Question about Diabetes and NMC policy.

[Lance Parsons]

I hve heard the the policy on diabetes at the NMC is that you must show a history of continous control of your diabetes eg. a Hg1c of under 8, in order to be elgible for a renewal of your Masters License. Can anyone expand on this?

[injunear]

When I renewed almost 2 years ago, under the new guidelines, my Dr. wrote a letter listing my A1Cs for the previous year. I had 3 A1Cs including the one for the renewal physical. They also asked for an eye exam from an ophthalmologist.

On renewal, my waiver stated I was required to submit my A1Cs annually to the NMC. A year later, I sent a letter from my dr. showing 2 A1Cs to the NMC. The NMC then rescinded the annual requirement with the stipulation that I notify them of any changes in my blood work.

[Lance Parsons]

Injunear, thanks for the input. When I renewed last time I got the letter saying I was required to report any changes in my status. I spent quite a lot of time yesterday and managed to dig out some guidelines from the NMC, so I hope for minimal slow down in the renewal process come Jan. 2013. Lance

[Snipe79]

All new to this type of issue but worrying because I now have no idea of how to make a living for a bit.

Was in the middle of switching company's, never had any physical issues and then literally out of the blue came down with a HgA1c with a 9.4. Literally have never had an issue, first time. So went to my doctor and started testing my blood and went on Metformin, this is only my first week on it. The company told me I need to get my blood below 8.0 to be employed by them. I do see that you need to have it below 8.0 to renew, but I think I am in limbo trying to figure out what to do. If I tell another company I am diabetic, I am sure they will do a test and find out mine is about 8 right? I think to sail you need to be below 8, right? I know some company's do not test but what if I am investigated, they find out its above that. Insane, anyone else have success with metformin? Worried because some people say it takes a few months for it to take effect but I dont have that kind of time, just took the summer off to be on the beach. Now screwed with debt.

So what do I do for a job while waiting for this number to drop... damn...

[injunear]

I've been on Metformin since 2002 and it does just fine for me. If you're monitoring and charting your glucose levels, you can tell if the Metformin is working. A low carb, low fat diet goes with it. Good luck!

[jdcavo]

You need to show two recent tests with A1C at 8 or lower, they have to be separated by at least 90 days, and the newest must be no more than 90 days old.

[Cal]

When you test your blood glucose level with a glucometer it measures the amount of glucose currently in your blood stream. An A1c tests the red blood cells for how much glucose they transported during their life cycle, approximately 100 to 120 days, which provides doctors with an average over a period of time, usually considered 90 days. Keep in mind that it is not a direct correlation, but you can estimate what your A1c will be using your daily BG tests. People without diabetes typically run between 80 and 110, the corresponding A1c's would be 4.4 and 5.5. To have an A1c at, or below, 8.0 you need to maintain daily BG levels of 183 or less.

How one accomplishes that is an individual endeavor. With Type I Diabetes the body no longer produces insulin, period. Type II Diabetes, for lack of a better description, is a degenerative disease. One of two problems is occurring, either the body does not utilize the insulin being produced as effectively as it once did or for some reason it is not producing the correct amount of insulin any more. The disease typically gets progressively worse, sometimes even when you're taking appropriate measures. For some diet and exercise changes resolve the problem adequately and no other changes are necessary. Some progress to needing medication assistance such as metformin or glucotrol (these are the ones I've heard of). After that it's insulin production outside of the body, i.e. injection (insulin does not survive the digestion process so it cannot be taken orally).

As with anything, a proper diet does not necessarily mean a restrictive diet. Moderation and common sense go a long way. The more you understand the potential effects of the foods you eat the better prepared you will be to maintain proper BG levels. There are "good carbs" and "bad carbs". How the body processes carbohydrates differs on the type of food. The more complex the carbohydrate the longer it takes the body to process it. The difference being when the dump of glucose into your blood stream occurs. Drink 8 ounces of orange juice and the entire carbohydrate value reflects in the glucose level in your blood stream within minutes. Eat a cup of white rice and it can take hours for the entire carbohydrate value to reflect in your blood stream. To learn more about "good carb" foods look into the glycemic index.

My 11 year old daughter was diagnosed with Type I Diabetes when she was 22 months old. If nothing else it is a learning experience. I used white rice in my example above but I am not stating that it is a "good carb" food. It is on special occasions that we have pizza or chinese food because they wreak havoc with her blood sugar control.

