US Army Soldiers With Type 1 Diabetes Mellitus

Abstract

US Army soldiers diagnosed with type 1 diabetes were previously considered unfit for duty. For highly motivated soldiers, current advanced technologies allow the possibility of not only retention on active duty, but military deployment. We present our experience at Fort Bragg, North Carolina, taking care of soldiers newly diagnosed with type 1 diabetes mellitus. Through intensive diabetes education, extensive military and physical training, optimization of diabetes technology, and remote real-time monitoring, soldiers are able to continue to serve their country in the most specialized roles.

When a US Army soldier is diagnosed with type 1 diabetes, it is widely assumed that they will be found unfit for duty and their military career is over. Previously, the rigors of an unpredictable lifestyle and intense physical requirements precluded continuation on active duty. But for a select group of highly motivated and skilled soldiers, continuation on active duty is possible.

Fort Bragg, North Carolina, is home to some of the most skilled men and women in the military, many having spent years of education and intense operational training to achieve their level of skill, experience, and proven performance. When a soldier is diagnosed with type 1 diabetes, the Army may face a difficult decision. What should be done for an exceptionally skilled soldier who is also highly motivated to stay on active duty? How will hypoglycemia and hyperglycemia be managed? From a tactical viewpoint, the unit commander has the responsibility to ensure not only the safety of the soldier with diabetes, but to ensure the safety of the entire unit. A soldier’s removal from assignment due to a medical complication could significantly affect the unit’s mission.

Army regulations stipulate that any soldier with diabetes requiring medication for glycemic control will be referred to a Medical Evaluation Board (MEB) to determine the soldier’s ability to serve on active duty. Many are found unfit for duty, ending their military careers. We have demonstrated that it is possible to not only retain but to deploy soldiers with type 1 diabetes.¹ Though not all soldiers deploy, our goal is to satisfy all deployment criteria at 6 months from diagnosis (Table 1). In addition, all soldiers pass the Army physical fitness test and successfully complete other unit related activities to prove that continuation on active duty and deployment will be safe. Ultimately, it is the Commander’s decision to not only deploy but utilize any soldier. Therefore, close collaboration between the soldier, medical team, and unit is required each time deployment or any other activity is considered. Even when a soldier’s military obligation ends, this pursuit of aggressive benchmarks for safe deployment criteria prepares the soldier to be successful in future life endeavors.

Table 1.

Guidance on Deployment of Soldiers With Diabetes.

Factor	OK to deploy	Should not be deployed
HbA1c (for patient)	At target	Not at target
Monofilament discrimination	Present	Absent
Autonomic neuropathy	Absent	Present
Knowledge of sick day rules	Sufficient	Insufficient
Proliferative diabetic retinopathy	Absent	Present
Macular edema	Absent	Present
Severe hypoglycemia (an episode requiring another person’s assistance)	Infrequent	Frequent
History of diabetic ketoacidosis in previous 6 months	No	Yes
Self-management skills	Good	Poor
Hypoglycemia unawareness	Absent	Present
Parameters of permanent profile can be followed	Yes	No
Significant comorbidities (for example, congestive heart failure, chronic kidney disease, significant coronary artery disease, poorly controlled hypertension) requiring intensive management	Absent	Present
Risk of hypoglycemia is high if meals are missed or delayed	No	Yes
Duty will place the soldier in an OCONUS-isolated area where appropriate medical care and means to monitor and support him/her are not available	No	Yes

Source: Army Regulation 40-501, Table 5-1. OCONUS, outside continental United States.

General Soldier Requirements

Preparation for military duty includes attention to event specific tasks, as well as sleep, nutrition, and hydration. We have used guidelines regarding sports nutrition promulgated by the American College of Sports Medicine and other professional organizations.^2,3 The soldier with type 1 diabetes must maintain this proper energy fueling and adequate glycemic control. Recommendations for athletes with type 1 diabetes are in agreement with the general guidelines for all athletes.⁴ Acutely this means prevention of hypoglycemia and control of sustained hyperglycemia that could lead to diabetic ketoacidosis (DKA). Such complications could temporarily incapacitate the soldier and put the unit at risk. Long term, control means maintaining adequate A1C to minimize the glycemic contribution to vascular disease. A more important long-term goal may be the prevention of type 2 diabetes, as it is expected that approximately 40% of adults with type 1 diabetes will develop type 2 physiology due to the high prevalence of overweight and obesity in the United States.⁵ In a high operational tempo environment, the latter is easy to overlook as a soldier may be able to perform optimally without hypoglycemia or DKA, yet with a suboptimal A1C. The challenge is to keep a soldier fit for duty for present mission success while preventing future medical complications.

