The topic of driving with type 1 diabetes (T1D) can be a tricky one. On one hand, of course we should have an equal opportunity to enjoy the essential mobility that a driver’s license provides. On the other hand, there truly is a great deal of potential to become a danger to ourselves and others when driving a car because we take insulin.

Does that mean we should live in fear of getting behind the wheel? Or is it possible that we could be denied a license or car insurance?

There are quite a few critical questions, so let’s take a look at seven things you need to know about driving with T1D:

“Driving with type 1 diabetes is a privilege,” said Dr. Steven Edelman, San Diego endocrinologist and founder of TCOYD (Taking Control of Your Diabetes), who has also lived with type 1 diabetes himself for decades. As much as we — people with T1D — don’t want to be seen as a more vulnerable, “sick,” or impaired population, research continues to identify that drivers with diabetes who take insulin face a markedly increased risk of crashing compared to other drivers.

There’s no way around this fact: The occurrence of a severe low or high blood sugar, while you’re driving a vehicle, can (and has) taken lives over the years.

“This is principally related to the risk of hypoglycemia (dangerously low blood sugar) associated with insulin therapy,” explained a 2015 study from Clinical Diabetes and Endocrinology. “Other glucose-lowering agents — particularly the insulin secretagogues, the sulfonylureas, and glinides — can also cause hypoglycemia, although are seldom reviewed in relation to driving performance.”

Edelman shared several heartbreaking stories for which he actually testified as a medical expert when these car accidents resulted in lawsuits.

“What would you think of a T1D individual, who had a continuous glucose monitoring (CGM) device but was not wearing it, who got low while driving and killed a pedestrian?” asked Edelman. “It was his first severe hypoglycemic event and he ended up getting a two-year jail sentence in the type of prison shared with cold-blooded murderers. Some may say that is where he belongs — jurors, judges, family of the victim — and others would be more lenient or sympathetic.”

Edelman feels it’s quite simple for all drivers with T1D: Either you should be wearing a CGM or manually checking your blood sugar at least every two hours when driving, whether you have a history of hypoglycemia unawareness or not.

Ideally, your blood sugar should be between 80 to 250 mg/dL while driving. This means you also need to take into account how much active insulin is lingering in your bloodstream and whether your blood sugar is rising, falling, or generally stable while you’re behind the wheel.

“Hypoglycemia unawareness” is a term used to describe the inability to feel symptoms of oncoming low blood sugars.

This issue is more common in people who have had T1Ds for decades, but anyone taking insulin can experience a severe low blood sugar that doesn’t present symptoms quickly or a rapid blood sugar drop due to the amount of insulin on board combined with other variables like having just exercised.

None of us are exempt from the potential of a car accident due to severe low blood sugar.

Severe high blood sugars are also a problem. Any numbers approaching or above 300 mg/dL are often accompanied by ketones that could lead to unconsciousness and other symptoms that impair your reaction time and ability to think clearly.

Edelman said severe high blood sugar levels essentially mean you are sick. “Would you drive if you were sick with the flu?” he asked.

Even driving yourself to the ER to be treated for diabetic ketoacidosis (DKA) is equally as dangerous as driving with hypoglycemia, he added. Even if you feel like you could “make it to the hospital” on your own, call a family member or a friend. Or, call an ambulance. Otherwise, the risk of a car crash is too high!

The glove compartment, the middle console, your purse, the side pockets in the door — these are all potential locations to stash fast-acting carbohydrates ready to treat low blood sugar while driving.

Ideally, we’d all immediately pull over safely in a parking lot when we realize our blood sugars are dropping low, but even then, fast-acting carbohydrates need to be in easy reach.

Because food stored in an automobile must be able to endure both extreme heat and cold, your usual go-to treatments for lows may not be ideal in the car. What should you use to treat?

Here are a few items that won’t melt, freeze, or rot when stored in your car:

  • Glucose tabs or glucose gel
  • Jelly beans
  • Half-hard candies like Smarties or chewable tarts

These items can also be kept in fairly large quantities, which means a fully stocked glove compartment can treat many lows before you have to replenish the supply.

The combination of T1D and a brand new driver (who may be unaware of just how easily a car accident can occur) calls for extra concern and discussion regarding the responsibility that comes with driving a vehicle.

Scott Benner, a diabetes dad, and host of The Juicebox Podcast, shared his own approach to discussing the responsibility of driving with his daughter, Arden, who was diagnosed with T1D as a toddler and is now just months away from receiving her license.

“I said, ‘Arden, listen, I know it seems unreasonable to you, but you could have blood sugar that drops so quickly that you’re unaware of it or you don’t get alarmed by your CGM in time,’” explained Benner. His daughter’s experience of severe low blood sugars is limited thanks to today’s modern technology and their family’s team approach to tightly managed diabetes care.

