Diving with Diabetes – Blowing Bubbles to a Chronic Illness
Diving with diabetes has been a taboo subject in the industry for many years. Many clubs and schools have outright rejected any applicants declaring the condition, as have many regulatory bodies, particularly in the UK, which until a few years ago still completely dismissed the notion that a person suffering from diabetes should, in any way, be allowed to dive.
With the growing incidence of the disease, which affects about 10% of the global population, the pool of prospective diabetic divers has increased. Driven by a worldwide surge in interest in the sport itself, this ban has only led to a significant portion of the diabetic community not declaring their condition, whilst anyway diving with diabetes, thus increasing the risk for their buddies and themselves in case of emergency.
Whilst the disclosure of any medical condition is advisable, these forerunners were instrumental in proving the regulatory bodies wrong, pushing the industry to reconsider the blanket ban on diving with diabetes.
Diving with Diabetes
Now for the disclaimer. I am not a medical professional. Anything you read here is aimed at describing MY own personal struggle with diving whilst suffering from Type 2 diabetes. The scope of this information is not to give medical advice, but encouragement to people, who like me, were ready to give up on their hobby after their diagnosis.
Professional guidance on the matter should be sought first. As you might be aware from your recreational diving training, failure to seek professional guidance about any medical issue may lead to serious consequences, including death.
While this article is intended for Type 2 diabetic persons wishing to (re)pursue recreational diving, be it a newly diagnosed case or otherwise, some information may be also useful to divers concerned about the well-being of a diving buddy who is diving with diabetes.
What is diabetes?
Despite what I’ve learnt through my own experience with the disease, I am in no way qualified to explain what diabetes is, and any in-depth knowledge of the subject is better sought from authoritive sources or better from an actual GP. My experience is related only to diving whilst coping with Type 2 diabetes.
In a brief and simplistic explanation, diabetes is a condition that occurs when a person is not able to control his blood glucose (sugar) levels. There are two main types of diabetes conditions, aptly named, Type 1 and Type 2.
They are different in cause and behaviour, and mostly require different treatment, but the end effect is basically the same. If left untreated, the condition can lead to an excess of glucose in the blood stream, a condition called hyperglycemia, leading to serious complications.
In order to prevent this, a diabetic person tries to lower his glucose levels ‘artificially’, either through diet and exercise (in the milder cases) or by means of oral and/or injectable medication. Adjusting the dose is, of course, more difficult than it sounds, especially when the amount of glucose in the blood stream varies according to diet, exercise, fitness level, mood(?), stress, sleep, hangover, pancreatic insulin secretion (if at all), and a load of other medical terms I can’t even spell.
Indeed, the process of ‘adjusting the dose’ is an iterative process performed over an extended period of time under regular supervision of a patient by his specialist consulting doctor.
Glucose in the blood stream is necessary as it provides energy to the cells. Yet, like all good things in life, it has to be present in moderation, with its concentration levels within a particular range. If left uncontrolled, its concentration in the blood stream starts increasing and creates complications.
Too little glucose on the other hand and the body has no fuel to burn. And that is basically the struggle a diabetic person tackles every breakfast, lunch and dinner, and in-betweens.
Too much glucose in the blood stream leads to hyperglycaemia. Too little glucose leads to what is called as hypoglycaemia (hereafter referred to as ‘hypo’). Monitoring is a constant activity, and many diabetic persons can be seen carrying a pouch around.
This pouch usually contains a glucose level monitor (which requires a little prick to the finger to read a sample blood droplet), insulin (or other glucose-lowering medication) in the form of a shot or tablet (to control high levels), and glucose supplements (sugary gel or sweets) to counter low glucose levels.
As far as tools go, the glucose level monitor is your best buddy, followed by the dive computer which will assist in keeping you out of narcosis territory. Unfortunately, other than some experimental trials, there are yet no diving computers which can also monitor your glucose levels! Choosing a diving computer is already a daunting task, we just need to wait a while longer until a glucose monitor is also integrated!
What are the risks of diving with diabetes?
Whilst hyperglycaemia carries its own (serious) baggage of conditions, it is not an immediate threat to patients who are already diagnosed and who follow a regular monitoring schedule. It is not something that will strike you out of the abyss (excuse the pun), in a few minutes or so.
The main concern for diving with diabetes on the other hand is a hypoglycaemic episode while underwater. A wrong dose of medication, or overexertion can ‘burn’ the body’s fuel in no time, leading to a loss of coordination, possibly loss of consciousness and eventually drowning.
