Insulin-Requiring Diabetes Mellitus – Legal Flight at Last?

    By Hunter Heath III, M.D.

    Sport Aviation, February 1997

    The FAA's late 1996 change of policy concerning the opportunity for insulin-treated diabetics to obtain a medical certificate is a major shift for the agency and pilots. A review of the ramifications of this policy shift for the pilot (and patient) will help us all put this change in perspective.

    The last 20 years have brought great advances in the diagnosis and treatment of diabetes mellitus, a disturbance of carbohydrate and fat metabolism best known for "high blood sugar." In fact, short-term complications are now uncommon, but late complications of diabetes remain distressingly common; for example, diabetes is THE leading cause of blindness, kidney failure, and limb amputations in the western world. This scary scenario is yielding to medical research, however, and there is great hope for a long, productive life without major health problems. In particular, the large, 9-year Diabetes Control and Complications Trial ("DCCT") has established recently that the key to a long, healthy survival with diabetes is the tightest possible control of blood glucose (sugar) levels.

    About 95% of all diabetics have "Type II" disease, formerly termed "adult-onset" or "non-insulin-dependent" diabetes (NIDDM). Most such folks are obese, and that is a major cause of their diabetes; simple weight loss will often bring the blood sugar under control, and medications taken by mouth ("oral agents") can control blood sugar in many others, at least for a while. Often, control of blood sugar will deteriorate over the years and ultimately require insulin injections. Fortunately, the Federal Air Surgeon's office recognized several years ago that Type II diabetics can fly safely even if taking oral agents, as long as their eyes, hearts, nerves, and kidneys are working well. It has been almost routine in recent years for Type II diabetics to get Class 3 medical certificates by special issuance, with only a moderate increase in monitoring.

    On the other hand, the FAA has been much more reluctant to allow Type I diabetics to fly. Type I diabetes is the most severe form, termed formerly "insulin-dependent diabetes mellitus," or IDDM. These folks must take insulin daily, or they will die within days or weeks of diabetic ketoacidosis. However, the life-giving insulin carries a definite risk: if there is more insulin in the blood than needed, the blood sugar level can drop so low that consciousness is lost - the brain needs sugar! It is this risk of low blood sugar and incapacitation ("insulin reactions") that has kept the FAA from issuing medical certificates to those taking insulin for diabetes. Nonetheless, the DCCT study showed clearly that the long-term gains from tight control of blood sugar outweigh the risks, in terms of protecting vital organs.

    Now, the FAA has yielded to advances in medical technology, the advice of an expert panel, and political pressure: for the first time, it will be possible - but not guaranteed - for Type I diabetics, and Type II diabetics taking insulin, to get a Class 3 medical certificate. In late 1996, as highlighted earlier in Sport Aviation, the FAA announced that "individuals with insulin-treated diabetes mellitus who have no other disqualifying conditions... such as (heart or blood vessel) disease, retinal (eye) disease, or chronic renal (kidney) failure, will be evaluated for special issuance of a third class medical..." This change of policy is made possible largely by the ready availability of devices that allow the person having diabetes to measure his or her own blood sugar accurately and quickly.

    Suspicious readers will note the wording, "will be evaluated for..." a medical. What's the catch? The conundrum facing the insulin-treated diabetic who wants to fly is that the FAA rule may require that the individual decrease the quality of blood sugar control in order to get a medical certificate, thus advancing the likelihood of having later disqualifying complications! Why is this? Concern about the risk of in-flight incapacitation due to low blood sugar has led the FAA to require that the applicant show evidence of having had essentially no major low-blood sugar reactions within five years. This is entirely feasible for Type II diabetics, but the hard truth is that only some Type I diabetics can maintain optimal control of blood sugar without at least occasional - and sometimes unpredictable - low blood sugar (hypoglycemic) reactions. Regrettably, insulin reactions are a fact of life for most Type I diabetics.

    So what is the insulin-taking potential airman to do? There is no "right" answer; each person will have to weigh the immediate, wonderful good of flight against the long-term risks of suboptimal control of his or her diabetes in order to hold a medical certificate. Concealing one's insulin reactions from the Aviation Medial Examiner is quite ill-advised, because lying on a medical certificate, if found out, may lead to very serious legal and economic consequences. As EAA Legal Advisory Council member James E. Cooling wrote (Sport Aviation, September 1996), "nothing excites the FAA more than the possibility of falsification of ... documents relating to pilot certification." Jail time is possible!

    As a physician and endocrinologist, I have mixed feeling about insulin treatment and flight; were I diabetic and taking insulin, I probably would seek a certificate, but if granted one, would only fly with someone capable of taking over the aircraft should I become incapacitated. I'd rather live with this limitation than die from rugged individualism! Perhaps this dilemma should motivate diabetic flyers to involve more family members and friends in aviation, another great good! In any case, I salute the EAA, the American Diabetes Association, and many persistent advocates for stimulating - and the FAA's medical staff for taking - a courageous step that will allow many insulin-taking diabetics to live their dreams of flight.

    (Dr. Hunter Heath III, EAA 37802, is a pilot, an endocrinologist and former professor of medicine now working in the pharmaceutical industry as a researcher and administrator. A resident of Indianapolis, IN, Dr. Heath is a member of the EAA Aeromedical Advisory Council.)

    Additional information regarding the FAA policy on Medical Certification of Insulin Treated Diabetic Applicants is available at their web site.

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