Combine that risk with the typical mentality of invincibility in any teenager, and it becomes especially important to double down on the potential consequences of severe low blood sugar while driving.

“I told her, ‘You have to be considerate of the fact that you’re driving a car and it’s big, heavy, and fast, and it could kill you and it could kill somebody else,’” added Benner. “’It’s not unlike wearing a mask during coronavirus — it’s as much for other people as it is for yourself. If you crash into a tree and kill yourself, that’s horrible. But imagine if you crash and hit someone else, and you wake up… and they don’t.’”

Benner recalled his own high school days with his friend, Mike, who had T1D and relied on both regular and existing NPH insulins. Back then, home glucose meters were far from mainstream and you were required to eat a specific number of carbohydrates every 3 to 4 hours to avoid severe hypoglycemia.

“We just didn’t let Mike drive us places,” says Benner. “We knew if Mike said ‘I’m hungry’ that he was going low. We never let him drive, it was too unpredictable.”

As Benner’s daughter finishes the process of acquiring her license in the state of New Jersey, her father made it clear that he isn’t going to let up on being hyper-vigilant about her blood sugar levels before getting behind the wheel.

“We said, ‘We are gonna be aware of this every time you drive until it becomes a muscle memory: You’re about to drive — what is your blood sugar right now and where is it headed?’”

In short, a diabetes diagnosis should not keep you from attaining your license, and your healthcare team is not legally required to tell the Department of Motor Vehicles (DMV) that you have diabetes (with some exceptions described below). But the laws around drivers with diabetes who take insulin are far from firm and clear across the United States.

You can look up your state’s laws regarding driving in this list compiled by the American Diabetes Association (ADA).

“Many jurisdictions place restrictions on occupational licenses for persons with diabetes because of the perception that the crash risk is higher for drivers requiring insulin,” explained a 2006 study conducted by the Association for the Advancement of Automotive Medicine. “Current events have led to a re-examination of the licensing policy debate.”

The first and most common question you’ll see in nearly every DMV’s application process is whether you have ever received treatment or taken medication for “a condition, which causes unconsciousness or unawareness.”

The ADA states that if you personally have never experienced a loss of consciousness due to hypoglycemia, then you can technically answer “no” to this question, but you should still answer “yes,” to the question asking if you have diabetes.

Regarding car insurance, there is no formal requirement to disclose your T1D when applying for insurance, but being pulled over or getting in an accident due to hypoglycemia will certainly raise your insurance rates.

When someone gets pulled over for a low blood sugar or gets in an accident, you lose your license immediately,” explained Edelman. “And if you end up in the ER after causing an accident because of a low, the doctor is legally required to report you, and you lose your license.”

In Edelman’s decades of work caring for patients with diabetes, he says he’s filled out countless forms helping patients get their license back.

“But I actually write on these forms that I only support the patient getting their license back if they wear a continuous glucose monitor (CGM). Not the Libre, but the Dexcom, that’s truly continuous with alarms for hypoglycemia.”

Edelman recalled testifying against one patient who deliberately neglected his diabetes by avoiding checking his blood sugar and refusing to improve his care. By his third car accident due to severe hypoglycemia, he killed a newlywed couple walking down the street.

According to 2015 research on driving and diabetes: “Other complications of diabetes, such as peripheral neuropathy, visual impairment, and cerebrovascular disease leading to cognitive impairment may also affect driving performance… a lower limb amputation may impair the ability of the individual to operate the foot pedals.”

Aside from obvious limitations due to amputations, Edelman said the neuropathy would have to be severe to leave a person unable to safely feel the gas and brake pedals under their foot.

When it comes to your eye health, new drivers are generally tested at the time of license renewals, and DMV officials generally trust the driver to report any issues with their vision.

Macular edema, in particular, can distort your vision,” explains Edelman, “far more so than retinopathy.”

If you have been diagnosed with any sort of eye health issue, talk to your eye doctor about how it impacts your vision. For many, diabetes-related eye disease is a health issue, but it does not necessarily impact your vision.

In short, being aware of and on top of your blood sugar levels before and while you drive is imperative to ensure your safety and the safety of everyone around you.

Edelman emphasizes that it truly is up to each one of us as individuals to acknowledge whether we should or shouldn’t be driving based on hypoglycemia unawareness or vision issues that may make us unsafe on the road.

“You know, it’s unfortunately like a drunk driver — too often the drunk driver lives and the people they hit are the ones who die,” he said solemnly. “Driving a car with type 1 diabetes is a tremendous responsibility.”

Ginger Vieira is a type 1 diabetes advocate and writer, also living with celiac disease and fibromyalgia. She is the author of “Pregnancy with Type 1 Diabetes,” “Dealing with Diabetes Burnout,” and several other diabetes books found on Amazon. She also holds certifications in coaching, personal training, and yoga.