Slide 1:
Diabetes at Work: Legal and Medical Answers for HR
Pam Allweiss MD,MPH
Shereen Arent JD

Slide 2:
Why are we discussing this?
Epidemic of diabetes
Working population now has many chronic conditions
How do we balance having a workforce, make accommodations for chronic conditions, avoid “discrimination”

Slide 3:
NY times: 12- 26, 2006 COSTS OF A CRISIS: Diabetics Confront a Tangle of Workplace Laws 
A mortgage loan officer in Oregon was denied permission to eat at her desk to stanch her sugar fluctuations, and eventually was fired.
-A Sears lingerie saleswoman in Illinois with nerve damage in her leg quit after being told she could not cut through a stockroom to reach her department.
-A worker at a candy company in Wisconsin was fired after asking where he could dispose of his insulin needles 

Slide 4:
What we have here is a failure to communicate: Open the doors to collaborate

Slide 5:
Crossing the Great Divide: Employers, Health Care Providers, Lawyers and Employees Come Together to Promote Health
    
Slide 6:
The health of a community    impacts the economic health of its businesses 
and Corporations are able to play a unique role in the development of a community’s health and continued vitality
Source: NBGH Kellogg paper

Slide 7:
Know the Language; Multiple ADAs
ADA; American Diabetes Association: Advocacy
ADA; Americans with Disabilities Act

Slide 8:
We Have an Epidemic of 
Diabetes! 
Graph showing steady increase in incidence of diabetes with 1 Million in 1958 to 10 Million in 1998.  A sharp increase between 1993 and 1998 (over 2 million new cases) (National Institutes of Health and Centers for Disease Control and Prevention) 
Slide 9:
Graphic of covers of major news magazines with issues regarding Diabetes featured on the cover (Newsweek and Time)

Slide 10:
21 Million with Diabetes
41 Million with Pre-Diabetes
(Graphic image of an iceberg floating in the water.  Shows how majority of the iceberg is under the water and not visible to the eye.

Slide 11:
Graph showing Diabetes trends in the US 1980-2002:
1980 – Less than 6 million
1990 – Approximately 7 million
1995 – Approximately 8 million
2000 – Approximately 12 million
2002 – Approximately 13 million

Slide 12:
Graph showing obesity trends in the US according to regions of the country 1991, 1996 and 2003: (Body Mass Index equal to or greater than 30 or 30lbs overweight for person 5 feet 4 inches tall)

1991 – Highest incidence in Michigan, West Virginia, Mississippi and Alabama.   Lowest incidence in Washington, Montana, Colorado, Utah, New Mexico and Georgia
1996 – Highest incidence in Majority of Midwest, northeast, mid-atlantic and southern states with exception of Georgia, Maine, New Hampshire.  Majority of western States showing moderate incidence with exception of high incidence in Oregon, Idaho, Nevada and Alaska.
2003 – Significant incidence of obesity in Louisiana, Mississippi, West Virginia and Indiana.  Moderate increase in Western states including Colorado, Utah, Arizona, New Mexico.  Rest of the Country has increased in incidence from 1996.

Slide 13:
Graph showing Adult Trends for Diabetes

Slide 14:
Obesity
Prevalence of obesity increased 61% since 1991.
More than 50% of US adults are overweight.
Only 43% of obese persons are advised to lose weight during checkups.
BME and weight gain are major risk factors for diabetes.

Slide 15:
U.S. Diabetes Prevalence
All Ages, 2005
20.8 million people have diabetes
Diagnosed: 14.6 million people
Type 1 diabetes accounts for 5 – 10%
Type 2 diabetes accounts for 90 – 95%
Undiagnosed: 6.2 million people
Incidence:  1.5 million cases diagnosed in 2005

Slide 16:
Diabetes also means:
2 x the risk of high blood pressure
2 to 4 x the risk of heart disease
2 to 4 x the risk of stroke
 #1 cause of adult blindness 
#1 cause of kidney failure
Causes more than 60% of non-traumatic lower-limb amputations each year
NIDDK, National Diabetes Statistics fact sheet. HHS, NIH, 2005.

Slide 17:
BOTTOM LINE
1/3 of Americans born in 2000 will develop diabetes sometime in their lifetime

Slide 18:
Graph showing U.S. Diabetes Prevalence
20 Years or Older, 2005
20-39 yrs old – approximately 5 percent
40-59 yrs old – approximately 10 percent
60 plus years old – greater than 20 percent

Slide 19:
Graph showing U.S. Diabetes Prevalence
20 Years or Older, by Race/Ethnicity, 2005
Non-Hispanic whites -  8 percent
Hispanic/Latino Americans – 14 percent
Non-Hispanic Blacks -  15.5 percent
American Indiana/Alaskan Natives – 18.5 percent

Slide 20:
EVERY 24 HOURS
New cases – 4100
Deaths – 810
Amputations – 230
Kidney Failure – 120
Blindness – 55
Derived from NIDDK, National Diabetes Statistics fact sheet. HHS, NIH, 2005.