Though there may be ‘tell-tale’ signs before a hypo becomes critical, these vary from person to person, and it takes time and a few ‘near-misses’ to master such signals. Fainting above ground is one thing, fainting underwater on the other hand …. well it is best avoided.
Seek professional medical guidance
Before myself attempting to dive after being diagnosed with Type 2 diabetes a few years back, I have on multiple occasions informed and sought the guidance of my diabetes specialist regarding my plans. I was expecting my consultant to trash out the idea but, as I found out, many consultants specialised in chronic illnesses would rather see their patients lead as normal a life as possible. I left most of these meetings encouraged to pursue my hobby … with appropriate caution.
I have also sought the guidance of a specialist diving doctor. I made sure to provide him with all necessary information, inclusive of an extended condition history. He ran a set of tests of his own of course, but ultimately, he was the person who certified me ‘fit for diving’! YAHOOOOO!
If you happen to be in Malta or have planned a diving holiday in this idyllic destination yours truly calls home, the island is equipped with a state of the art Hyperbaric Unit complimented by truly dedicated staff, headed by a diver himself, a well-known local authority when it comes to diving. Run an appointment and get yourself checked and professionally guided.
Get to know your condition before diving with diabetes
Take your time to familiarise yourself with the condition above water. Exercise under different ‘fasting’ conditions and see how your body reacts to different glucose levels, what does and what doesn’t work for you. Experiment with diets and medication (with the consent of your doctor) and constantly prick that finger, before and after exercise, to monitor fluctuations in your glucose levels.
While no case is similar to another, it is fundamental to be familiar with how your own body reacts to fluctuations in your glucose levels. If you are prone to sudden seizures or lack of coordination when hypos kick in, then it is advisable that you don’t dive.
Whilst recreational diving with diabetes is not discouraged, it also implies that you should understand when your condition has become stable enough to be safe for you and your buddies. This process for me was paramount and not rushing it is key. My own fins remained dry for over a year before I decided to take the plunge (a long stride to be more specific).
This familiarisation process should be repeated, and diving halted, every time there’s a change in medication, or after episodes of hypos, as your body’s behaviour could have changed.
One step (metre?) at a time: diving with diabetes taken slowly
Recreational diving has not been around for too long, a few decades at best, and data on the body’s reaction to the demanding ‘unnatural’ conditions are relatively pretty scarce. Put a chronic illness in the equation, and one can only appreciate what little information is available on recreational diving with diabetes!
Remember when you first started diving, and assume that you are once again a novice. Start off shallow, in perfect weather conditions, in familiar territory and with trusted buddies. This process took me back to my first diving memories, well before my open water certification. There I was again blowing bubbles at 2m, then 5m, then again at 7m, 10m, 15m … and the rest is history as they say.
It is not really known (or at least I haven’t been informed yet) how extra-long dives or excessively cold dives effect glucose stability. Deep and repeated dives should be undertaken with caution, and only after sufficient confidence is built against a number of ‘normal’ dives.
Once you get into nitrogen narcosis territory, it is very easy to confuse the symptoms with a hypoglycaemic event. It is also best to avoid decompression when diving with diabetes, as you want to make any emergency ascent as easy as possible, just in case you need to! It is yet unknown if diabetes makes you more susceptible to decompression illness!
It took me more than a year of familiarising myself with my condition with ‘normal’ dives, before attempting repeated and deeper dives. I have so far managed 3 consecutive repeated dives, and I’ve been to a maximum of 35m, none requiring decompression. So far, this was my most recent achievement whilst diving with Type 2 diabetes. These are numbers I have no intention of stretching, at least not in the near future.
Disclose all with your diving peers
Inform the dive master or your diving buddies that they are diving with a diabetic person, and take your time to brief them about what diabetes is, how it affects you, and how it could affect them. Albeit a common condition, don’t underestimate the fact that people might not know what suffering a ‘hypo’ really entails.
Briefing has taken on a whole new level now, and whilst you may be met with scepticism and awkward stares, many professional dive masters/instructors will appreciate your honesty. Discuss your condition openly and make sure your diving buddies are as comfortable to dive with you as you are with them. It is your duty to convince them that you are aware of the risks, know what you are doing, and that you have taken all necessary precautions to make your (and their) dive enjoyable.
