The integration of diabetics into Industry poses a significant challenge to Industry, especially type I diabetics. Up until a few decades ago, fear and ignorance of diabetes, coupled with lack of awareness and education by the public and patients led to diabetics being excluded from the work force.
The introduction of MIT (multiple injection therapy) regime of insulin and newer oral hypoglycaemic medication led to better management of diabetes and a good level control.
Hence Type II Diabetics are capable of doing most jobs, with minimal disruption of their lives.
Diabetics in the U.K. are protected via the (Disability Discrimination Act) D.D.A. of 1995, against unfair discrimination in the workplace.
However some jobs are barred to type I diabetics (those requiring insulin).
This article deals with the occupational aspects of Diabetics.
The role of occupational health in diabetes management
Diabetes mellitus is one of the most common non communicable diseases in the world, with a greater proportion of cases arising in the working age population. There are up to 2.3 million people with diabetes in the UK, and an estimated 750,000 who have the condition but don't know. Many of these are likely to be in work1.
There are two major types of diabetes. The causes and risk factors are different for each type:
• Type 1 diabetes can occur at any age, but it is most often diagnosed in children, teens, or young adults. In this disease, the body makes little or no insulin. Daily injections of insulin are needed. The exact cause is unknown.
• Type 2 diabetes makes up most diabetes cases. It most often occurs in adulthood. However, because of high obesity rates, teens and young adults are now being diagnosed with it. Many people with type 2 diabetes do not know they have it2.
Prevention
Prevention of diabetes mellitus includes lifestyle changes for those who are high-risk by eating a healthy diet and regular exercise leading to weight loss. High risk individuals are likely to be overweight, over 40 years of age, and have other relatives who have been diagnosed with the condition. After being diagnosed the treatment of diabetes mellitus helps to keep levels of blood glucose consistent so less complications will occur. Controlling blood pressure, cholesterol, triglycerides, and weight are vital components for successful treatment. Risks of developing heart, kidney, eye, and nerve disease can be reduced when blood sugar levels are moderately controlled. Extended high glucose levels over a prolonged period will have damaging effects to the body because of too much sugar in the bloodstream. The effects of high glucose can cause damage to blood vessels leading to heart disease, stroke, and vision loss. High blood sugar can cause bleeding in the eye vessels but laser therapy can reduce the risks of vision loss.
The role of the OH physician
Managers work in partnership with occupational physicians and require guidance on whether employees can remain in a particular job or whether they need to be redeployed. Some occupations have tightly defined fitness standards to allow work to be carried out safely. A sound opinion about these standards allows for a careful match between the employee's abilities and health whilst observing statutory requirements. This is especially true for the fitness assessments required in military employment. Periodic medical assessments in the transportation industry may reveal occult diabetes before it has an impact on employee health and safety.
Diabetic employees need to be assessed for the likelihood of sudden incapacity. Examples include an episode of hypoglycaemia, sudden cardiovascular event or loss of vision. Risk assessments need to be done in safety critical environments. Where control measures cannot be put in place then work should be restricted.
Legal issues
The Driver and Vehicle Licensing Agency restricts diabetics on insulin from holding Group II licenses and also recommends that they should not drive emergency vehicles due to the risk of sudden incapacity from hypoglycaemia1. Similar restrictions are applied to train drivers but not all pilots on insulin3. This is because aircraft have advanced automatic safety systems and, usually, two pilots.
Disability legislation4 requires consideration to be given to reasonable adjustments being made to the workplace. It does not require that adjustments for the disabled employee are made at all costs. If the disabled employee could endanger him or herself or others in the workplace then it is in the best interests of all concerned for him/her not to be there. Some environments may allow for the provision of equipment to assist with low vision and impaired sensation. However, for a driver or a pilot good vision and normal sensation are important.
Diabetes is a long-term condition, a true chronic illness. A diabetic employee may meet the required fitness standard at induction or at diagnosis, but this may change as complications develop. For these reasons diabetic employees in hazardous work need to be monitored regularly by the occupational health department. If a diabetic's own GP has not carried out the necessary blood tests then the OH appointment is an opportunity to ensure that the necessary monitoring and education take place.
The OH appointment may need to include all elements of relevant history, lifestyle assessment, risk profiling and physical examination. Decision support tools and risk profile software allied to patient education materials are important adjuncts to this.
Referral routes
all diabetics should be encouraged to register with appropriate primary care services. Not all will do this, citing work and travel patterns as obstacles. Indeed, for those in employment, OH may provide the main healthcare service. Close liaison between all practitioners caring for the diabetic employee is important, with the OH physician taking the role of facilitator.
For advice on medication and treatment, OH physicians can refer to GPs or specialists. Employees whose absence has a significant financial impact on a company may find that their employer will fund referrals to ensure a rapid return to work. A return to work in a particular role may be an inducement to help patients achieve monitoring targets.
In summary, Diabetics who are well controlled and uncomplicated make good employees and present with minimal risks in employment and studies have shown diabetics to have good sick leave records, comparable to their non-diabetic colleagues.
The HCW (Health Care Worker) must exercise constant vigilance for complications in Diabetics, especially sight threatening retinopathy, neuropathy, Ischemic Heart Disease, Nephropathy and Cerebro-vascular disease.
References:1- Diabetes UK, Research charity, at: http://www.diabetes.org.uk/
2- National Center for Biotechnology Information, U.S. National Library of Medicine, NML,
3- NHS, Guidelines For Insulin Adjustment In Primary Care, January 2010
4- The Equality Act 2010 and Disability Guide, August 2010, at: http://www.cardiff.ac.uk