Slide 21:
Estimated Cost of 
Diabetes in U.S.
Total: $132 billion
Direct Medical Cost: $92 billion
Indirect Cost: $40 billion

Slide 22:
What is Diabetes
Not just a “sugar” problem
Interaction of food, insulin, other hormones (glucagon)
Physical activity
Obesity
Pancreatic function
Other commonly associated conditions: hypertension, lipid problems

Slide 23:
Diabetes 101
The complications, not just the diagnosis of diabetes, cause the problems
Diabetes is common, serious BUT treatable
 Not all therapies for type 2  diabetes cause hypoglycemia
Remember that many people are afraid of discrimination and some do not share the diagnosis

Slide 24:
Diabetes: Each Day, A New Drug, Each Day, A New Diagnosis
Earlier diagnosis, Can diabetes be prevented?
Fasting glucose:126mg/dl,
Post glucose load 2h:>200 mg/dl
Impaired fasting glucose:>100 but <126
Impaired glucose Tolerance: >140  but <200

Slide 25:
Types of Diabetes
Type 1: traditionally less than 20 years old, no endogenous insulin, may be 15 or 50 years old, Rx = insulin only
Type 2: traditionally more than 40 years old, multiple problems with insulin secretion and action, may be 15 or 50, Rx may include oral agents and/or insulin

Slide 26:
Characteristics of Type 1 Diabetes
Beta cells of pancreas have pooped out
Etiology questioned auto immune, viral questioned
Question of a Genetic component

Slide 27:
Characteristics of Type 2 Diabetes
Absolute or relative insulin deficiency: impaired beta cell function and/or insulin resistance
Twin components: Fasting hyperglycemia and/or postprandial hyperglycemia
Associated problems: Hypertension, fasting and postprandial dyslipidemia, arteriosclerotic changes

Slide 28:
Therapies
Type 1: Insulin: many types and duration of action. Goal to mimic normal physiology
Type 2: many oral agents. May also use insulin
New agents: incretins, GLP1   

Slide 29:
Consequences of 
Uncontrolled Diabetes
Loss of productivity
Increased direct and indirect health care expenditures
Poorer quality of life for employees 
Possible permanent disability 

Slide 30:
Complications
Eyes
Kidneys
Nerves
Cardiovascular disease and stroke
Randomly controlled studies show that these complications can be prevented or controlled with good blood sugar control but this might involve multiple shots etc
More shots does not mean “worse diabetes”!

Slide 31:
Why Control Diabetes?
Better control translates into fewer complications in eyes and kidneys
Fewer complications translate into fewer days lost to absenteeism and disability, and future savings on health care expenditures

Slide 32:
Complications of diabetes: Issue for disability
Balance between appropriate therapies to PREVENT complications and accommodations such as needles at the worksite, breaks for snacks
Wellness programs to PREVENT  and improve control

Slide 33:
Economic Benefits of Improved Glycemic Control
Workers with better  A1C have fewer days lost to absenteeism*
Fewer days of restricted activity
*Testa et al, JAMA, Nov 1, 1998

Slide 34:
Diabetes and the Workplace- General Considerations
Type of job
Physical activity
Hours
Coworkers
Physical environment

Slide 35:
Type of Job
Desk job
Physically active job
Stress
Supervisor
Handling equipment
Physical requirements
Special license or qualifications

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Physical Activity
Active and less active days
Type of activity: constant vs episodic
Handling moving or hazardous equipment: forklifts, assembly lines, cutting equipment
Lifting required: how much, how frequent

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Physical Environment
Hazards
Working alone or with others
Exposures: need for protective equipment, respirators etc
Location: outside, inside, Near lockers or source of food etc
Heights

Slide 38:
Shift Work
Hours of work: 8, 10, 12, 14 etc
Number of days/week
How often does shift change: weekly, monthly?
Type of shift: day, night, other
Hours of meals and snacks
Source of meals and snacks

Slide 39:
Individual assessment
LEO (Law Enforcement Officers): ACOEM
Avoid blanket bans!
Focus on specific complications: eyes, neuropathy just like other physical conditions such as back pain, repetitive motion injuries etc

Slide 40:
Examples
Box cutter and hypoglycemia
Short term use of insulin in type 2 diabetes in an employee who drives a forklift
Disposal of needles: pens, ADA guidelines
Shift work

Slide 41:
Individual Assessment
Work with health care provider
Education!
Assessment of physical condition
Assessment of therapeutic regimen. Can insulin, for example be adjusted (dose, type, timing) to better control glucose level (avoid hypoglycemia, keep good control)

Slide 42:
Individual Assessment
Accommodation may be short term until glucose levels are stable
Be proactive

Slide 43:
Why pick diabetes for a health promotion intervention at a business?
Costs over $100 billion/year in health care expenditures
Effective interventions promote multiple good outcomes
Loss of productivity due to uncontrolled diabetes
Increased direct and indirect health care expenditures
Poorer quality of life for employees 
Possible permanent disability 

Slide 44:
Why the workplace as a site of disease education?
Unique opportunity for education
Less time away from work
Improves employer-employee relations and shows employer cares about employees

Slide 45:
National Diabetes Education Program: Business and Managed Care Workgroup
What are we?
What do we do?
Why do we do it?

