Good day, ladies and gentlemen, and welcome to the Accommodating Diabetes in the Workplace conference call. At this time all participants are in the listen only mode. Later we will conduct a question-and-answer session and instructions will be given at that time. If anyone should require assistance during the conference, please press star and then zero on your touchtone telephone. As a reminder this conference call is being recorded. I would now like to introduce your host for todays conference Miss Robin Jones, Director of Great Lakes ADA Center. Miss Jones, you may begin.
Thank you and good afternoon to everyone as well as good morning to those joining us from other parts of the country where it still may be morning. We are at the September session for the 2006-2007 Audio Conference Series. We are happy to have you join us today. This is a collaborative effort of the regional DBTAC ADA Centers across the country. There are 10 regional centers and we are happy to be able to bring you a variety of topics throughout the year addressing ADA related issues. We have individuals joining us today in a variety of modes. We have people on the telephone. We have individuals who are using streaming real-time on the internet as well as individuals who are using real-time captioning on the internet. So we have a variety of methods and means by which individuals are participating. This program will be recorded digitally as well as a transcript created which will be later posted within 10 business days following the conclusion of the program on the ADA audio conference website which is www.ada-audio.org and you will be able to find the program under the archived section. So as we get going today, I just like to welcome you to the session which again is titled Accommodating Diabetes in the Workplace. We are very pleased to have two distinguished speakers with us today. We have Pamela Allweiss who is a physician with the University of Kentucky as well as a consultant to the Centers for Disease Control and the National Institute of Health. And we also have Shereen Arent who is the Managing Director of Legal Advocacy at the American Diabetes Association and I will introduce them more formally here in a second. This is a topic that we have heard a lot of interest in across the country. This is an issue that I know our technical assistant centers receive a number of phone calls regarding and as well as requests to address this issue in relationship to our training programs. So we are hopeful that you will find the content of this program valuable today in the work that all of you do. So without further adieu, I am going to go ahead and introduce our speakers and then turn over the session to them. As was indicated by the Operator, we will have a question-and-answer period by which you the participants will have an opportunity to direct questions to our speakers, get some clarification or some additional information that you might want. So I will start by introducing Dr. Allweiss, she is an Endocrinologist, she completed her residency in Internal Medicine at the LA County - USC Medical Center. She had a fellowship in Endocrinology at Cedars Sinai Medical Center in LA and was chief clinical fellow at the Joslin Clinic in Boston. She also has a Masters in Public Health and so she has a variety of all these different backgrounds. She has had an Intergovernmental Practice Agreement with the Centers for Disease Control, Division of Diabetes Translation since 1999 which where she is been working on diabetes education programs in the workplace as part of the National Diabetes Education Program which is a joint CDC and National Institutes on Health program. She did a sabbatical in 2004 with the CDC specifically with the Division of Diabetes Translation, and she is on their Business Team which has a cooperative agreement with organizations like the National Business Group on Health and the National Business Coalition on Health. So she is involved in a number of different areas. She also is working with the University of Kentucky, Department of Family and Community Medicine on developing some collaborative chronic care models for diabetes care in academic settings. So as you can see from her background, it is extremely varied and she is well prepared to be able to talk to us on this particular topic today. Our second speaker is Shereen Arent. She is the Managing Director of Legal Advocacy at the American Diabetes Association. The Associations mission is to prevent and cure diabetes and to improve the lives of people affected by diabetes. It is the nations leading nonprofit health organization providing diabetes research information and advocacy. In her position, she coordinates a nationwide campaign to eliminate discrimination against people with diabetes in employment, education, correctional institutions and places of public accommodation. To accomplish that, she uses innovative approaches and combines education to prevent discrimination, litigation when necessary, addressing legislative and regulatory reform as necessary. Prior to being with the American Diabetes Association, she established the first Equal Employment Opportunity office for the Architect of the Capital, an agency of the Congress. So she has worked with the federal government in different aspects and as a partner at two public interest law firms in the Washington, D.C. area as well as Little Rock, Arkansas. So she has been involved in employment discrimination litigation. She has worked with unions as plaintiffs in employment discrimination class action suits as well. She has also been a clerk in the Court of Appeals and a graduate of the Stanford University and Harvard Law School. So she has obviously a lot of variety in her career. Hers as well as Pamela''s bio is available on the website www.ada-audio.org. So without further ado, Ill go ahead and turn it over and we will begin by hearing from Pamela and then she will turn over to Shereen. So I will go ahead and hand it over to you, Pamela.
