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control can reduce the incidence of complications. Subsequently the UK prospective study on diabetes
(UKPDS) has confirmed the benefit in those with Type 2. It is thus essential in aircrew to reinforce the
importance of good control of diabetes being the key element in management.
Classification
The classification of diabetes can essentially be divided into two categories; Type 1 (insulin dependent
diabetes) which presents in the young individual, and Type 2 (non insulin dependent diabetes) which
presents in the middle years.
Treatment
The goal of treatment in diabetes is to correct the metabolic disturbance and to improve the patient’s
quality of life by diminishing the long term complications. In Type 1 diabetes the mainstay of treatment is
insulin. In Type 2 diabetes, treatment consists of dietary adjustment with the addition of oral
hypoglycaemic agents as required. Insulin may be needed if adequate control is not achieved by these
measures.
When the diagnosis of diabetes is made, the licence holder will have to be removed from aviation duties
and other safety-critical functions for a suitable period of time. The situation should then be reassessed
after appropriate control has been achieved and a decision made based on relevant reports from the
treating diabetologist/physician.
Operational implications of diabetes
The risk in diabetic aircrew may be divided into those intrinsic to diabetes mellitus itself and those which
are iatrogenic due to the therapeutic intervention in the disease process. The main risks, intrinsic to the
disease process, are cardiovascular disease, visual problems, nephropathy and, to a lesser extent in the
aircrew population, neuropathy. The only significant iatrogenic complication with profound implications
in aviation is hypoglycaemia.
After assessment of the risks, a reasonable policy for medical certification must be established. The
simple approach would be to disqualify all diabetic pilots. However, a more scientific approach can be
developed from a careful literature review, which can then be cautiously applied to the diabetic
ICAO Preliminary Unedited Version — March 2010 III-4-18
population and audited over time. The following section summarises the literature and discusses the
development of a certification policy based on that literature.
Cardiovascular disease
Premature vascular disease is one of the most common and serious complications of diabetes. The
Whitehall Study (Fuller, 1980) showed that coronary heart disease mortality was approximately doubled
for those with impaired glucose tolerance in a standard glucose tolerance test. Data from a number of
studies suggest that the risk of cardiovascular disease is two to four times higher in patients with diabetes
compared to those without. A major study from the Joslin clinic of over 2000 diabetic patients reported
that almost 75% died of vascular causes and the ratio of deaths from all vascular causes compared to the
general population was 2.4 in males and 3.4 in females (Entmacher et al, 1964). The risk of
cardiovascular disease is high, even at the time of diagnosis of Type 2, and is independent of the duration
of diagnosed diabetes, because diabetes is present for approximately seven to 12 years before formal
diagnosis. Perhaps even before that time, patients would be classified as having impaired glucose
tolerance, which from the Whitehall Study is associated with an increased risk of cardiovascular disease.
Nephropathy
Kidney disease is a significant problem in the diabetic population. Nephropathy affects approximately 35
per cent of patients with Type 1 diabetes and about 5 to 10 per cent of patients with Type 2. Despite this
lower prevalence in the latter group, the impact of renal disease caused by Type 2 diabetes is substantially
greater, since Type 2 diabetes is far more common than Type 1. The importance of identifying those at
risk of developing nephropathy, whether they are potential or active aircrew, lies in the finding that in
Type 1 patients with proteinuria the relative mortality from cardiovascular disease is almost 40 times that
of the general population and in those without proteinuria only four times that (Borch-Johnson, 1987).
Thus, the presence of nephropathy is a surrogate for cardiovascular disease.
There is evidence that the presence of micro-albuminuria (defined as urinary albumin excretion greater
than 30 mg and less than 300 mg per 24 hours) may predict, with some accuracy, the development of
diabetic nephropathy. Preliminary evidence is also available that therapeutic intervention with ACE
inhibitors may halt this progression (Viberti et al, 1994). Thus, the measurement of micro-albuminuria is
a useful adjuvant to risk assessment in the diabetic pilot.
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Manual of Civil Aviation Medicine 1(131)