Physical Activity

Civilian athletes with type 1 diabetes currently compete in professional sports and endurance events, such as Ironman Germany Triathlon and others.^6-9 Perhaps most notable to the diabetes community is the success of the Team Novo Nordisk professional cycling team. Such endurance events require tremendous preparation for any athlete to safely compete, and they demand even more preparation for those with type 1 diabetes. For soldiers who were previously endurance athletes, we endorse continuation of such activities. Our goal is to carefully train and optimize maximal performance. In addition, for those who do not participate in such activities, we encourage participation in other strenuous pursuits beyond standard Army physical fitness testing requirements. Successful completion within established glycemic boundaries provides the confidence to pursue all military duties.

To accomplish militarily relevant training, strict attention to multiple factors is required. As required for safe deployment, we stress prevention of hypoglycemia/sustained hyperglycemia, reliable monitoring, and communication with the medical team. The optimal target glucose during activity is 100-180 mg/dl, and several excellent reviews are available that provide guidance on the management of the athlete with type 1 diabetes.^10-13 Ultimately, it is through graduated activities and careful monitoring that an activity management plan is tailored to fit the unique metabolic and lifestyle signature of each soldier.

Use of Available Technologies

Established guidelines and our past experience provide a model for activity planning. Considerations include effect of rest/sleep,¹⁴ caffeine,¹⁵ type of diet (eg, pizza),¹⁶ environmental temperatures,¹⁷ and most importantly activity (type, intensity, duration, frequency). Previously, we required each soldier to perform self-monitoring of blood glucose (SMBG) 6-10 or more times per day to adequately assess the effect of these and other variables.¹⁸ Remote electronic downloads provided easy information exchange, however multiple testing was cumbersome due to the impracticality of SMBG during activities. Use of real-time continuous glucose monitoring revolutionized testing for our soldiers and is now a prerequisite for completion of our training program.

We currently use the Real-Time (Medtronic Diabetes, Northridge, CA, USA) and Dexcom G5® (Dexcom, San Diego, CA, USA) continuous glucose monitoring systems. Sensors allow near simultaneous verification of initial basal and bolus parameters. We ask the soldiers to fast until lows are predicted to occur. Such information is invaluable as unexpected fasts may be unavoidable. After the insulin pump settings are calibrated, soldiers are instructed to wear the sensor continuously and to record as much detail as possible surrounding any event or activity. As alluded to earlier, being aware of the internal and external factors associated with the event can build an “activity database” from which future decisions can be made. A soldier going on a 10-mile road march carrying 45 pounds of equipment would make note of such variables as time of day, temperature, humidity, terrain and altitude, amount of sleep and rest, emotional state, fitness level to include baseline heart rate, diet, hydration status, and length of activity. We have found that there is no substitute for the data and immediate safety feedback provided by the continuous glucose sensors.

In particular, the Dexcom G5 is helpful as it provides the ability for our entire team to see real-time glucose values. As an example, when a soldier is going on a timed 10-mile road march, the soldier, medical team, and unit assets are able to remotely monitor real-time values. We are able to communicate with an embedded medical team member and provide immediate feedback and suggestions for care. We highly encourage our soldiers to evaluate their real-time values, make self-care decisions, and to communicate with our team 24/7 as the need arises. Such immediate feedback provides invaluable lessons learned, and through repeated practice and communication, direct reliance on our team becomes less important.

During the initial 1-2 months of training, we emphasize that soldiers must notify us immediately whenever sugars are below 70 mg/dl or above 250 mg/dl. Though trained soldiers have written action plans, we encourage immediate calls to reinforce proper management decisions to achieve our number one priority of keeping sugars out of the danger zone.

Fort Bragg Outcomes

Over the past 25 years, we have taken care of hundreds of soldiers, from junior enlisted to senior general officers, with type 1 diabetes. Our service members have not only been retained, but they have been able to remain in their military occupational specialty which includes assignments within the 82nd Airborne Division and Special Operations Command. They have completed training such as the challenging Survival, Evasion, Resistance, and Escape course.

Our last 50 consecutive soldiers with newly diagnosed type 1 diabetes seen at Womack Army Medical Center provide a snapshot of our experience at Fort Bragg (Figure 1). All soldiers were immediately introduced to advanced technologies and most were placed on an insulin pump and sensor within weeks of diagnosis. Intensive face to face training occurred within the first two weeks involving multiple visits with our diabetes team; preferably our team sees them within 24 hours of diagnosis. Telehealth was used immediately upon diagnosis and almost exclusively after the MEB process was initiated. A1C was obtained at diagnosis, MEB referral, and every 3 months until separation from the military and/or relocation.

Figure 1.

Active-duty soldiers with type 1 diabetes: administrative outcomes.

The average age was 29.3 years; all but two were men. The average follow-up time was 28.7 months. Mean A1C at diagnosis and final visit was 11.4 and 6.6, respectively (Table 2). The only adverse events were hypoglycemia requiring assistance (one) and DKA (two, one related to drug abuse). All 18 soldiers who desired to stay on active duty were retained.

Table 2.