Thank you very much and this is an issue close to my heart. I see this happening every single day. So the first group of slides, Slide number 1 says Diabetes at Work: Legal and Medical Answers for HR. I know that our audience is varied. And so we are going to start with that set of slides. So why are we discussing this? Well we have an epidemic of diabetes. And many people in our working populations have chronic conditions. It isn''t something that work sites can ignore or they would not have any employees. 100 million people have some chronic condition and many people have diabetes so we need to see how this can affect the productivity. We need to know how we can effectively place people who might have diabetes, and we will talk again is this a disability or isn''t diabetes a disability? What I want to do in my part of the talk is to give you like a Diabetes 101 and to also look at some of the myths that many people have regarding diabetes. So how do we balance having a workforce and how do we make accommodations for chronic conditions at the same time avoiding discrimination? So let''s look at Slide 3 and certainly this is an issue that has been in the news. In the New York Times last December, there was a headline that said Diabetics Confront a Tangle of Workplace Laws. They were talking about people who had different issues at work because they wanted to control their diabetes so they might have to take time to eat a snack or they might have an issue of taking multiple shots or they may have been told that oh, you have diabetes, you can''t do this job. When in reality, individual assessment might be very, very important. So we know that it is a topic that is very prevalent and as I say, when it makes the New York Times, it has to be important. So we have failure here to communicate. We have to collaborate with the doctors and the lawyers and the employees. We all have to come together to promote health. So if we look at Slide number 6, we see something that was from the National Business Group on Health that said that the health of the community impacts the economic health of its businesses. And corporations are able to play a unique role in the development of the community''s health and vitality. So everybody has to work together. The doctor has to talk to the lawyer who has to talk to the HR person and then we also have all of our people with diabetes who are in the middle of this collaboration. We also have to know the language. We have multiple ADAs. We have the American Diabetes Association. We have the Americans with Disabilities Act. We even have the American Dental Association and the American Dietetic Association. Our talk today is to look at the Americans with Disabilities Act and how the Americans with Diabetes Association can all work together. So we are going to start out with our epidemic of diabetes. On Slide number 8, it shows a slide that from 1958 to 1998, so 40 years, it shows how the number of persons with diabetes has increased dramatically. It has also made the front pages of Time, of Newsweek. And now we know that 21 million people have diabetes but that is only the tip of the iceberg. Another 41 million people have pre-diabetes. Now we all have our soapbox and the term pre-diabetes would consider people who are at risk for developing diabetes. But I don''t like the term borderline diabetes or a touch of sugar because borderline diabetes in my view is like being a little pregnant. You either have abnormal glucoses or you don''t, and people who even have pre-diabetes can also have an increased risk of heart disease and of stroke as well. So we need to look at these people as well. On slide 11, it shows diabetes trends from 1980 to 2002. And, of course, it is just going up dramatically. Now what is one of the reasons? What are some of the reasons? Slide number 12 shows some math that will show the obesity trends among U.S. adults. Now I don''t care if you are in a blue state or a red state, but on these maps, if you are in a red state, that means that over 20% of the population in that state is obese. When you look at Slide 13, those are the diabetes trends among adults in the U.S. And you can almost superimpose the obesity trends and the diabetes trends in the United States. So that certainly our epidemic of obesity can be one of the causes of our epidemic of diabetes. On Slide 14, the prevalence of obesity has increased 61% since 1991. And more than 50% of U.S. adults are overweight. So that we really need to look at people''s BMI and weight gain as a risk factor for developing diabetes. So as I said before, almost 21 million people have diabetes, and about 14, 15 million people we know have diabetes but there are another 6 million people walking around who don''t know that they have diabetes. And the NIH has said that sometimes people might have Type 2 Diabetes for 10 years before they are diagnosed. So many times people present with their complications already and they never even knew that they had diabetes before. Now we also have to look at what diabetes also means. We know that people with diabetes have two times the risk of high blood pressure, of heart disease, of stroke, and it is the number one cause of adult blindness and of kidney failure. It also causes 60% of the non-traumatic lower-limb amputations. So we know that it is a major cause of impairment and of disability. But the bottom line on Slide 17 is that one out of three Americans born in the year 2000 will develop diabetes sometime