Diabetes Mellitus. Melissa Meredith M.D. Diabetes Mellitus

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1 Melissa Meredith M.D. Diabetes mellitus is a group of metabolic diseases characterized by high blood glucose resulting from defects in insulin secretion, insulin action, or both Diabetes is a chronic, complicated disease with potentially devastating consequences when not managed appropriately Uncontrolled diabetes is the leading cause of blindness, kidney failure, and non-traumatic amputations in the U.S. 2-4 fold increase in risk of cardiovascular disease 7 th leading cause of death in the U.S. (though underestimated) 1

2 Distribution of Glycemic Abnormalities in US 8.3 % of US Population has diabetes Diagnosed type 1 diabetes ~1.0 million Undiagnosed diabetes 7 million Additional 79 million with prediabetes Diagnosed type 2 diabetes 18.8 million CDC. Available at: ADA. Facts and Figures. Available at: Number and Percentage of U.S. Population with Diagnosed Diabetes, CDC s Division of Diabetes Translation. National Diabetes Surveillance System available at 2

3 Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes Obesity (BMI 30 kg/m 2 ) No Data <14.0% % % % >26.0% Diabetes No Data <4.5% % % % >9.0% CDC s Division of Diabetes Translation. National Diabetes Surveillance System available at The good news Majority of costs of diabetes are related to micro and macrovascular complications Studies show that controlling diabetes can prevent or significantly reduce the complications of diabetes It is essential that people with diabetes have access to health insurance that covers diabetes education, health care visits, medications, and diabetes supplies The majority of people with diabetes are employed and a supportive work environment will promote optimal management of their disease and thus make them more productive and less costly The old adage, pay me now, or pay me later seems appropriate 3

4 Relative Risk Alliance Learning Circle: Adding up the Costs of Diabetes Glycemic Control: Effect on Microvascular and Macrovascular Complications Each 1% fall in A1C means a risk reduction of: 21% for any diabetes-related endpoint P< % for diabetes-related death P< % for all-cause mortality P< % for myocardial infarction P< % for stroke P= % for peripheral vascular disease * P< % for microvascular disease P< % for cataract extraction P< *Lower extremity amputation or fatal peripheral vascular disease. Stratton IM et al. BMJ. 2000;321: Relative Risk of Progression of Diabetic Complications as a Function of Mean A1C* A1C *Based on DCCT data Diabetic retinopathy Nephropathy Severe nonproliferative or proliferative retinopathy Neuropathy Microalbuminuria Reprinted with permission from Skyler J. Endocrinol Metab Clin North Am. 1996;25:243 4

5 Targets for Diabetes Treatment Biochemical Index ADA* Goal ACE *Goal A1c <7%* 6.5% Preprandial glucose mg/dl <110 mg/dl Peak postprandial glucose <180 mg/dl 2-Hr postprandial glucose (2-hr PG) *2010 American Diabetes Association (ADA) guidelines suggest individualizing the A1c goal Based on measurements of plasma glucose. *American College of Endocrinology (ACE). Endocr Pract. 2002;8(suppl 1):5-11. ADA. Diabetes Care. 2004;27(suppl 1):S15-S35. <140 mg/dl Type 1 Diabetes Type 1 diabetes is an autoimmune disease, with destruction of the insulin producing ß- cells of the pancreatic islets- absolute insulin deficiency People with type 1 diabetes are absolutely dependent on insulin injections to survive Majority will use multiple daily injections (typically before each meal/snack) or insulin pump therapy To best manage their diabetes, they need to check blood sugars regularly 5

6 Insulin Action Glucose (mg/dl) Insulin (µu/ml) Alliance Learning Circle: Adding up the Costs of Diabetes Physiologic Insulin Secretion 24-hr Profile Basal Insulin Breakfast Lunch Dinner AM Time of Day PM Basal Glucose Skyler JS. In: DeFronzo RA, ed. Current Therapy of. St. Louis: Mosby- Year Book; 1998: ; Galloway JA, Chance RE. Horm Metab Res. 1994;26:591 Basal/Bolus Treatment Program With Rapid- and Long-Acting Analogs Breakfast Lunch Dinner Rapidacting Rapidacting Rapidacting Glargine or detemir 4:00 8:00 12:00 16:00 20:00 24:00 4:00 Time Adapted with permission from Leahy JL. In: Leahy J, Cefalu W, eds. Insulin Therapy. New York: Marcel Dekker Inc.; 2002:87; Nathan DM. N Engl J Med. 2002;347:1342 8:00 6

7 Type 2 Is a progressive disease caused by decreased insulin secretion and increased insulin resistance Can be treated with diet/exercise, oral medications and/or insulin Depending on the treatment, they may need little or no accommodations in the workplace People on insulin or certain medications that can cause hypoglycemia will need to monitor blood sugars Diabetes in the workplace The majority of people with diabetes can perform the majority of jobs effectively and safely ADA position: Any person with diabetes, whether insulin or non-insulin treated, should be eligible for any employment for which s/he is otherwise qualified People with diabetes may need some accommodations on the job in order to perform their work effectively and safely There may be daily accommodations or accommodations for dealing with chronic complications of the disease 7

8 Daily accommodations Testing blood glucose Typically will need to check before meals/snacks May need short breaks to check if feeling a low blood sugar reaction or high blood sugar Only takes a few minutes and can usually be done wherever the employee is located without putting other employees at risk Employees should not be limited in where they can check sugars In some settings, employers may prefer to offer a private or nearby location for testing Daily accommodations Administering insulin Employees may need short breaks to administer insulin when it is needed- usually before meals/snacks or if glucose abnormally high It can be safely administered wherever the employee happens to be The employee may need somewhere to store insulin and supplies if work conditions (such as extreme temperatures) prevent keeping them with the employee 8

9 Daily accommodations Food and drink Employees may need access to food or drink during the work day This is particularly important for eating to treat a low blood sugar or drinking if sugars are high Employees should be able to eat or drink if needed at their work station unless it would pose a hazard or safety issue Employees should be allowed to keep a glucose source on their person Depending on type of treatment, some employees may need to eat at specific times of the workday Daily accommodations Leave employees may need leave or a flexible work schedule to accommodate medical appointments (average 5 per year for wellcontrolled patients without complications) May need to miss work for unexpected events e.g. severe hypoglycemia or illness Work schedules such as rotating or split shifts may make it difficult for some employees to effectively manage their diabetes 9

10 Hypoglycemia The biggest concern and safety risk is development of hypoglycemia (low blood glucose) Occurs mainly in people with type 1 diabetes or type 2 on insulin and certain medications Most reactions are mild and easily treated Breaks of minutes may be needed to treat Severe hypoglycemia (employee requires assistance to treat) is a safety issue for the employee and coworkers An isolated episode of severe hypoglycemia does not automatically make employee unsafe to perform job Best way to avoid hypoglycemia is to allow employees to immediately monitor blood sugar as needed and follow other accommodations as listed Accommodating complications of diabetes Some employees may need work modifications for chronic complications to be able to remain productive: Vision impaired employees may benefit from big screen computer or other visual aids Employees with significant neuropathy may not be able stand for long periods or be exposed to extreme temperatures Employees with renal failure may need flexibility to take time off for dialysis These accommodations will need to be individualized for each employee 10

11 Diabetes in the workplace Not every individual with diabetes will be qualified for or able to perform every available job If there is any concern about safety or ability of the employee to effectively perform their job due to diabetes or its complications, employee should be referred to a diabetes specialist for thorough evaluation and recommendations. 11

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