Fort Bragg Outcomes: Average Follow-Up of 28.7 Months.

A1C	Total (N = 50)		Retaineda (n = 18)		Not retained (n = 32)
	Mean	Median	Mean	Median	Mean	Median
Diagnosis	11.4	11.2	11.8	11.8	11.1	11.0
At MEBb referral	6.6 (1.8)c	6.1 (5.0-13.3)d	6.7 (1.3)	6.6 (5.0-11.2)	6.6 (2.0)	6.0 (5.2-13.3)
All values excluding diagnosis	6.6 (1.2)	6.2 (5.1-11.1)	6.8 (1.0)	6.7 (5.3-8.6)	6.5 (1.3)	6.1 (5.1-11.1)

^aSoldiers found fit for duty were retained; those found unfit were not retained. There were no statistically significant differences between retained/not retained A1C values.

^bMEB, Medical Evaluation Board.

^cMean reported with standard deviation.

^dMedian reported with range.

Of the 18 soldiers retained, all used insulin pumps and all but one used a continuous glucose sensor ( insulin pump or sensor is not a requirement for retention). Some soldiers utilized a pump with threshold suspend but we did not notice any difference in severe hypoglycemia less than 50. No soldier utilized the Medtronic 670G closed loop system as military insurance did not allow use.

Five soldiers had deployments. One soldier was denied deployment due to the unit requirement of a fixed hospital facility; this was not a factor in those who deployed as long as access to equipment and medical care was available. Environmental extremes, such as temperatures >90ºF, did not preclude assigned activities or significantly affect glucose control. All soldiers successfully completed their tours. No complications occurred in any of the 18 soldiers except one who required assistance for hypoglycemia in a nondeployed setting.

Telemedicine at Remote Locations

Through effective use of various telemedicine venues, we can communicate with soldiers nearly anywhere in the world. Though not all deployments are approved, we nonetheless work to ensure all soldiers and their units have the ability to contact our medical team 24/7 in the event a soldier is cleared for such assignment. In terms of control, maintenance or slight increase in A1C to reduce risk of hypoglycemia is preferred. An average glucose less than the renal threshold during deployment is sufficient, for example, 170 mg/dl or A1C of approximately 7.5. We feel this slight elevation in glycemic level, if it occurs, is reasonable in an effort to prevent hypoglycemia.

Telemedicine capabilities can be used in the deployed or other remote settings in the same manner as during the training period to provide immediate feedback to our soldiers if needed. For instance, identification of stress-induced hyperglycemia during deployment activities would be helpful to mitigate future potential problems. Use of real-time monitoring and other telecommunication technology allows the medical team to connect with the soldier in any location that is accessible by cell phone; it is not common for a soldier to be in an isolated region for long periods of time without such access. Challenging circumstances could arise and a team effort is required to weigh the net benefit for the deployment of any soldier for any given situation. Optimization of current technology enables us to provide the greatest opportunity for the unit commander to best utilize soldiers with type 1 diabetes.

We can also train soldiers who were diagnosed at another location. For instance, we recently trained a Special Forces soldier with type 1 diabetes who was sent to Fort Bragg for two days temporary duty for intensive insulin therapy and remote technology capabilities training. We now periodically monitor this soldier using the Dexcom Follow App (Dexcom, San Diego, CA, USA). Similarly, we can continue to monitor Fort Bragg soldiers who are found fit for duty and then move to another location. With the cooperation of their local medical teams, we can continue full diabetes care for those who desire this arrangement.

Discussion

Our experience at Fort Bragg, North Carolina, does not reflect Department of Defense policy or practices at other military installations. Rather we describe our attempts at optimization of soldier performance and unit readiness when a highly motivated team of soldier, medical staff, and unit support is available. Individualization is key. Each soldier and their military occupational specialty, location of unit, training mission, and deployment must be carefully considered. For instance, are their information technology security concerns for use of sensor technology, let alone real-time transmission to a medical team? Even if all current capabilities are accessible, is it overall in the best interest of the unit particularly during deployment to utilize a soldier with type 1 diabetes? What about extremes of environment? For instance, we had a soldier’s pump fail during deployment and we determined it was due to dust/sand during a particular weather pattern; use of a shower bag solved the problem. What about resupply issues particularly with regard to insulin in the improbable but possible event of capture by the enemy? Finally, is the soldier capable of maintaining adequate control to prevent acute and long-term complications? These are all significant and serious considerations made on a case-by-case basis that involve shared decision making between the soldier and their family, medical team, and unit.

Conclusion

We describe possible but not necessarily practical nor generalizable approaches for a soldier diagnosed with type 1 diabetes. None of this would be possible without current advanced technologies. Real-time remote monitoring in particular prepares the active-duty soldier for military duty and successful life pursuits. Use of these current technologies has allowed us the opportunity to keep our best and motivated soldiers ready to serve their country when duty calls.