Diabetes

[Doug Taylor]

Hi Doc!

My father died of Type-I diabetes. My middle brother has Type-II/adult onset diabetes and he's pretty much standard weight for his height and in otherwise good shape.

My oldest brother is fairly heavy and doesn't have Type-I or Type-II. Also, my AME did a blood test back in the late 90's for 'precursors to type-II' but it turned up negative. I'm not a doctor so I'm not sure of the science behind the tests at all.

What can I do, if anything, to avoid coming down with a disqualifying condition? My blood pressure is normal, my weight is high for my height, but I'm getting it under control via exercise and diet.

[Maximillian_Jenius]

Also to add to Doug's post. I was strongly mulling starting a diabetes thread as I often have people ask me if they can be an airline pilot with diabetes and I have no solid answer for them.

Is diabetes a disqualifying condition according to the FAA? I'm good as there are no natural or genetic diseases in my family so it's not a worry to me. But I would like to be able to have an answer for these people next time I'm asked.

My ex was diabetic and my uncle by marriage is also diabetic. They're both on good strict diets and excercise regulary and take their insulin when needed.

So in my naivte I don't see how or why (if disqualifying) the reasons why it would be as it is a very manageable condition with diet or exercise!

[My Flight Surgeon]

Thanks for the question Doug. Your body changes most of the food you eat into glucose (a form of sugar). Insulin, a hormone produced by the pancreas, allows glucose to enter all the cells of your body and be used as energy. Diabetes is a disease that occurs when a person’s body doesn’t make enough insulin or can’t use insulin properly. When you have diabetes, the sugar builds up in your blood instead of moving into the cells. Some, but not all, of the excess sugar is carried out of your body (through urine), and the energy is wasted.

There are two types of diabetes. Type 1 occurs when the body doesn’t produce any insulin. People with type 2 diabetes either don’t produce enough insulin or their cells ignore the insulin. Nearly 95% of people with diabetes have type 2.

The problem is diabetes causes many other health problems. These include:
Blindness. Diabetes can damage the small blood vessels in the retina. It is the leading cause of blindness in people ages 20 to 74.
Heart disease. People with diabetes are 2 to 4 times more likely to have heart disease and damage to the blood vessels in the heart. This increases their risk of heart attack and stroke.
Nerve and blood vessel damage. Damage to blood vessels in the legs can limit the supply of blood to the nerves in the legs and feet. This can make it difficult to feel injuries (such as foot sores). Damage to the blood vessels can also put you at risk for infections and sores that don’t heal. In severe cases, parts of the foot or lower leg may have to be amputated (removed).
Kidney disease. Diabetes can damage the small blood vessels in the kidneys, which then can’t filter out the body’s waste. In some people, the kidneys stop working completely. These people require dialysis or a kidney transplant. Dialysis is a treatment that eliminates wastes in the blood.

Treatment
Diabetes can be controlled with diet, oral medications and/or insulin. If one controls their diabetes, complications can often be prevented. The way to stay healthy with diabetes is control your blood sugar level. You can do this by eating right, exercising, maintaining a healthy weight and, if needed, taking oral medicines or insulin.
Eat a healthy diet. The recommended diet for many people who have diabetes is very similar to that suggested for people who don't have diabetes. It's important to eat at least 3 meals per day and never skip a meal.
Exercise. Exercising will help your body use insulin and lower your blood sugar level.
Maintain a healthy weight. Losing excess weight and maintaining a healthy body weight will help you in 2 ways. First, it helps insulin work better in your body. Second, it will lower your blood pressure and decrease your risk for heart disease.
Take your medicine. If your diabetes can’t be controlled through diet, exercise and weight control, your doctor may recommend medicine or insulin. Oral medicines (taken by mouth) can make your body produce more insulin or help your body use the insulin it makes more efficiently. Some people need to add insulin to their bodies. Always take medicines exactly as your doctor tells you to.

Now related to aviation, the FAA states Applicants with a diagnosis of diabetes mellitus controlled by diet alone are considered eligible for all classes of medical certificates under the medical standards, provided they have no evidence of associated disqualifying cardiovascular, neurological, renal, or ophthalmological disease. So these folks will maintain a lean body weight, exercise regularly and watch their diets very carefully. What he FAA asks of the pilot is to essentially adhere to the treatment guidelines of the American Diabetic Association.

For pilots with Type 2 diabetes requiring oral medications (type 1 requires insulin therapy) the FAA says An applicant with a diagnosis of diabetes mellitus controlled by use of a medication may be considered by the FAA for an Authorization of a Special Issuance of a Medical Certificate. Following initiation of medication treatment, a 60-day period must elapse prior to certification to assure stabilization, adequate control, and the absence of side effects or complications from the medication. The initial decision is made by the FAA in OKC but if the pilot meets the FAA’s criteria for disease control, the AME may issue subsequent certificates and forward the supporting documentation to the FAA for review. (This is the new AME Assisted Special Issuance (AASI) the FAA instituted to facilitate keeping pilots in the air. The medical criteria are included in this link http://www.faa.gov/about/office_org/headquarters_offices/avs/offices/aam/ame/guide/dec_cons/disease_prot/diabetes_med/ . I have several captains who are type 2 diabetics and fly on a Special Issuance with no problems.

