Memorial Day is a time to honor all Americans who died while in the military service, and while we're remembering those who've fallen in the line of duty, we also wanted to check back in with someone extremely knowledgeable about the mix of diabetes and military service.
Dr. Jordan Pinskeris a research physician at the Williams Sansum Diabetes Center in Santa Barbara, CA, where he leads their Artificial Pancreas trials. Previously, he was Chief of Pediatric Endocrinology at Tripler Army Medical Center in Hawaii. He has deployed to Iraq in support of Operation Iraqi Freedom, and has been awarded numerous medals of distinction for his military service. After many years of active duty military service, he now maintains his ties to the US Army by serving as Division Surgeon for the 40th Infantry Division of the California National Guard, where he holds the rank of Lieutenant Colonel.
He's also a wonderfully warm and caring person, who thanked us profusely for allowing him to share his knowledge when we originally posted his answers below a few years ago.
NOTE that just recently in March 2018, Dr. Pinsker received the US Army's highest medical honors: he was inducted into the Order of Military Medical Merit and received the Department of the Army Surgeon General's Physician Recognition Award. Congratulations, Sir!
Five Key Questions on Diabetes in the Military
DM) It seems lot of people have been barred from military service because of diabetes over the years. What's the current state of affairs on that?
JP) Official Army regulations (40-501, standards of medical fitness) have traditionally stated that for appointment to the military, “current or history of diabetes mellitus (250) does not meet the standard.” But the regulation is now a little more lenient and does state that if a soldier is diagnosed with diabetes once in active service, this requires a medical board evaluation, and if found fit for duty, can stay in.
If a person with diabetes requires a significant amount of medication then that could make them medically non-deployable. If you are medically non-deployable you would go before a medical board for review to be either boarded out of the military or allowed to stay on active duty. This is quite variable in how tough these rules are applied to each individual. Note that a medical board evaluation is not required if the person is maintaining a hemoglobin A1C at less than 7% using only lifestyle modifications (diet, exercise). Of course this would not apply to a person with type 1 diabetes.
For those requiring insulin, if found fit for duty, the soldier is not eligible to deploy to areas where insulin cannot be properly stored (above freezing level but at less than 86 degrees Fahrenheit) or where appropriate medical support cannot be reasonably assured. Deployment only follows a predeployment review and recommendation by an endocrinologist.
So is type 1 diabetes sort of “don't ask, don't tell” in the military?
In the Army, diabetes requiring any medication requires a medical board review. There is really no way around that. In the past, many people with type 1 diabetes did not pass this board and had to be medically retired. Rarely there was a person with an extremely uncommon skill set and meticulous glucose control, where the soldier’s unit shows their strong support for that soldier to stay in active service, and then the board allows them to stay on active duty. If you have type 2 diabetes and only take metformin, you may also pass the medical board. Other cases are much less likely. As noted above, the current regulation allows for continued service if found fit for duty by the medical review board, but there are limitations on where you can be stationed or deployed to.
Interestingly, these medical boards vary by service (Army, Air Force, Navy). Each service may decide differently in terms of meeting military fitness standards, so it is still a very individualized process.
The most important point to understand is that the goal of the Army is to maintain the readiness to deploy as a unit all together. When a soldier cannot go with their unit for a mission that is a big issue, and can hurt the unit in terms of unit cohesiveness. Unfortunately it can also adversely effect a soldier’s career development and promotion, as they may not be able to go to certain assignments. This is not limited to diabetes, but any medical condition limiting a soldier’s readiness. This is very different from the civilian world, and intuitively is not ‘fair’ if we consider any chronic medical condition a disability, but the Army is all about readiness for the mission, and as an officer I recognize its importance. At the same time, it is very nice to see the regulation allows for soldiers who develop diabetes to stay in active service and contribute in a positive way. It is important for the individual soldier to educate the medical review board on this and be an advocate for him or herself.
You've worked work with many military families with children with type 1 over the years. Do they get access to the most state of the art treatment, or are they facing greater challenges than civilian families?
Yes, children with type 1 diabetes get access to the latest technologies. As Chief of Pediatric Endocrinology at Tripler Army Medical Center, we routinely used CGM, insulin pumps, and pumps with LGS (Low-Glucose Suspend). We have published extensively on this. Rarely did I have to petition Tricare (health care program of the U.S. Department of Defense) to pay for these items -- and almost always they were approved immediately and we had many children on pumps and sensors as soon as possible after diagnosis. It was a great joy of mine to work with families to teach them to use the latest technology as effectively as possible. In fact, I think reimbursement for these technologies was generally much easier for active duty families than on the civilian side. Occasionally a family would request more test strips than Tricare would routinely authorize, but a quick phone call always led to an updated authorization for more strips.
For children of active duty personnel, in many cases there are no co-pays for these devices and supplies. I have heard from many soldiers that they joined the military or stay on active duty because of the free medical care they get for their families. For children of retirees, the co-pays or cost-share from insurance can be significant, and occasionally would be too much for a family to start using a pump and/or sensor for their child.
If you are not in the military, you may not be aware of the EFMP (Exceptional Family Member Program) that requires all military personnel who are moving to a new location to have all family members medically screened. So a family with a child with type 1 diabetes could not move to a location where they would not have access to a pediatric endocrinologist. Access could also include a nearby civilian medical center. But for example, you could not move your family to Japan if you had a child with type 1 diabetes and the military clinic there had no specialty services to help you care for your child. This would be blocked during EFMP screening. Of course everything can be individualized, and sometimes exceptions are made as a move to a new location and position might be necessary to advance the career of a soldier and the family felt they could handle their child’s diabetes, but it takes great effort to obtain special EFMP approval. This is an excellent service that helps families.
Overall, what things would civilian PWDs (people with diabetes) most like to share with servicemen and women, and/or what are the downsides of care in the military?
As we all realize, diabetes technology has rapidly progressed over recent years, and if used well can really make a difference to quality of life and diabetes care. However, technology as it stands today does not solve all problems. In fact, without a strong family and social support, uptake and continued use of diabetes technology is poor. The key to making technology work best is involving families and having a good support system.
Perhaps the greatest contribution a person with diabetes could make is to simply be supportive of families with children with diabetes who are in the military. Often a parent is deployed overseas, and this puts an incredible stress on the family. Just being supportive and sharing how you handle diabetes management can be very helpful.
One way that our diabetes educators at Tripler supported families was to hold events for children with diabetes and even had older children with diabetes babysit the younger ones so that parents could get together for the events.
What would you most like to say to anyone with diabetes or parenting a child with diabetes about dealing with this disease while in the U.S. Army?
First, I would like to thank them for all they do for our country. Also, never forget that the true strength of our military comes from all of the great families that support us. Although moving frequently and having family members deployed can be extremely difficult, it is important to work with the community of families who are in the same position you are. I have always been so impressed how giving and caring military families are, even though so much is constantly asked of them. They are our best resource!
Thank you, Dr. Pinsker, for everything you do!