There was such little information out there on SD and diabetes. I used your post as part of my reference material in preparing for my trip. So, thank you.

I actually have my own diabetes blog that I'd like to link to your post. Hope that's okay.

Melissa said...

Hey Bonnie! Glad to hear that my diving posts have been helpful to you. Congrats on your open water certification!

Yvonne said...

I was so glad to find this blog. I have been diabetic -type 1 for 6 years and run, bike, swim hike etc.. I was actually surprised at the dive shop when I was told I could only be certified through 1 association, PADI. I never thought about it being a problem until that day. They actually put doubt into my mind and fear in me for my saftey and for my buddy, so I began reading everything I could find on diving with diabetes. I too am new at this I was certified in August, but already have had 8 successful dives. I also check my blod sugar 3 times before a dive and want a steady rise to between 150 and 300 (DAN recommendation), I also reduce my basal isulin the night before a dive, and usually reduce my carb count by 1/2. It has worked for me so far. I can understand other peoples hesitancy dealing with a diabetic diver, they don't understand the disease and know what it take to take care of yourself. And like anonymous said not eveyone takes good care of themselves, but I have meet several overweight middle aged men who scuba dive one who had by-pass surgery or others who have some type of cardiovascular disease and no one stops them from boarding the boat. No one asks them for a wavier for being over weight. I actually had to explain things to my dive shop, which in my mind is a good thing. Thanks again for this blog.

Melissa said...

Yvonne - I'm glad that this information has been helpful to you and that you were able to find a dive shop to work with you to get certified. Hope you have some fun diving destinations in your future! I agree that a lack of understanding it what makes dive operators reluctant to work with us. But every time I enter the water I know exactly where I stand with my health, unlike many others who may be a higher risk in the water than me. But because I have that label (diabetic), I get the extra scrutiny.

sandman3168@hotmail.com said...

been a type2 for nearly 20 yrs and recently diagnosed with type 1. I always carry 2 glucose gel tubes in my BC when diving. have used it underwater twice with positive results.

Melissa said...

Thanks Sandman - Nice to see other folks enjoying scuba diving.

Anonymous said...

South Pacific Underwater Medical Society (SPUMS covers Australia) in May 2010 updated their Medical Certificates to allow for Type 1 Diabeteics to dive.