Q&A: How adults with type 1 diabetes can become commercial airline pilots
Key takeaways:
- In November 2019, the FAA began allowing adults with insulin-treated type 1 diabetes to become commercial pilots.
- Pilots with type 1 diabetes must use a CGM and fulfill strict glycemic control requirements.
Data from the Barbara Davis Center for Diabetes at University of Colorado show pilots with type 1 diabetes are not just thriving in the air, but also with their diabetes management.
In November 2019, a change to Federal Aviation Administration regulations permitted people with insulin-treated type 1 diabetes to receive first-class and second-class medical certificates, allowing adults with type 1 diabetes to fly commercial airplanes in the U.S. for the first time. In an e-letter published in Diabetes Care, researchers from the Barbara Davis Center for Diabetes shared data with 1 year of follow-up from six pilots with type 1 diabetes who earned their first-class medical certification.
Adults with type 1 diabetes who wish to earn a first-class or second-class medical certificate from the FAA must fulfill several requirements, including receiving care from a board-certified endocrinologist, using a continuous glucose monitor for at least 6 months prior to certification and providing ambulatory glucose profile reports that shown consistent glycemic control with minimal excursions. Some of the glycemic control requirements detailed in the Diabetes Care letter include a CGM wear time of 90% or more, a time in range with glucose between 70 mg/dL to 180 mg/dL of 70% or greater and a time below range with glucose of less than 70 mg/dL of less than 4%.
The six pilots had a mean HbA1c of 5.9% at the time of certification and 6.3% at 1 year and a mean time in range of 88% at certification and 88.8% at 1 year. Time below range was less than 2% at certification and 1 year, and none of the pilots had a severe hypoglycemia event. No adverse events related to diabetes were reported during a flight.
Halis Kaan Akturk, MD, associate professor of medicine and pediatrics at the Barbara Davis Center for Diabetes at University of Colorado, said his team wanted to provide real-world evidence of how pilots can manage their type 1 diabetes while also succeeding in their career.
“We wanted to give a message to people with type 1 diabetes that you can be a pilot right now,” Akturk told Healio. “You don’t need to cancel your dreams of flying. It gives people lots of confidence that with hypoglycemia avoidance, with diabetes technology and strict glycemic control, you can follow your dreams of flying.”
Healio spoke with Akturk about the challenges pilots with type 1 diabetes face, the requirements pilots must fulfill to receive their medical certificate, and the role diabetes technology plays in helping pilots maintain glycemic control.
Healio: Why did you decide to publish this e-letter on managing type 1 diabetes as a commercial airline pilot?
Akturk: Here at the Barbara Davis Center, we have a program in the adult clinic for pilots with type 1 diabetes, or people who want to be pilots. Previously, if you had diabetes and if you were using insulin, you were not allowed to [be a commercial pilot]. In November 2019, the FAA made some new rules and now they give first- and second-class medical certificates to people with insulin-treated diabetes, type 1 or type 2, but with some strict rules. Our center has a program for the pilots. The FAA has a list of [requirements] on its website, and we follow that.
Healio: Why did the FAA previously have restrictions for people with diabetes?
Akturk: Historically, hypoglycemia and other diabetes-related complications may have been a problem. People were scared of certifying a pilot with type 1 diabetes because they can get hypoglycemia [while] flying.
Now, the use of diabetes technologies — and continuous glucose monitors especially — made a huge change in the field. The FAA now requires that [pilots] have to be using a CGM and preferably an automated insulin delivery device. There are some strict rules that you have to be managing diabetes very well, receive a physical and regular follow-ups with a board-certified endocrinologist. If you prove that you are not having severe hypoglycemia, you are meeting goals to minimize hypoglycemia and you have really good glycemic control, you can be a commercial airline pilot.
Healio: What is the biggest challenge pilots with insulin-treated type 1 diabetes face with their diabetes management?
Akturk: There are a couple of challenges. One is hypoglycemia response. When you have hypoglycemia, your response to any situation changes. You can be unconscious, you can have confusion, you cannot make decisions and other things. But if you are using the best technologies, the risk for having these complications is minimized by a lot. And when you are using automated insulin delivery or CGM, these [complications] occur much less frequently. When you are a pilot, you know you only have one other person with you in the cockpit. There are no other people that can help you.
The other problem is that there are recent papers published that found insulin pumps can have some bubbles form because of the atmospheric pressure changes, so they could underdeliver or overdeliver insulin. In one study, [an insulin pump] overdelivered in a 20-minute ascent and underdelivered during descent. This is theoretically proven, and there are recently published data on that. But we have passengers, frequent fliers and pilots with type 1 diabetes using insulin pumps. [The pilots] haven’t had any clinical problems so far and we have followed these people for over 1 year. They are doing just fine.
We just want to emphasize that 6 to 7 years ago, we were saying if you have type 1 diabetes, you can do anything but be a pilot. Now, people with type 1 diabetes can be a pilot, too.
Healio: Some of the glycemic control data you shared on the pilots attending your center looked strong. Is that in part because of the strict FAA requirements?
Akturk: These people have to meet their requirements to keep their job. I realized that pilots are very punctual people for their appointments, they never miss. They are also very detailed-oriented people, maybe because of their personality, maybe because of their job, maybe because of their training.
Some pilots had previously been a pilot, were diagnosed with type 1 diabetes and had to stop [flying]. Then they gained their certificate again [after the FAA regulation changes]. We have a couple of people like this. Most of them had never flown before, they went through pilot school and now they are pilots. That’s two different people, but both of these groups have personalities that are the same. They follow very strict diabetes control, and they take care of themselves really well, because they have to meet these criteria.
Healio: How much does CGM and automated insulin delivery benefit pilots with type 1 diabetes?
Akturk: The FAA requires the use of a CGM. Insulin pump use or automated insulin delivery system use is not a requirement, but CGM use is. Pilots have to use CGM more than 6 months before [flying], and they have to document that, download the data and submit that [to the FAA].
Pump use is not a requirement, but most pilots use [automated insulin delivery] because it makes things a little bit better. It is another layer of protection for hypoglycemia.
There are some limitations for them because some of the data comes to their phone. They may have to carry another receiver because their phone may not have a signal. There are different obstacles they may experience, but overall, they are doing fine.
Healio: What is the take-home message for airline passengers?
Akturk: We’re telling the public a message about diabetes stigma. Maybe you just flew yesterday, your pilot had type 1 diabetes, and you didn’t even know. These people with type 1 diabetes are flying, and everything is good. There are rules and regulations, so there is no point to have stigma for people with diabetes.
References:
- Garden GL, et al. Diabetologia. 2024;doi:10.1007/s00125-024-06295-1.
- Karakus KE, et al. Diabetes Care. 2025;doi:10.2337/dc25-0025.
For more information:
Halis Kaan Akturk, MD, can be reached at halis.akturk@cuanschutz.edu; X (Twitter): @drhkakturk.
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