in their lifetime. And it is our job to be sure that we can give people the tools to control their diabetes so that their outcomes can improve. Slide 18 shows the prevalence of people who are 20 years or older and that is our working population. So as I say, we know that it is a problem. How can we deal with it because we cannot just ignore it. I am going to go to Slide 20, because every 24 hours there are 4,000 new cases diagnosed, 800 deaths, 230 amputations, 120 cases of kidney failure. And as I say, we want to try to improve these numbers. The estimated cost of diabetes in the U.S. is $132 billion with a b, and that includes direct medical costs, but also costs associated with decreased productivity. So I want to talk about what is diabetes so that if we know what it is, we can then control it better. It isn''t just a sugar problem. It is an interaction of food, insulin, other hormones, physical activity, pancreatic function. All of these things come together to cause a problem with blood glucose regulation, high blood pressure, et cetera. Slide 23 is important because it is the complications, not just the diagnosis of diabetes, that can cause many of the problems. Just because a person has diabetes doesn''t mean that that person has all of the complications. And our research has shown that controlling the blood glucose levels can help prevent the complications. That many times people will hear oh, that person has diabetes and automatically may have some preconceived notions on what the person can or cannot do. Diabetes is very common and serious, but very, very treatable. Another myth that many people have is that therapies with diabetes should automatically cause low sugar hypoglycemia. People seem to be very afraid of the possibility of low blood glucose at the work site. Now of course, we don''t want people to have a low blood glucose and become confused. But there are many therapies that dont automatically cause low blood glucose. So we have to look at our preconceived ideas that not all therapies for especially Type 2 Diabetes can cause hypoglycemia. The other thing is that many people are afraid of discrimination and many do not share the diagnosis. There is a study that show that many people do not tell their supervisor that they have diabetes because they are afraid of discrimination. Now many work sites have wellness programs. Well, if people are so afraid to share this information because of discrimination, sometimes we can''t be sure that they will get the help that they need to control their blood glucose, to prevent complications. So we want a work site where people really know the information. So every day, the Slide 24, we have a new day, a new drug, a new diagnosis. We want earlier diagnosis of diabetes because we know if we control it earlier, we can prevent the complications and the eyes and in the kidneys. So I have just posted the definitions of fasting glucose, of over 126 is diabetes. After a person eats their sugar should be less than 200, over 200 means that they have diabetes. We also have a group of people in between. A normal sugar before a person eats should be less than 100. So we have people in between who have a fasting sugar of over 100 but less than 126 and these people have impaired fasting glucose. We also have people with this pre-diabetes who have impaired glucose tolerance. If a person eats 10 little Debbie snack cakes and 10 pieces of fried chicken, et cetera, their sugar really should not go over 140. But let''s say a person has 180, that is not over 200, so they don''t have quote true diabetes but they have impaired glucose tolerance. And we know that if we intervene in this group, and we will talk about this later with diet and physical activity, we can actually prevent many people from developing quote the real diabetes. So the diagnosis is very, very important. I want to talk briefly about types of diabetes. Type 1 Diabetes traditionally people are less than 20. The old word for this Juvenile Type Diabetes. But people can be 15 or 50 and have Type 1 Diabetes. If a person is diagnosed with Juvenile or Type 1 Diabetes at age 15, when the person is age 45, that person does not develop adult-onset diabetes. That person will always have Type 1 Diabetes and will need insulin. At the time, insulin is not the main therapy for Type 1 Diabetes. It is about 10% to 15% of the population. Now Type 2 Diabetes traditionally is over 40 and these people use multiple regimens, pills, insulin, sometimes both, sometimes diet alone will do it, sometimes exercise. That is about 85% of most of the people who have diabetes. Again people can be 15 or 50, and we are seeing an epidemic of adult-onset diabetes even in children. Now, 26 characteristics of Type 1 Diabetes, the beta cells of the pancreas that produce insulin have basically pooped out. Is it viral? Is it autoimmune? Is it environmental? Is there a genetic component? Yes, to all of these things. Now, Slide 27, the characteristics of Type 2 Diabetes. People with Type 2 might not have insulin that is as responsive as should be. So sometimes they need pills, sometimes insulin and Slide 28 shows the different therapies. Type 1 insulin, many types and duration of action, our goal is to mimic normal physiology. Normal physiology is if there is a little bit of insulin every hour and then in response to food, you increase the amount of insulin that is secreted. For Type 2 Diabetes, we have pills. We have injections, you name it, we have many different therapies for diabetes. But when we try to imitate normal physiology, sometimes people need multiple shots of insulin or other medications. Unfortunately many people have the myth that the more shots a person has to take, quote the worst the diabetes is. That