[Snipe79]

Sorry to hear about your daughter, can't imagine how tough that must be to deal with in. I have a two year old and now everything I eat makes me wonder about her and the future. I've been testing like a mad man trying to see how foods react with me as well as this whole glycemic index & load. One thing I have noticed in reading about three books, researching as much as I can and with this proactive testing I can really see the health issues in real time.

I am just a little distraught because I think in 2009 or so I had a 6.1, which is borderline prediabetes. I really didn't think much of it besides weight loss until just recently. In that time I have lost over 100lbs as this whole BMI thing with the USCG and as well as for my own life. I haven't worked in about nine months waiting on a pristine job, spending some time commercial fishing and then a job came up. I have done about four weeks of training in this time and was about three weeks away from joining the ship. Out of the blue is when I popped up with that 9.4 A1c. I lost that job opportunity and now am freaking racking up the last of my credit card available. So, really have my back towards the wall here, unable to sail. I am still high in the mornings but by mid day and below are testing just above normal. I guess it could take up to 4-6 weeks to get the full effect and maybe longer to get my A1C lowered, no pay until then.

One thing that gets me is this whole 8.0 for the USCG. I can totally agree about how it shows the value over the 90 days or so. I would think though that carrying a high blood sugar level on a A1C, shouldn't be a show stopper the first time. To me, I would think that if you could show daily control, lets say a lower A1C than a month ago, on medication and a letter from your doctor stating that your are not a jeopardy. It is my understanding that I will not go low on Metformin and have had no issues while I have been a this 9.4 A1c in the past who knows how long. I guess in my position this isn't a yo-yo type of thing, for now anyways. I of course realize that we deal with a government organization, things will not change and also realize if the USCG had to process thousands of "first time diabetes" issues there would be a huge backlog, etc. etc. etc. I know I will get this down and get back on a ship, time just costs a lot of money paying out bills everyday in the mailbox.

Am I right in thinking that I can't sail until I get this under a 8.0? This wasn't just a company own policy correct? I realize that you need to have it below 8.0 to apply and renew, but in the middle, I must fall out to a not fit for duty right? I believe that is what our REC friend above stated which I believe is legit.

[Cal]

The reason it is a show stopper is because of the potential side effects of long term high blood glucose levels. People with diabetes have an increased risk for so many life ending diseases. You don't hear about people dying from diabetes as it is not frequent that someone goes into a coma and dies as a result of ketoacidosis or hypoglycemia. You don't normally hear how the heart disease, kidney failure, or liver failure that ended someone's life was due to complications from diabetes. Fact of the matter is Diabetes is the number one contributing factor to so many deaths, it's just not the primary cause of death.

Until blood glucose levels are brought under control and a pattern of control has been established, there is simply no way of knowing when a sudden incident may occur that inhibits your ability to safely perform your job duties. As such, it's simply not worth the risk. You state that your morning blood glucose level is still high, what is it at 0100? Is your blood glucose level high from 2100 after dinner until 0600? This can be very detrimental to your ability to do your job safely. While the factors and effects tend to be more extreme with Type I, the same rules apply with Type II. Those rules are, there are no rules. The lowest recorded blood glucose level we have for my daughter is 23. She looked and acted fine, neither my wife nor I can specify what didn't "feel right" that caused us to test her. Fortunately we have never had to administer glucagon, call 911 because she's passed out due to low blood glucose level, or experienced her going into seizures. A friend of ours son, who is also diabetic, has seized with a blood sugar of 63. When she is acting out or not following direction we usually have her test her blood glucose level, 99 times out of 100 her reading is high. We've watched patterns of good control and all of a sudden the numbers go wild and we are desperately searching for a cause. It took us about 6 years to realize it, but usually within 72 hours of her control getting out of hand she's sick. Be it vomiting and flu like symptoms down to a common cold or strep throat. The point I'm trying to make is twofold. Number one, you may not realize the adverse effects poor control may be having on you. Number two, the disease is different for every person AND different within every person. What works for you may not work for someone else. At the same time, what works for you today may not work tomorrow, there are simply too many factors and unknowns.

As far as your morning blood glucose levels are concerned. First of all find out what they are doing overnight. Test right before you go to bed and set an alarm to test at the midpoint of your sleep cycle. If you are consistently high with both you may need to adjust your evening meal, activity, or both. If you are normal at bedtime but extremely high or low at the midpoint, you may need adjust or have a bedtime snack. The body can "panic". When it does so it causes the liver to dump stored glucose in an attempt to preserve your life (the same thing giving my daughter an injection of glucagon does). When my daughter was young after diagnosis we had problems with her going low during the night. We learned a little "trick". Just before bedtime we made her a "cocktail". It consisted of a drinkable, lowfat yogurt (the protein) and 1 tablespoon of corn starch. Corn starch is the most pure carbohydrate, it's also very complex. This "cocktail" carried her through the night as the combination of protein and longer processing time of the complex carbohydrate resulted in more even numbers. Make sure you test before exercising. If need be, wait until it is below 250, if you don't you will only drive it higher.