Emergency hand gestures and signals for diving with diabetes
While addressing a briefing, ensure that you coordinate your underwater communication signals and hand gestures. I have read somewhere that the signal for a hypo (low blood sugar) is an ‘L’ indicated with the thumb and the index finger at a right angle on your forehead.
I have not seen this in any official training document (it’s not that I have an international network mind you), but I doubt that it is a very commonly recognised signal in the industry. It is thus best to point it out in a briefing.
Extend your flattened hand and rotate slightly left and right doing the ‘so and so’ gesture to indicate something is wrong. Immediately after drawing attention, place your index and thumb at right angles in the form of an ‘L’ above your forehead. Be sure to have explained the signal to your diving buddy and team before going underwater!
Diving with diabetes – planning, pre-dive checks and snacks
For my pre-dive and buddy checks I have been taught that Big Women Are Really Fun (B.W.A.R.F.), a great instructor I had, who made sure I never forget this (thanks Brian)! ‘Burger With Relish and Fries’ is the more politically correct version of course, but it just doesn’t fit here! When you are diving with diabetes, I would have to add that ‘Good Looking Big Woman Are Really Fun’.
Before even setting off to drive to the dive site, check your G.L. (Glucose Level), and again do so a few minutes before diving. At the end of the dive, it’s also a good practice to re-test it, as this will support your understanding of how the dive has affected your glucose levels.
Being a Type 2 diabetic myself, I skip my glucose-lowering mediation (as guided by my doctor) the morning of a dive, and I make sure to have a carb-rich breakfast (slow release diet). I also top it up with a good sugary soft drink (a non-carbonated drink works better as I find the others upset my stomach, and I end up burping acid underwater – not pleasant).
The target (for me) here is to keep my pre-dive GL higher than 8.5 mmol.L (150mg.dL). I find that after a dive this combination ensures that my GL is no lower than 4.5 mmol.L. When it comes to going on a repeated dive, I have a snack based on nuts (or any other high-protein food), a soft drink and preferably some carbs during the surface stop. A re-test process ensues.
Do not shy from aborting a dive if you are not comfortable with your GL levels! When diving with diabetes, you alone have the responsibility to take action.
Plan B – diving with glucose-rich supplements
Whilst a dive is more enjoyable when you don’t need to exert yourself too much, you never really know when your fins have to work on overtime! An unexpected current could take you on an unplanned detour. Whilst a certain amount of exertion is to be expected (hence this is why we familiarise ourselves with our glucose fluctuations above water and then slowly below water, before attempting more challenging dives), over exertion could easily lead to a hypo.
As a precaution, it is wise to carry some form of glucose supplement with you (underwater). Though not easy as it sounds, there are a number of solid and/or liquid options available. My personal preference goes to Glucogel sachets (Sports Gel), the like more commonly used by cyclists. I prefer liquid based solutions as I find it easier to sip underwater, rather than chew and swallow.
These gels unfortunately are not so common in some regions (like the time I went diving in Indonesia), and other alternatives should be sought. Though not my favourite, semi-solid and non-permeable foods (like gummy bears) can also provide some backup, though they require more work and their absorption may not be as rapid as a liquid based supplement.
Be warned though, these options don’t come without risk. If not administered correctly, these supplements could stimulate cough and even irritation, or get stuck in your airway (in the case of solid food).
Drinking and eating underwater is not something you are taught about normally, so it is also best to practise this repeatedly during your familiarisation stages, i.e. your first assisted dives at very shallow depths.
Truth be told, it is yet unknown if diving can worsen the diabetic condition, or if diabetes can make you more susceptible to decompression sickness. It is for this reason that one should understand that diving with diabetes comes with an inherent risk.
Suffering from diabetes is in itself, not a sufficient reason to outright give up on the sport, but it has to be seen in a wider context with respect to general health and possible complications due to other medical conditions. How many times have people been warned not to dive after a hangover and, ermmm, overlooked it? You do get the idea, right? Extra vigilance and due caution should always be exerted when diving with diabetes, but that is also true for recreational diving under absolutely normal conditions.
Prepping for your first dive with diabetes takes a lot (should I say months?) of planning, lots of patience and a little bit of courage too, but believe me, it is all worth it!
Disclaimer – the intention of this article is to provide encouragement to people suffering from Type 2 diabetes in seeking medical advice regarding the possibility of diving with their condition. It is not a substitute for medical advice, nor is it intended for Type 1 diabetics.