For those with type 1 or 2 diabetes that is treated with insulin, the FAA has established a policy that permits the special issuance medical certification of insulin treated applicants for third class medical certification. You cannot obtain a First or Second class medical if you take insulin! The FAA states Consideration will be given only to those individuals who have been clinically stable on their current treatment regimen for a period of 6-months or more. Consideration is not being given for first or second class certification. Individuals certificated under this policy will be required to provide substantial documentation regarding their history of treatment, accidents related to their disease, and current medical status. If certificated, they will be required to adhere to stringent monitoring requirements and are prohibited from operating aircraft outside the United States. These monitoring criteria are extremely rigid and would be difficult to follow for all but the most dedicated pilot. The link to initial evaluation, monitoring and subsequent evaluation is included here http://www.faa.gov/about/office_org/headquarters_offices/avs/offices/aam/ame/guide/dec_cons/disease_prot/diabetes_insulin/ .

Now to Doug’s question (LONG ANSWER to a short question ), diabetes tends to be hereditary, especially type 2. The best advice I have is to maintain a lean body weight (DROP THE WEIGHT), exercise on a regular basis and eat a health conscious diet. The diet should be well-balanced and probably not exceed 2000 calories a day. The “precursors to type 2” testing may have been a serum insulin level. There is no screening test that I am aware of that can tell you if you will become a diabetic. If the serum insulin is high, it may indicate one has glucose intolerance or “metabolic syndrome” and that can be a pre-diabetic condition. There are diabetic who are not overweight but the majority of type 2 diabetics we see are too heavy.

One last comment about diabetes, about 3% of the US population has been diagnosed with diabetes and they utilize 15% of healthcare resources. So you can see, the complications of the disease are very costly.

*comments from FAA documents are in italics

[Nick]

What a response! This flight surgeon forum is awesome!

Dr. Forred I read somewhere that since a lot of the actions of the body parts involved in metabolizing process are timed by the circadian rythm, that having a steadier sleep cycle can be considered one way to prevent the onset of diabetes.

If someone eats healthily, exercises, but by nature of the job often must sleep at different times, do you know how much of an effect that might have on the risk of diabetes being acquired? Thanks if you have any idea; I've been curious about that for a while.

[My Flight Surgeon]

I have seen nothing to verify this in the medical literature. If I find anything, I will post it here.

[Doug Taylor]

Thanks Dr. Forred!

[Bandit_Driver]

In Regards to weight control, I have been hearing a lot of commercials about insulin resistance from clinics in the local area. Is this just another diet fad and another non FDA approved gimmick?

[My Flight Surgeon]

Insulin resistance does exist. There is a constellation of symptoms in one individual. They include:

• Abdominal obesity (excessive fat tissue in and around the abdomen)
• Atherogenic dyslipidemia (blood fat disorders — high triglycerides, low HDL cholesterol and high LDL cholesterol — that foster plaque buildups in artery walls)
• Elevated blood pressure
• Insulin resistance or glucose intolerance (the body can’t properly use insulin or blood sugar)
• Prothrombotic state (e.g., high fibrinogen or plasminogen activator inhibitor–1 in the blood)
• Proinflammatory state (e.g., elevated C-reactive protein in the blood)

People with the metabolic syndrome are at increased risk of coronary heart disease and other diseases related to plaque buildups in artery walls (e.g., stroke and peripheral vascular disease) and type 2 diabetes. The metabolic syndrome has become increasingly common in the United States. It’s estimated that over 50 million Americans have it.
The dominant underlying risk factors for this syndrome appear to be abdominal obesity and insulin resistance. Insulin resistance is a generalized metabolic disorder, in which the body can’t use insulin efficiently. This is why the metabolic syndrome is also called the insulin resistance syndrome.

We are often asked "How do you diagnose metabolic syndrome?"
The American Heart Association and the National Heart, Lung, and Blood Institute recommend that the metabolic syndrome be identified as the presence of three or more of these components:

• Elevated waist circumference:
  Men — Equal to or greater than 40 inches (102 cm)
  Women — Equal to or greater than 35 inches (88 cm)
• Elevated triglycerides:
  Equal to or greater than 150 mg/dL
• Reduced HDL (“good”) cholesterol:
  Men — Less than 40 mg/dL
  Women — Less than 50 mg/dL
• Elevated blood pressure:
  Equal to or greater than 130/85 mm Hg
• Elevated fasting glucose:
  Equal to or greater than 100 mg/dL

With the expansion of the average American (getting fatter) there are an increasing number of people with the metabolic syndrome. The primary goal of clinical management of the metabolic syndrome is to reduce the risk for cardiovascular disease and type 2 diabetes. Then, the first-line therapy is to reduce the major risk factors for cardiovascular disease: stop smoking and reduce LDL cholesterol, blood pressure and glucose levels to the recommended levels.
For managing both long- and short-term risk, lifestyle therapies are the first-line interventions to reduce the metabolic risk factors. These lifestyle interventions include:

• Weight loss to achieve a desirable weight (BMI less than 25 kg/m2)
• Increased physical activity, with a goal of at least 30 minutes of moderate-intensity activity on most days of the week
• Healthy feating habits that include reduced intake of saturated fat, trans fat and cholesterol

You don't need to go to a special clinic, just use common sense for most of it. I would suggest everyone over the age of 18 years know what their various cholesterol levels are and what they should be. http://www.nhlbi.nih.gov/health/publ...chol/wyntk.pdf I discuss this with all of the pilots I see since we can "change the course of history" with good cholesterol management.

Here is a good diet for both blood pressure and cholesterol. http://www.nhlbi.nih.gov/health/publ...h/new_dash.pdf

[Bandit_Driver]

Great answer...Thank you...

[My Flight Surgeon]

You are welcome.