Soldiers with Diabetes in Theater Increase Clinicians’ Disease Management Challenges

by U.S. Medicine

November 11, 2012

By Annette M. Boyle

BETHESDA, MD — The Army is retaining an increasing number of personnel with diabetes, and, despite directives to the contrary, these soldiers may be deployed to active war zones where typically recommended methods for managing the disease might create more problems than they solve.

“Medical evaluation board decisions have changed over the last 10 years, so that most soldiers who develop diabetes while on active duty are now retained on active duty,” said Medical Corps Col. Robert A. Vigersky, MD, director of the Diabetes Institute at Walter Reed National Military Medical Center and professor of medicine at the Uniformed Services University of the Health Sciences.

The boards generally “recommend that those on medications that potentially can cause hypoglycemia or those that might put a soldier at risk if dehydrated not be deployed to active war zones,” noted Vigersky. “Many commanders will override that recommendation and take that soldier into theater with their unit,” he adds. While many diabetics who are deployed will have supportive roles in fixed facilities with access to ongoing medical care, others will be in riskier situations.

For them, managing diabetes might involve challenges unknown to stateside servicemembers. Meters for monitoring blood sugar are not validated in extreme conditions, such as desert summers, and insulin might become denatured and inactivated in high heat. In addition, soldiers on extended patrol or performing certain hazardous duties might not have access to food on the regular intervals most conducive to control of blood-glucose levels.

In these situations, a diabetic soldier cannot obtain food to counteract hypoglycemia if it develops and might develop “cognitive impairment, behavioral changes or go into a coma and die,” Vigersky cautioned. “We try to advise our soldiers about these issues and what precautions to take to ameliorate them.”

Soldier serving in Kuwait checks his blood sugar levels in 2007.
Photo by Spc. Wesley Landrum.

Focus on Safety

During deployment, preventing hypoglycemia must be the first priority. “They’re going to be deployed for a limited time period. The focus should be on keeping them safe, rather than maintaining perfect control” of blood-glucose levels, Vigersky maintains.

The Veterans Administration/Department of Defense Clinical Practice Guidelines for the Management of Diabetes Mellitus recommends a target glycated hemoglobin (HbA1c) level of less than 7% for younger patients with uncomplicated diabetes. Metformin is generally the drug of choice, with insulin recommended for patients who have HbA1c levels above 10% initially or have difficulty controlling their blood-glucose levels on other medications.

In a war zone, however, Vigersky recommends a very different course of treatment. “Stay away from insulin as much as possible [because of the risk of hypoglycemia.] Metformin may be OK, but I worry that if a soldier becomes dehydrated, renal function could be dangerously impaired.”

Instead, Vigersky advises medical providers in theater to consider using thiazolidinediones (TZDs) or oral dipeptidyl peptidase-4 (DPP-4) inhibitors, as both classes moderately reduce blood-glucose levels without posing a significant risk of hypoglycemia. While glucagon-like peptide-1 (GLP-1) agonists also do not cause hypoglycemia, they are delivered by injection and “no one has a clue about their stability in those [extreme] environments,” he pointed out.

Managing diabetes among active-duty servicemembers is likely to become an increasingly common issue for providers.
While a 2009 study published in Medical Surveillance Monthly Report (MSMR) found no increase in the incidence of diabetes in the 10-year period from 1997 to 2007, Vigersky challenges those findings.

“We think that is not reflective of what is really going on,” he said. As the report shows, “the incidence of diabetes is five times higher among those 30 to 40 years old than those 20 to 30 years of age. We certainly see a lot of overweight and obese soldiers in the later years of their careers developing diabetes. Seeing that obesity rates go hand in hand with increasing incidence of diabetes, it wouldn’t be surprising to find that we haven’t got an accurate count.”

The MSMR study attributed the reportedly low rate of diabetes in part to height/weight and physical fitness standards. 

Vigersky doesn’t see those standards as particularly protective, however, noting, “We see soldiers yo-yoing — dieting twice a year to meet weigh-in goals. Others have waivers of injuries or medical illnesses that allow them to keep a higher weight.”

Those views align with a 2001 study published in Diabetes Care that reported “medical surveillance of the U.S. military indicates that the incidence of all types of diabetes is similar to that in the civilian population (1.9 vs. 1.6 cases per 1,000 person-years) despite weight and fitness standards.” That report noted that as type 2 diabetes is a preventable disease, “it is of concern that it is occurring in this population of younger and presumably more fit individuals.”

Focus on Prevention

Efforts to keep diabetes rates down among active-duty servicemembers focus on prevention. “Most medical treatment facilities have programs for those with pre-diabetes — soldiers with a very high likelihood of developing diabetes in the next five years — and for those newly diagnosed that help with nutrition, diet, exercise, and general lifestyle changes,” Vigersky said.

In addition, the Diabetes Institute at Walter Reed has 12 studies under way looking for ways for patients and providers to control diabetes. On the provider level, one is evaluating the use of artificial intelligence that applies computer algorithms to better manage patients using blood-sugar levels and other laboratory results, plus current medications.

On the patient side, a study published in Diabetes Care in January reported excellent results for patients who wore a continuous glucose monitor that reports blood-sugar levels every five minutes on a personal digital assistant (PDA)-like device. Study participants who used the device for three months achieved a reduction of about 1% in blood-glucose levels in the first two weeks and sustained that reduction for a year post-study.

Patients “learned what caused sugar to go up and how to better manage it. Now we’re applying the same technology to pre-diabetics so they can see in real time what their blood sugar is doing in response to what they’re doing or eating,” said Vigersky. “This is cutting-edge research, and the benefits will extend far beyond the military.”

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