Chief Cavo is an invaluable contributor to this board. I know he studied law and, if I remember correctly, was a lawyer at some time during his maritime career. If he knows the answer to a question he will state it as such, if it is merely an educated opinion he makes that clear. You'll have to wait until he weighs in on your further questions or attempt to obtain an answer from the NMC because I simply don't know.

I hope you find some of my suggestions useful and/or beneficial. However, please note that they are merely suggestions based on my own personal experience with my daughter. I am not a medical professional and no opinion offered is to be construed as medical advice.

[jdcavo]

[A lot of good advice, cut for brevity]

Very good description and advice. I have a similar understanding as my wife has type 1 diabetes, her family has a history of type 1 (juvenile onset) starting relatively late, my wife was 19 when she was diagnosed, her brother was 40. As noted above, the A1C is a relaible indicator of general management of the condition. From experience, I know that when my wife's A1C dips below 8.0, there have been a few low blood sugar events over the past few months. Even if you have good control and can get the waiver, it would probably be a good idea to test your sugar levels often dutring a watch, at my insistence my wife checks every time she gets behind the wheel of a car.

I was a lawter for 5 years after I stopped sailing. After some very ugly litigation over the failure of two sewage barges on their delivery trip from the Mississippi to Boston (the bows fell offf both off of Fla), I realized I didn't particularly like it and ended up at the (old) NMC.

[Snipe79]

Pretty interesting group of people here and appreciate all the advice. Like I said, sort of new at this bit and trying to pin things down. I know I think one of my next steps is to find a primary care that deals with or atleast has some knowledge of the USCG or Transportation issues. When I told him I can't work unless I get below an 8, I do not think he really understood that. That also makes me question if I am doing this in a timely matter.

I think the biggest thing I am noticing is the fact in regards to sugar levels and diabetes everything can be up in the air and things apply to different people differently. This is just a little hiccup for me sailing but a big health issue long term. It is funny though ever since I told people about diabetic, they are like oh yeah, I am one too.

[Cal]

I know I think one of my next steps is to find a primary care that deals with or atleast has some knowledge of the USCG or Transportation issues.

I had a Nurse Practitioner that understood what I do for a living even though she had no direct experience. When she left the practice my file was taken over by the MD, he was completely clueless (aside from the bedside manner of a cold fish). When I searched for a replacement primary care physician I paid attention to where the doctors did their residency. I found a husband and wife that both did their residency at the Naval Base in Pensacola, FL. While I am not positive yet that he completely understands the regulations I have to deal with, he has a pretty good understanding of what my work schedule and environment is like.

[injunear]

Snipe..I had very much the same problem several years ago. I went on a "cat food and hay" diet and lost 50 lbs over a 3 month period. I started on metformin xr the same day I started my diet. I started noticing a reduction in glucose several days later. 4 weeks or so later I passed my SIU physical without any problems. My dosage has increased over the last 11 years (in proportion to my weight) but is still holding very good.

Good luck!

[DVanNevel]

Am I right in thinking that I can't sail until I get this under a 8.0? This wasn't just a company own policy correct? I realize that you need to have it below 8.0 to apply and renew, but in the middle, I must fall out to a not fit for duty right? I believe that is what our REC friend above stated which I believe is legit.

Need to distinguish between company policy and the "law." If you have a valid credential, you are authorized to sail until it is suspended, revoked, or expired. When you seek to renew your credential, NVIC 04-08 provides the guidelines---Mr. Cavo quoted them above. Company policy (and perhaps common sense) is a different matter. While you might have a valid credential, you need to consider the risk that your condition presents and perhaps not sail until your diabetes is under control. If you were to have an incident and cause an accident, you could lose your license permanently and maybe even kill someone.

[Snipe79]

For those who are curious about their A1c. I have tested 4 times in the past two weeks compared with lab results and found out that the Bayer A1C over the counter kit for $25 is pretty accurate. Now that I know this I can watch my long term average, knowing ahead of having real blood work done. Granted if you want to, most medical places with insurance do it for free. I just know I was in a jam, wanted to know, then did it the day before and after the test. It is slow, being a weighted average, to change reminds me of boiler chemistry!