is untrue. We are trying to develop a regimen that can mimic normal physiology which means that sometimes people will have to take their medication at the work site, so we want to accommodate the person. Slide 29, Consequences of Uncontrolled Diabetes, loss of productivity, increased expenditures, poor quality of life for employees, and possible permanent disability. But we have to address this because so many of our employees may have diabetes that we want them to have good outcomes. We talked about Slide 30 before about the complications in the eyes, in the nerves, but as I said before, controlled studies show that if we control the glucose and blood pressure, we can prevent many of these complications. Why control diabetes? Because better control translates into fewer complications in the eyes and the kidneys and from a work site point of view, fewer complications translate into fewer days lost to absenteeism and disability and we can save money as well. Now we have to balance a tight rope here. Slide 32, Complications of Diabetes, it is an issue for disability. We have to balance between appropriate therapy to prevent complications. And we also have to accommodate people, so where do they get rid of their needles? Is there a place where they can give their shots? Things like this. Many work sites also have wellness programs to help prevent and improve control. But if people are afraid to say that they have diabetes, we can''t make any inroads, so we have to balance these complications. There is also been a study that showed that better glucose control, people who had better A1Cs which is like a report card for diabetes had fewer days lost to absenteeism and few days of restricted activities. So we talked about a person who has diabetes, Slide 34, we have some general considerations, what type of job does a person have? What is the physical activity? What are their work hours? What is the physical environment? Is the person real active half the day? Or is it a desk job? Because this can change the therapy. Slide 35, does the supervisor know that the person has diabetes? Are there physical requirements? Is the person handling heavy equipment or moving equipment? Does the person need a special license or special qualifications? We want to ask people about their physical activity. Do they have active days and less active days? Is there lifting required? How much, how frequent? Because all of these considerations will influence where the person is qualified to work. Slide 37, physical environment. Is the person working alone or with others? Is the person working at heights? Is the person outside with temperature extremes? We need to consider this. Is the person working shift work? Do we have to arrange their therapy accordingly? Do we have to adapt their insulin so that this person can work third shift. Just because a person has diabetes doesn''t mean that the person automatically cannot work second shift or third shift. We need to accommodate this, and that is why the doctor, the supervisor, the HR person all have to work together. Slide 39, Individual Assessment. We have examples, for instance, of law enforcement officers. At one point there was a blanket ban. If you had to take insulin and you had diabetes, automatically for certain jobs, you could not do it. Now the American College of Occupational Medicine has helped to develop some guidelines that there is Individual Assessments. For instance, if somebody comes to you, does not have diabetes, and has had a back injury, there is Individual Assessment to see how much can this person lift? How much weight can they bear, et cetera. We have to do the same thing with the person who has diabetes. What kind of eye disease does this person have? Does this person has neuropathy? Can this person lift? We have to individualize the requirements of the job with what the person can do. Slide 40 shows some examples. We saw a person who was a box cutter and every morning at 10:30 he was dizzy and he almost felt like he was going to pass out. Well, he was working with equipment that was dangerous, so he certainly could be a threat, a danger to himself or the people around him. Well, it turns out that when we looked at his insulin use, it turns out that the type of insulin that he took, regular insulin, that he took at 7:00 every morning would peak two to four hours later. So bingo, at 10:30 in the morning, every morning he got dizzy. As soon as we changed his insulin around, he was just fine. We saw somebody who had to use a forklift. His diabetes was under poor control so his doctor wanted to put him on some insulin for a short term period of time. So we put him on temporary restrictions, got his glucoses under better control, then could change his therapy a little bit so then he could work with a forklift again. We have also a problem sometimes with disposal of needless. The American Diabetes Association has some guidelines. They are posted on the website. So it really is not a problem. We also have pens to give insulin because I know at work sites people are very worried about needles at the work site. So again Slide 41, individual assessment, work with the health care provider and education very, very important. As I said before, accommodation might be short-term until glucose levels are much more stable. So Slide 43 is a slide that is going to lead me into a resource that people can also use to help improve the health of their folks at the work site who have diabetes. Why should a work site pick diabetes for health promotion? Well, the costs are high, but we know that effective interventions can promote multiple good outcomes and we can improve productivity with better outcomes. Why the work site? Why the work place as a site for disease