Scuba diving, snorkeling, and swimming with diabetes (and #OpenAPS)

tl;dr – yes, you can scuba dive with diabetes, snorkel with diabetes, and swim with diabetes! Here’s what you need to know.

I meant to write this post before I left for a two-week Hawaii trip, and since I answered about a question a day on various platforms as I posted pictures from the trip, I really wish I had done it ahead of time. Oh well. :) I especially wish someone had written this post for me 2 years ago, before my first scuba dive, because I couldn’t find a lot of good information on the practicalities of good approaches for dealing with all the details of scuba diving with diabetes and an insulin pump and CGM and now closed loops. Scuba diving, snorkeling, and swimming with diabetes are actually pretty common, so here are a few things to keep in mind/tips from me, before diving (pun intended) into some explanations of what I think about for each activity diabetes-wise.

scuba_diving_with_diabetes_tips_water_activities_by_Dana_M_Lewis

General tips for water activities when living with diabetes:

  1. Most important: be aware of your netIOB going into the activity. Positive netIOB plus activity of any kind = expedited low BG. This is the biggest thing I do to avoid lows while scuba diving or snorkeling – trying to time breakfast or the previous meal to be a few hours prior so I don’t have insulin peaking and accelerated by the activity when I’m out in the water and untethered from my usual devices.
  2. Second most important: CGM sensor and transmitter on your body can get wet (shower, pools, hot tubs, oceans, etc.), but keep in mind it can’t read underwater. And sometimes it gets waterlogged from short or long exposure to the water, so it may take a while to read even after you get it above water or dry off. And, historically I’ve had sensors come back and the CGM will sometimes read falsely high (100-200 points higher than actual BG), so exercise extreme caution and I highly recommend fingerstick testing before dosing insulin after prolonged water exposure.
  3. Know which of your devices are waterproof, watertight, etc. Tip: most pumps are not waterproof. Some are watertight*. The * is because with usual wear and tear and banging into things, small surface cracks start showing up and make your pump no longer even watertight, so even a light splash can kill it. Be aware of the state of your pump and protect it accordingly, especially if you have a limited edition super special super rare DIY-loopable pump. I generally take a baggie full of different sized baggies to put pump/CGM/OpenAPS rig into, and I also have a supposedly waterproof bag that seals that I sometimes put my bagged devices into. (More on that below).
    1. And in general, it’s always wise to have a backup pump (even if it’s non-loopable) on long/tropical/far away trips, and many of the pump companies have a loaner program for overseas/cruise/tropical travel.
  4. Apply sunscreen around your sites/sensors because sunburn and applying or removing them hurts. However, as I learned on this trip, don’t do TOO much/any sunscreen directly on top of the adhesive, as it may loosen the adhesive (just surrounding the edges is fine). I usually use a rub sunscreen around the edges of my pump site and CGM sensor, and do the rest of my body with a spray sunscreen. And pack extra sites and sensors on top of your extras.

Why extras on top of your extras? Because you don’t want to have a vacation like I did where I managed to go through 5 pump site catastrophes in 72 hours and run out of pump sites and worry about that instead of enjoying your vacation. Here’s what happened on my last vacation pump-site wise:

  • Planned to change my site the next morning instead of at night, because then I would properly use up all the insulin in my reservoir. So I woke up, put in a new pump site (B) on my back hip, and promptly went off to walk to brunch with Scott.
  • Sitting down and waiting for food, I noticed my BG was rocketing high. I first guessed that I forgot to exit the prime screen on the pump, which means it wasn’t delivering any insulin (even basal). Wrong. As I pulled my pump off my waist band, I could finally hear the “loud siren escalating alarm” that is “supposed” to be really audible to anyone…but wasn’t audible to me outside on a busy street. Scott didn’t hear it, either. That nice “siren” alarm was “no delivery”, which meant there was something wrong with the pump site and I hadn’t been getting any insulin for the last hour and a half. Luckily, I have gotten into the habit of keeping the “old” pump site (A) on in case of problems like this, so I swapped the tubing to connect to the “old” site A and an hour or so later as insulin started peaking, felt better. I pulled site B out, and it was bent (that’s why it was no delivery-ing). I waited until that afternoon to put in the next pump site (C) into my leg. It was working well into dinner, so I removed site A.
  • However, that night when I changed clothes after dinner, site C ripped out. ARGHHHH. And I had removed site A, so I  had to put on another site (D). Bah, humbug. Throw in someone bumping a mostly-full insulin vial off the counter and it shattering, and I was in one of my least-pleased-because-of-diabetes moods, ever. It was a good reminder of how much a closed loop is not a cure, because we still have to deal with bonked sites and sites in general and all this hoopla.
  • Site D lasted the next day, while we went hiking at Haleakala (a 12.2 mile hike, which was amazing that neither my site or my sensor acted up!). However, on the third day in this adventure, I put on sunscreen to go to the beach with the whole family. When we came back from the beach, I went to remove my cover up to shower off sand before getting into the pool. As my shirt came over my head, I saw something white fly by – which turned out to be 4th pump site, flying around on the end of the pump tube, rather than being connected to my body. There went Site D. In went my fifth site (E), which I tackled down onto my body with extra flexifix tape that I usually use for CGM sensors because I. Was. Fed. Up. With. Pump. Sites!
  • Thankfully, site E lasted a normal life and lasted til I got home and did my next normal site change, and all is back to normal.

