There's a whole world under the ocean, and scuba diving and snorkeling offer a great way to get a glimpse of that world. But for people with diabetes, it can be tricky to decide whether to dive in -- due to our need to continually monitor blood sugars to assure our safety at all times.

Fortunately, there are many PWDs (people with diabetes) who've dared to try, dive successfully and have even managed to figure out ways to even take D-technology underwater with them. We're fascinated by their stories, and of course the official "diving with diabetes" protocols that do exist but some D-Divers say don't go far enough and are actually too dangerous to use as written -- especially in this era of modern-day of D-tech.

 

Diving with Diabetes: Protocols

The leading authority that sets the rules on this type of thing is the Divers Alert Network (DAN), a group of non-profits that aim to improve diving safely. They mapped out specific policies just over a decade ago. Interestingly, before 1997, the DAN had discouraged PWDs from seeking diving certification because of the hypo risk. After studying the issue about two decades ago, the network found shifted its policy on allowing insulin-dependent PWDs to dive recreationally.

It took several more years beyond that for DAN and the professional Undersea Hyperbaric Medical Society (UHMS) to formalize an official policy, followed by a formal policy follow-up from the World Recreational Scuba Training Council (WRSTC), established in 1999 to create minimum training guidelines for certification agencies worldwide.

So that's great, right? Well, sure. But it still offers no practical advice to our D-Community on the "how" of blood sugar management while diving, so many have opted to either not dive, or to do all of their insulin dosing and BG checks before getting in the water. And it may not actually be safe.

"In my opinion, it's risky because the time between symptoms and treatment could make hypoglycemia worse," says T1D peep Erica Rossato, a 20-something from Italy diagnosed in 2009 and who's been diving in Croatia and the Red Sea for years before that. "Furthermore, the rapid ascent and skipping the safety stop increase the risk of decompression sickness," she adds.

 

Diving with Diabetes: Around the D-Community

Within our Diabetes Online Community (DOC), we hear stories and see the fun photos of PWDs who seem to be having a blast doing it. More recently, we've even heard a few fellow type 1s share their personal practices of monitoring CGM data and blood sugars when they are underwater on actual dives.

An Italian and Croatian Experience

Earlier this summer, we saw an Instagram video that Erica shared of her underwater experience using the FreeStyle Libre Flash Glucose Monitoring system. The 24-year-old med student -- who happens to have a dad who's an endocrinologist and her parents were both diving instructors when she was young -- says she's been diving for years, even before diagnosis.

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@Erica_Rossato_ on Instagram

After T1D diagnosis, she says she tried to just eat glucose underwater to treat oncoming lows, but mostly "continued diving like before."

The more she looked into it, the more she saw that in many ways it seemed like the medical and diving professionals saw diving as a forbidden or taboo activity for PWDs -- especially when it came to the WRSTC protocol, which she views as a good start but insufficient overall.

  • they recommend keeping glucose levels between 150-300 mg/dL due to fear of hypos, which can increase dehydration (dangerous while diving)
  • also their emergency protocol is risky, as they don't treat hypoglycemia immediately and surface quickly -- which can increase the likelihood of decompression sickness

"(The guidelines) are good because they try to give diabetics the opportunity to dive, but also narrow-minded because they just teach their protocol and they don't want it to be improved... it is not demonstrated or validated yet, so I think it could be re-thought now that CGM is spreading and working."

During a dive in Croatia in May 2018, Erica used a water-tight camera case to secure the handheld reader of her new Abbott Libre FreeStyle flash glucose monitor. She attached it to a bungee cord, and found it connected properly through the case and her wetsuit. She was able to scan and get readings, and the Libre sensor getting wet didn't impact her readings. It worked very well, she says, and "made diving more secure."

She created a short video and posted that on Instagram about how she uses the Libre underwater, and since then she's made another pool version showing the Libre scanning as well as how she treats Lows underwater. Erica's continuing her experiments with the hope of validating the existing WRSTC and DAN protocols and eventually working with those groups to improve the guidelines on the books for underwater scuba diving with diabetes. 

 

An Australian Adventure

Our Seattle-based friend Dana Lewis, well known in the #WeAreNotWaiting community for inventing the do-it-yourself closed loop OpenAPS technology, has also been chronicling her diving with diabetes experience lately. She just returned from a trip to Australia, where she and her husband Scott Leibrand had some scuba diving fun in the Great Barrier Reef.

This wasn't the first time Dana has been scuba diving and had to factor in her diabetes and OpenAPS system, and she wrote about that in early 2017 about how she navigated the adventure in Hawaii. For this latest trek across the globe, Dana noted that Australia actually has some of the strictest diving-and-medical-condition restrictions in the world, and there was a specific process there she had to go through.

This time, using the FreeStyle Libre (much like Erica described above), Dana used a waterproof phone case/bag for the handheld receiver, and was able to scan her Libre sensor underneath two wet suits.

It worked great, Dana reports!

She shared the full experience in a blog post, while still on vacation, but noted that her underwater MacGyverying made the multiple dives an even more awesome experience.

"The waterproof case had a strap where you could wear it around your neck, which is what I did. That ended up being annoying occasionally (because the bag would float above you during the die, and sometimes got caught on my snorkel), but it worked. (For future trips I’d probably find a stretchy cord to attach it to my BCD where it was accessible but didn’t have to float or be hung around my neck.)"

Awesome! We also enjoyed seeing Dana's tips and tricks for any underwater activities, ranging from using tech to treating and just being mindful of all the D-management tasks while submerged.

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Diving with Diabetes in Central America and Asia

Diagnosed at 27 back in 2000, Brian Novak in the Boulder, CO, area says that he's been an adventurer with T1D on board for years and that has included diving. He's been diving across the world and is certified in Honduras, Panama, Routan, and Thailand.

"Of all the adventures I’ve had, nothing is quite as unique as diving," he wrote in a Beyond Type 1 post back in 2015. "I love it! With some education, training and a little planning, diving is something that most people with diabetes should be able to do."

Brian recently told DiabetesMine that he hadn't used a CGM while diving and wasn't sure how well it might work underwater. Aside from diving, he noted having trouble keeping CGM sensors on when spending time in the ocean and so he usually doesn't use his CGM for the week that he's diving.

Hearing Dana and Erica's stories from above and mentioning the Libre, Brian marveled at the possibilities. 

"Wow, that's awesome! Being able to use a CGM and knowing that you aren't going to crash while diving would definitely help put your mind at ease so that you can enjoy the dive," he shared in an email. "Very cool!"

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We totally agree!

We're happy to hear stories of how our friends in the diabetes community are using technology (not to mention some cool D- Life Hacks!) to do what they love to do. We hope that these types of conversations can help others, and maybe even influence change at the policy level.