education? It is a unique opportunity for education, it promotes better employee-employer dynamics and people know that their employer will care. One of the resources, this is National Diabetes Education Program , and the goals of NDEP as it states on Slide 46, this group was formed after science showed that better control of diabetes can improve outcomes. And we have multiple work groups and one of the work groups that we have is the Business Health Strategy Work Group. Slide 48 shows the goals are to increase awareness of the benefits of quality diabetes care among employers, benefits managers, and managed care decision-makers. Slide 49 shows who we are, CDC, NIH, large and small businesses, GE, Lands End, unions, occupational health professionals, doctors, nurses, nurse practitioners, this whole group. Slide 50 shows what we are very proud of. We have a website called diabetesatwork.org, and it was developed to meet the business communitys need for easily accessible diabetes-focused work site health information. Slide 51 shows our website, the best thing is that there is no copyright. You can download Lunch and Learn on basic diabetes care. This will also be on the website as well. We have information about general diabetes education, a supervisor''s guide, and you can adapt the information to your particular setting. So why focus on work site health program on diabetes? We want to make the link. We also want to make the link between diabetes, heart disease and stroke as well. We have an employer showcase that will have Best Practices. We have it in several languages. We have information in Spanish. We even have information in Hmong and other pacific island languages as well. So it is a good resource for you. The last thing I wanted to touch on is Don''t Forget about Diabetes Prevention, Slide 55. We have a campaign that is called Small Steps, Big Rewards. These people that we looked at before who had quote pre-diabetes, the borderline diabetes folks, we can intervene and work site programs are doing this to help prevent people from developing diabetes. As we said before, millions of people have blood glucose levels that are higher than normal but not high enough to be diagnosed with diabetes. We have evidence that shows with lifestyle change and with some diet change, we can help prevent diabetes. Slide 57 shows that lifestyle intervention could delay the onset of diabetes by 11 years. We also have some information to do awareness campaigns. Slide 58 just shows one of the examples, Get real! You don''t have to knock yourself out to prevent diabetes. People don''t have to lose 82 pounds. They can lose 10 to 15 pounds and decrease their risk for diabetes. Slide 59 says you do not have to eat like a bird with one little bean to prevent diabetes. Again, some physical activity and correct diet can go a long way. And I want you to remember that the lifestyle changes in medical care recommended for diabetes control, helps to prevent and control many chronic diseases. You have many of our websites. Now I will turn it over to Shereen Arent who will talk about the legal aspects after you have received your Diabetes 101. Thank you, Shereen.
Hi, thank you. I am going to take what Pam has talked to you about in terms of the medical and scientific public health world and move it into the legal world in which I function. With the caveat that a lot of what I do is preventing things from moving up the legal chain. This is not about what lawsuits for folks with diabetes would look like as much it is about how employees and employers can work together to accommodate each other in the workplace. So turning to my second slide, what are the goals which the American Diabetes Association has for workers with diabetes. Each person with diabetes, to be able to hold any job for which he or she is otherwise qualified. And what that means is that not everybody as Pam explained with diabetes can do every job. Someone who because of complications of diabetes cannot see, is not going to be a truck driver. I mean what we are looking for is the individualized assessment that Pam spoke of. And then for every person with diabetes to get the reasonable accommodations that he or she needs to protect his or her health on the job. And I will talk more about some of what those accommodations are, but what I think we can see from that, that those of us who work with employers, those of us who work with employees, that these should be similar goals. Employers want the best person to do the job. Employees want a fair shake at doing the job that they are good at. So moving to Slide 3, and I understand that many of you who have been on a series of calls or work in the legal area, so I am not going to spend a lot of time talking about what the basic laws are. But the first three listed on that page, the Americans Disabilities Act, the Rehabilitation Act of 1973, the Congressional Accountability Act, are three laws that prohibit discrimination based on disability and they apply to different employers. The ADA applies to private employers and government, local and state government The Rehab Act to employers that get federal funding or federal employers, and the Congressional Accountability Act to agencies of Congress itself. So those prohibit discrimination against somebody with a disability, and we will talk a little bit more about what those terms mean. But two other areas of legal protection that are worth at least noting here is the Family and Medical Leave Act. People with diabetes and other chronic illnesses may need to take time off because of an operation that you know could be weeks off or could need a day off for a doctors appointment. The Family and Medical Leave Act protects employees to be able to do those