Slide 46:
National Diabetes Education Program (NDEP) Goals www.ndep.nih.gov :
CDC and NIH program formed after evidence showed that better glucose control translated into fewer complications
Public and private partnerships to improve diabetes treatment and outcomes 
Increased public awareness of the seriousness of diabetes, its risk factors, and strategies for preventing diabetic complications

Slide 47:
NDEP Business Health Strategy Workgroup

Slide 48:
Business Health Strategy Workgroup Goals
1)	To increase awareness of the benefits of quality diabetes care among employers, benefits managers and managed care decision makers
2)	To provide employers, health plans and employees with tools and information for incorporating diabetes education programs into the workplace
3)	To promote the value of investing in prevention

Slide 49:
NDEP Business Health Strategy Workgroup:  Who are we?
CDC and NIH
Large and small businesses: GE, GM, Land’s End
Unions
Occupational health professionals
Public health agencies state Diabetes Prevention and Control Programs)
Managed care groups
National associations representing employers, business coalitions and health care insurers 

Slide 50:
www.diabetesatwork.org
Developed to meet the business community’s need for easily accessible, diabetes-focused worksite health information
Users: human resource managers, occupational health professionals, supervisors, wellness coordinators, employees and their family members

Slide 51:
Image of the www.diabetesatwork.org website

Slide 52:
www.Diabetesatwork: Content
General Diabetes Education :
Nutrition, Weight Control, and Physical Activity 
Lesson Plans (English and Spanish)
Fact Sheets (English and Spanish)
Guide to choosing a health plan, developed with AAHP
Supervisor’s guide
NO COPYRIGHT!

Slide 53:
Why Focus a Worksite Health Promotion Program on Diabetes?
Make the link:  Diabetes, heart disease and stroke

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Additional Resources 
Employer showcase
Links to NDEP materials in English, Spanish, Asian and African languages
News You Can Use
Links to information on preventing diabetes and the diabetes and heart disease connection
Federal government agencies and health and business associations Web sites

Slide 55:
Don’t forget about diabetes prevention
Prevent Type 2 diabetes

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Pre-diabetes? 
People with pre-diabetes have blood glucose levels higher than normal but not high enough to be diagnosed with diabetes
At least 54 million U.S. adults age 20 and older have pre-diabetes—which raises their risk for type 2 diabetes and cardiovascular disease
58% of people with pre-diabetes (DPP study) prevented or delayed the onset of type 2 diabetes through lifestyle change 
NIDDK, National Diabetes Statistics fact sheet. HHS, NIH, 2005. 
The Diabetes Prevention Program Research Group. Diabetes Care. 1999;22:623.
NIDDK. http://www.niddk.nih.gov/welcome/releases/8_8_01.htm. 

Slide 57:
Diabetes Prevention Efforts worth every penny
Lifestyle intervention could delay the onset of DM by 11 years
Decrease the risk of developing DM by 20%
QALY (Quality Adjusted Life Years)
Over a lifetime, intensive lifestyle intervention =$8,800 for every QALY saved = very cost effective 
Herman,W,,Cost Effectiveness of lifestyle modification or metformin in preventing type 2 diabetes in adults with impaired glucose tolerance, Ann Int Med, 142: 323-342, March 2005

Slide 58 and 59 
Images of brochure available

Slide 60:
REMEMBER
The lifestyle changes and medical care recommended for diabetes control helps to prevent and control MANY chronic diseases.

Slide 61:
Websites
http://ndep.nih.gov
http://www.cdc.gov/team-ndep
http://www.diabetesatwork.org
http://www.betterdiabetescare.org 
Commercial printer-ready Zip cartridges or CDs also available.   Call 1-800-860-8747
http://www.healthdisparities.net 

Slide 62:
Resources
www.diabetesatwork.org
www.cdc.gov/diabetes
www.ndep.nih.gov
National Business Group on Health www.wbgh.com
National Business Coalition on Health www.nbch.org
American College of Occupational and Environmental Medicine www.acoem.org
American Occupational Health Nurses www.aaohn.org

Slide 63:
Resources
www.cdc.gov/needledisposal, 
Arent S, The Role of Diabetes Health Care Professionals in Diabetes Discrimination Issues at Work and School Diabetes Spectrum 15:217-221, 2002 
Questions and Answers About Diabetes in The Workplace and the Americans with Disabilities Act (ADA)
Job Accommodation Network (http://janweb.icdi.wvu.edu/media/diabetes.html)
www.eeoc.gov/facts/diabetes.html