Lessons learned about pump sites: I repeat, don’t sunscreen too much on the adhesive, just sunscreen AROUND the adhesive. And pack extras, because I went through ~2 weeks of pump sites in 3 days, which I did not expect – luckily I had plenty of extra and extras behind those!

Now on to the fun stuff.

Scuba Diving with diabetes:

  • 2 years ago was my “Discovery” dive, where you aren’t certified but they teach you the basics and do all the equipment for you so you just do some safety tutorials and go down with a guide who keeps you safe. For that dive, I couldn’t find a lot of good info about scuba diving with diabetes, other than logical advice about the CGM sensor not transmitting under water, the receiver not being waterproof, and the pump not being waterproof. I decided to try to target my BG in advance to be around 180 mg/dl to avoid lows during the dive, and for extra safety eat some skittles before I went down – plus I suspended and removed my pump. Heh. That worked too well, and I was high in the mid-200s in between my two dives, so I found myself struggling to peel my wetsuit off in between dives to connect my pump and give a small bolus. The resulting high feeling after the second dive when my BG hadn’t re-normalized yet plus the really choppy waves made me sea-sick. Not fun. But actually diving was awesome and I didn’t have any lows.
    • Pro tip #1 for scuba diving with diabetes: If you can, have your pump site on your abdomen, arm, or other as-easy-as-possible location to reconnect your pump for between-dive boluses so you don’t have to try to get your arm down the leg of your wetsuit to re- and disconnect.
  • I decided I wanted to get PADI certified to scuba dive. I decided to do the lessons (video watching and test taking) and pool certification and 2/4 of my open water dives while on a cruise trip last February. Before getting in the pool, I didn’t do anything special other than avoid having too much (for me that’s >.5u) of netIOB. For the open water dives at cruise ports, I did the same thing. However, due to the excitement/exertion of the first long dive, along with having to do some open water safety training after the first dive but before getting out (and doing my swim test in choppy open water), I got out of the water after that to find that I was low. I had to take a little bit longer (although maybe only 10 extra minutes) than the instructor wanted to finish waiting for my BG to come up before we headed out to the second dive. I was fine during and after the second dive, other than being exhausted.
    • Pro tip #2 for scuba diving with diabetes: Some instructors or guides get freaked out about the idea of having someone diving with diabetes. Get your medical questionnaire signed by a doctor in advance, and photocopy a bunch so you can take one on every trip to hand to people so they can cover themselves legally. Mostly, it helps for you to be confident and explain the safety precautions you have in place to take care of yourself. It also helps if you are diving with a buddy/loved one who understands diabetes and is square on your safety plan (what do you do if you feel low? how will you signal that? how will they help you if you need help in the water vs. on the boat, etc.?). For my training dives, because Scott was not with me, I made sure my instructor knew what my plan was (I would point to my arm where my sensor was if I felt low and wanted to pause/stop/head to the surface, compared to the other usual safety signals).
  • This past trip in Hawaii I was finishing off a cold at the beginning, so at the end of the trip I started with a shore dive so I could go slow and make sure it was safe for me to descend. I was worried about going low on this one, since we had to lug our gear a hundred feet or so down to the beach and then into the water (and I’ve never done a shore dive prior to this). I did my usual prep: temp basal to 0 on my pump for a few hours (so it can track IOB properly) and suspend; place it and CGM and OpenAPS rigs in baggies in my backpack; and confirming that my BG was flat at a good place without IOB, I didn’t eat anything extra. We went out slowly, had a great dive (yay, turtles), and I was actually a little high coming back up after the dive rather than low. My CGM didn’t come back right away, so I tested with a fingerstick and hooked my pump back up right away and gave a bolus to make up for the missed insulin during the dive. I did that before we headed off the beach and up to clean off our gear.
    • Pro tip #3 for scuba diving with diabetes: Don’t forget that insulin takes 60-90 minutes to peak, so if you’ve been off your pump and diving for a while, even if you are low or fine in that moment, that missing basal will impact you later on. Often if I am doing two dives, even with normal BG levels I will do a small bolus in between to be active by the time I am done with my second dive, rather than going 3+ hours with absolutely no insulin. You need some baseline insulin even if you are very active.
  • While in Hawaii, we also got up before the crack of dawn to head out and do a boat dive at Molokini. It was almost worth the 5am wakeup (I’m not a morning person :)). As soon as I woke up at 5am, I did an “eating soon” and bolused fully for my breakfast, knowing that we’d be getting on the boat at 6:30amish (peak insulin time), but it’d take a while to get out to the dive site (closer to 7:30am), so it was better to get the breakfast bolus in and let it finish counteracting the carbs. I did, but still ran a little higher than I would have liked while heading out, so I did another small correction bolus about half an hour before I temped to zero, suspended, and disconnected and baggied/bagged/placed the bag up in the no-water-shelf on the boat. I then did the first dive, which was neat because Molokini is a cool location, and it was also my first “deep” dive where we went down to about ~75 feet. (My previous dives have all been no deeper than about ~45 feet.) Coming back onto the boat, I did my usual of getting the gear off, then finding a towel to dry my hands and do a fingerstick BG test to see what I was. In this case, 133 mg/dl. Perfect! It would take us almost an hour for everyone to get back on the boat and then move to dive spot #2, so I peeled down my wetsuit and reconnected my pump to get normal basal during this time and also do a small bolus for the bites of pineapple I was eating. (Given the uncertainties of accuracy of CGM coming out of prolonged water exposure, since they sometimes run 100+ points high for me, I chose not to have the loop running during this dive and just manually adjust as needed). We got to spot #2 and went down for the dive, where we saw sharks, eels, and some neat purple-tailed fish. By the end of the dive, I started to feel tired, and also felt hungry. Those are the two signs I feel underwater that probably translate to being low, so I was the first from our group to come up when we got back from the boat. I got on the boat, removed gear, dried hands, tested, and…yep. 73 mg/dl. Not a bad low, but I’m glad I stopped when I did, because it’s always better to be sure and safe than not know. I had a few skittles while reconnecting my pump, and otherwise was fine and enjoyed the rest of the experience including some epic dolphin and whale watching on the return boat ride back to the harbor!
    • Pro tip #4 for scuba diving with diabetes: You may or may not be able to feel lows underwater; but listening to your body and using your brain to pay attention to changes, about low or not, is always a really good idea when scuba diving. I haven’t dived enough  (7 dives total now?) or had enough lows while diving to know for sure what my underwater low symptoms are, but fatigue + hunger are very obvious to me underwater. Again, you may want to dive with a buddy and have a signal (like pointing to the part of your body that has the CGM) if you want to go up and check things out. Some things I read years ago talked about consuming glucose under water, but that seems above my skill level so I don’t think I’ll be the type of diver who does that – I’d rather come to the surface and have someone hand me from the boat something to eat, or shorten the dive and get back on the boat/on shore to take care of things.