things which is Pam points out those are things that make them more productive. And then states have Anti-discrimination Laws and Leave Laws themselves which sometimes provide greater protection. So, if you turn to Slide 4, what is the purpose of anti-discrimination law? And the first reason is to prohibit discrimination in employment against a qualified person with disabilities which includes the legalese about what you need to prove. But really it is the second one, it is to make sure that misinformation and fears about medical conditions do not stand in the way of an employee getting the job that he or she deserves and the employer getting the very best employee possible. And a lot of that we deal with at ADA is ignorance about this disease. Someone who knew someones great-aunt Sadie who has diabetes and she always used to pass out because of it and not someones knowledge based about diabetes. The first thing is to make sure that we understand diabetes and we understand that person. So I am now turning to Slide 5, what I have chosen to illustrate the legal world, is a case of a guy named Gary Branham and Gary whose picture you see there worked for the IRS for about 17 years. He has Type 1 Diabetes which as Pam explained means he produces no insulin. It is not equated with obesity or overweight but he has to take insulin daily and multiple doses either by pen or by pump in order to survive. He does a great job of managing his diabetes because he is well-educated by diabetes because he has access to insurance and because his diabetes affects him. Sometimes you can do your best job and still face a lot of complications but lucky for Gary he has not. He does not experience high blood glucose levels that incapacitate him. He does not have low glucose levels that incapacitate him and Gary working for the IRS, he has a CPA and decided he wanted a promotion to a Special Agent. A Special Agent is a law enforcement job at IRS so you have to carry a gun. It does not have a lot of law enforcement involved in it but you have to have that capacity. And he had all the qualifications and got the job. And then when he went for the physical, he was told that he could not explicitly because of his diabetes and they said, well, it was not a situation of a de facto blanket ban, in other words, the books did not say no one with diabetes can do this job. But that is what it really became because here was someone who with really good medical records showing he was not having a problem but he was told that he was too sick to do the job. And the fear was that he would because if you take insulin, your blood glucose can go too low, you can pass out. They were worried about that happening with someone who had a gun, that he would be a safety risk. So he was too sick to do the job. Gary did not feel he was too sick to do the job. So he brought a lawsuit and when he brought the lawsuit, the IRS said in return, well, we know, Mr. Branham, you do a great job with your diabetes. You do such a good job that you are so healthy that you are not protected by in this case the Rehabilitation Act or the Americans with Disabilities Act because you do not have a disability. So Gary is caught in a conundrum of being told he is too sick for the job but not sick enough to be able to have protection against discrimination and unfortunately that is all too common of a dilemma. So I want to walk through that as a way of talking about the important legal issues that impact people with diabetes going through Garys case. So moving to the next slide, Slide 6, there is a legal standard as to whether this guy could do the job. It has to do with whether it can be looked at whether he is qualified for the job or more appropriately, is he a direct threat and that is when the individual assessment that Pam talked about comes into play. You need to look at Gary and how diabetes affects him and the quote comes from regulations adopted by the Supreme Court. It needs to be based on a reasonable medical judgment relying on the most current medical knowledge and/or best available objective evidence. That is how you are supposed to determine whether he can do the job. Turning to the next slide, there are three what I call the hallmarks of a good individual assessment. First, is that it looks at the individual job. I do not have diabetes but if I did, I work at a desk job, if I passed out because of low blood glucose, the worst thing in the world that would happen is that I would hit my head on my keyboard. It is not an issue and for most jobs there is not a safety issue. And you need to look at the blanket applicant. Is there someone who has had trouble with their diabetes in the past such that they were incapacitated? Is it someone with a complication that it prevents them from climbing? So the first thing is they are not basing it on stereotypes about the disease or not looking at the job. The second is that in order to make this individual assessment we need to include the expertise of both healthcare professionals with knowledge of occupational medicine and those with knowledge of the medical condition at issue. So that is why Pam is such a great expert, she understands both occupational medicine and she understands endocrinology. The other part of that is including the knowledge of the treating physician who understands this patient and their records best of all. And the third hallmark of a good individual assessment is realizing that with most disabilities and with diabetes, there is not going to be one test and one cut-off score that is going to say yea or nay as to whether the person can do the job. Within the world of diabetes, there is a test call the Hemoglobin A1C. It gives you an average blood glucose over the last two or three