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again become a problem.
Aeromedical considerations
The applicant can probably be certificated in any class if physically and biochemically normal. In
common with all previous conditions, close surveillance by the aeromedical officer and an
endocrinologist is mandatory.
DIABETES MELLITUS
Annex 1 specifies in Chapter 6 that:
6.3.2.16 Applicants with insulin-treated diabetes mellitus shall be assessed as unfit.
6.3.2.16.1 Applicants with non-insulin-treated diabetes mellitus shall be assessed as unfit unless the condition
is shown to be satisfactorily controlled by diet alone or by diet combined with oral anti-diabetic medication, the
use of which is compatible with the safe exercise of the applicant’s licence and rating privileges.
Note.- Guidance on assessment of Type 2 insulin-treated diabetic applicants under the provisions of 1.2.4.8 is
contained in the Manual of Civil Aviation Medicine (Doc 8984).
Introduction
The guidance material contained in this section does not have any regulatory status beyond that of the
medical provisions cited above. Its main purpose is to aid in the implementation of the medical provisions
of Annex 1. It contains methods for comprehensive evaluation and assessment of applicants in whom
there is a suspicion or overt manifestation of diabetes. The aim is to eventually achieve international
uniformity of procedures which will allow comparison of data to assist in the assessment of aeromedical
borderline cases.
The prevalence of diabetes has increased over the past 100 years and the condition is now common,
affecting approximately three per cent of the population and increasing with age. There are a number of
sound reasons why diabetes is one of the most common chronic disorders in the industrialized world. The
life expectancy of the general population including diabetics with improved quality of control is
increasing. In addition, the current high standard of living has led to a higher intake of calories
accompanied by a lower level of physical activity, resulting in an increased prevalence of obesity.
Contributing to the decrease in physical activity may be the dependency by many on private or
commercial transport. Health screening programmes for the general population have also contributed to a
perceived increase in the prevalence of diabetes by diagnosing a number of diabetics at an early stage. In
obstetrics, it is now common practice to screen pregnant women for diabetes; those found to be diabetic
are carefully monitored and controlled, and the resulting fall in perinatal mortality contributes to an
ICAO Preliminary Unedited Version — March 2010 III-4-15
increased number of offspring who will continue to transmit the disease. Routine periodic medical
examinations of licence holders contribute to the early detection of diabetes in otherwise healthy
individuals without subjective symptoms of disease. This also contributes to the increased prevalence in
aviation medicine practice.
To obtain accurate figures of prevalence, however, it is important that diagnosis of diabetes is equally
accurate. With a glucose tolerance test using a 75 g glucose load and by applying the interpretation
described by the WHO guidelines – see below – an accurate initial diagnosis can be made.
This section also contains guidance material on the acceptability of oral anti-diabetic therapy.
Definition
Diabetes may be defined as a metabolic disease with some genetic predisposition which is characterised
by an impaired ability to break down, store and utilise carbohydrates effectively. This may be due to
failure of production of insulin from the beta-cells in the islets of Langerhansin the pancreas or the
presence of insulin resistance impeding the action of the endogenously produced hormone.
Aetiology and pathogenesis
The precise aetiology of diabetes remains unknown, but there are many theories including genetic,
autoimmune and viral causes, all with a common result: the destruction of the pancreatic beta-cells
resulting in impaired production of insulin in response to glucose ingestion. Many factors may be
simultaneously involved in an individual developing diabetes including obesity, pregnancy, infection and
other mechanisms which might determine the onset of the disease in genetically predisposed individuals.
Symptoms
Lack of insulin results in a disruption of the normal metabolic processes of all dietary elements including
protein, carbohydrate and fat. The resultant metabolic upset causes water and electrolyte disturbance. The
classic symptoms of insulin deficiency are characterised by polyuria, polydipsia, weight loss, itching and
a predisposition to chronic infection of the external genitalia. In severe cases that go on untreated, this
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