All things considered, scuba diving with diabetes is just like anything else with diabetes – it mostly just takes planning ahead, extra snacks (and extra baggies) to have on hand, and you can do it just like anyone else. (The real pain and suffering of scuba diving in my opinion comes not from high or low BGs; but rather pulling hair out of your mask when you take it off after a dive! Every time = ouch.)

Snorkeling with diabetes:

  • Most of my snorkeling experiences/tips sound very similar to the scuba diving ones, so read the above if you haven’t. Remember:
    • Don’t go into a snorkel with tons of positive IOB.
    • Have easy-access glucose supplies in the outer pockets of your bag – you don’t want to have to be digging into the bottom of your beach bag to get skittles out when you’re low!
    • Sunscreen your back well 😉 but don’t over-sunscreen the adhesive on sites and sensors!
    • Make sure your pump doesn’t get too hot while you’re out snorkeling if you leave it on the beach (cover it with something).
    • You could possibly do baggies inside a waterproof bag and take your pump/cgm/phone out into the water with you. I did that two years ago when I didn’t trust leaving my pump/receiver/phone on shore, but even with a certified waterproof bag I spent more time worrying about that than I did enjoying the snorkel. Stash your pump/gear in a backpack and cover it with a towel, or stick it in the trunk/glove compartment of your car, etc.
    • Remember CGMs may not read right away, or may read falsely high, so fingerstick before correcting for any highs or otherwise dosing if needed.

Swimming with diabetes:

  • Same deal as the above described activities, but with less equipment/worries. Biggest things to think about are keeping your gear protected from splashes which seem more common poolside than oceanside…and remember to take your pump off, phone or receiver out of your pocket, etc. before getting in the water!

Wait, all of this has been about pump/CGM. What about closed looping? Can you #OpenAPS in the water?

    • If you don’t have your pump on (in the water), and you don’t have CGM data (in the water, because it can’t transmit there), you can’t loop. So for the most part, you don’t closed loop DURING these activities, but it can be incredibly helpful (especially afterward to make up for the missing basal insulin) to have once you get your pump back on.

However, if your CGM is reading falsely high because it’s waterlogged, you may want to set a high temporary target or turn your rig off during that time until it normalizes. And follow all the same precautions about baggies/waterproofing your rig, because unlike the pump, it’s not designed for even getting the lightest of splashes on it, so treat it like you treat your laptop. For my Hawaii trip, I often had my #OpenAPS rig in a baggie inside of my bag, so that when my pump was on and un-suspended and I had CGM data, it would loop – however, I kept a closer eye on my BGs in general, including how the loop was behaving, in the hour following water activities since I know CGM is questionable during this time.

I’m really glad I didn’t let diabetes stop me from trying scuba diving, and I hope blog posts like this help you figure out how you need to plan ahead for trying new water activites. I’m thankful for technology of pumps and CGMs and tools like #OpenAPS that make it even easier for us to go climb mountains and scuba dive while living with diabetes (although not in the same day ;)).

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