months. So it is going to average the highs and lows and it gives you a good solid number. And unfortunately we see employers trying to use that number to say if you have above this or below that or whatever you cannot do the job. That does not tell you whether the person is having any incapacitation. So the tendency is to try to find a quick fix number. It is not going to happen for diabetes. Rather, looking at Slide 8, it is important to come up, that does not mean that you have to start if you are a HR person all new every time someone with diabetes walks in. What we like to do is work with groups like the American College of Occupational and Environmental Medicine to work out guidelines that can help people to do that sort of assessment. So if someone comes in for a law enforcement job, the ACOEM guidelines are a good way to do that assessment. It brings in the parties that I just talked about and talks about given this sort of job. We have also worked in several other areas that are listed on that Slide. But it is important to realize that if somebody is applying to be a clerical worker, you do not pull out the law enforcement guidelines, they are just simply not applicable. So what happened when Gary''s case, by the way he was thrown out of court at the district level. The case was reinstated at the Court of Appeals. Then he went back down for a jury trial, many years later. The jury came to its verdict and they said he is not a direct threat on the job. That is he is not too sick to do this job. So what went wrong? Why did the IRS come to the other conclusion? Why did they think he was too sick? And when we look back at what happened in that case, and I am looking at Slide 10 now, we look at what information those people making the decision ought to give him the job, what did they look at, what did not they look at? They ignored the opinions of experts in diabetes, they ignored the judgment of his own Mr. Branhams endocrinologist. They ignored the information they had received from him, they ignored the fact that he did not have a history of diabetes problems, they even ignored Mr. Branhams bosses at IRS who were advocating on his behalf. So they looked at a bunch of documents but the documents were being looked at by someone without expertise in diabetes and they reached the wrong conclusion. Turning to Slide 11, when there was trial testimony, one of the form of experts in the country, Dr. Charles Clark talked about and explained to the jury why he was not a direct threat and in fact, even the expert on the other side had to admit that he could not disagree with that. So, then we turn to the other side of Gary Branham''s case. Was he sick enough? That is, did his diabetes qualify as a disability? And this comes when the Americans with Disabilities Act was passed in 1990, and it adopted what was in the Rehab Act which goes back to the early ''70s. It was well understood by Congress that this law was intended to cover people with diabetes and other serious chronic illnesses. It is all over the legislative history. So why is it an issue? Mostly it is an issue because of a series of Supreme Court cases that you may be familiar with beginning in 1999. The Sutton Trilogy which says you decide if someone has a disability without taking into account any mitigating measures they may take. So the argument here would be, well, Gary wants to take his insulin, he is just fine and dandy and that indeed, was what IRS argued in this case. To prove that you are sick enough, you have to show that you have an impairment and everyone agrees that diabetes is an impairment of the endocrine system that substantially limits a major life activity. So there is a lot of discussion about what substantial limits and major life activity are all about. Those of you who work in other areas know that this is not specific to diabetes. So again moving to Slide 13, we see that we need to do an individual assessment. And we need to understand diabetes. We need to understand diabetes as it affects Gary Branham. We need to look at any short or long-term complications, but we also have to look at how he lives his life every day. Turning to Slide 14, what major life activities does diabetes impact? And you will see a whole list of them there. But I want to sort of focus again on Gary''s case. What did the jury decide? They said does this guy have a disability? And turning to Slide 15, yeah, they said Gary Branham has a disability. He is sick enough, that is to be protected by our federal law. So what went wrong? Why did the IRS reached the wrong conclusion here? And again, got to look at what came out in the trial here and that is what I have on page 16. Gary is doing a great job with his diabetes but he does not live his life like someone without diabetes because someone without diabetes is not checking their blood glucose numerous times a day, administering insulin numerous times a day, walking the tight rope between high blood glucose which can hurt you in the long run and low blood glucose which can cause immediate impairment. They are not having to think about everything they eat and how it impacts their life. They are not having to think about their physical activity and how that affects their blood glucose levels. Gary''s life is different than my life and that is how it is substantially limiting in this case and the major life activity of eating but he can do it. He does all those things and that is why he can be a law enforcement agent. Yes, he lives his life differently than I do, and yes it is substantially limiting to do it that way but he is still a winner. And if our disability laws are to protect anybody, it is the folks who can actually do the job, folks like Gary. So what I tried to do through the Gary Branhams case study is to show how the major issues come up and how we can avoid those issues from coming up by at the beginning of looking at someones diabetes, doing the assessment that we need to do. The last major issue that I want to talk about that we see a lot in the workplace are reasonable accommodations, the law provides, and this is Slide 17 that an employer is required to make reasonable accommodations such as making facilities accessible, job restructuring, changing schedules, adaptive devices, unless doing so would provide an undue hardship. So that is the basic law. The easy and the good news here is, Slide 18 talks about it. Within diabetes, it is usually very easy to accomplish. If I needed to check my blood glucose at work and administer insulin or eat, it would not matter. No one cares what I am doing during the day whether I take a break or not. But if you are working in a factory, you might need an accommodation to give you 5 minutes to do those things. Some people might need a consistent shift. Some people with some vision difficulties might need a larger computer screen. There was a case in which again sort of ridiculous but this went up to the Court of Appeals twice, a woman who all she needed was to be able to have a little bit of a shortcut at a shopping center for her to be able to do her job. Really easy accommodation that people with diabetes need. Sometimes they are more complex, and then it is a matter of working with the employer in an interactive process. I want to end my remarks by talking about how we approach all of these things, whether someone is qualified for the job, whether they are protected by the Act, whether they need accommodations and that is what Robin referred to at the beginning of the American Diabetes Associations approach to this which is Slide 19. Four words, educate, negotiate, litigate and legislate and the idea being that we try to resolve problems in the workplace by education, before there is a problem. On page 20, you will see how we educate workers about their rights. We do what I am doing here which is talking to employee and employer advocates, people who work for HR departments to help them understand diabetes because that will make my life a lot easier and make for many fewer discrimination cases and providing resources such as Pam talked about, such as what I have talked about. That is how we get around these issues. I joke that I sometimes think that everyone is discriminated in the workplace because no one calls up a lawyer to say, hey, everything is going fine in my workplace. Just wanted to tell you, no, people call me when things are not going well. So I know that the problems are serious by the numbers of calls but I also know that there are a lot of employers that are just doing the right thing and realize that they have valuable employees or applicants and are trying from the beginning to figure out how they can work diabetes seamlessly into the workplaces. Moving on a little bit about education, I just want to talk a little bit about the American Diabetes Association. We are generally a scientific and health medical organization so that helps us to come forward, we are not, I do advocacy within the organization but what we really are, are the scientists coming together to say what makes the best medical and healthcare sense. You will see our physician statements are the basis of all of our advocacy. Slide 22 talks about some of the resources that we have on the web. You will see 1-800-DIABETES and diabetes.org on the bottom of all of my slides. But specifically www.diabetes.org/discrimination is where we provide resources on for issues that come up in employment and schools, correctional institutions as well. The next stage when education does not resolve the problem is not going to court, it is negotiating, it is collaborating with other organizations like I talked about with ACOEM and others to come up with standards so that each employer is not looking having to reinvent the wheel in terms of how to do these sort of individual assessments and it is providing attorneys with tools for successful settlements. I think some of the most rewarding experiences I have had is when both sides with disagreements have agreed to bring ADA (American Diabetes Association) in as a neutral, so that we can provide information to get through the dispute. Because the next step was negotiating, sometimes that does not work. You will have someone like Gary Branham going to court. And the sad story of that is it is -- Gary was one of the first people I talked to when I got to the American Diabetes Association in 1999 and his case finally resolved last year. And that was time consuming and difficult for him as a person. It was expensive for the government, it was on the other side. So that is why we try to avoid litigation. But sometimes it has to happen and ADA (American Diabetes Association) provides support for lawyers and comes in sometimes as amicus curiae or a friend of the court and once in a while as a plaintiff, an actual party in a lawsuit. The last thing is since our goal at ADA (American Diabetes Association) is to improve the lives of all people with diabetes, if the law is not protecting people with diabetes, we seek to change the law. And maybe some of you out there are familiar with the Americans with Disabilities Act, Restoration Act which was introduced actually at the end of last year but we introduced in this session of Congress by Representatives Hoyer and Sensenbrenner on the House side along with us now got close than 200 co-sponsors and Senator Harkin on the Senate side. The whole thing that I went through about whether Gary was sick enough and the ridiculously personal questions that Gary Branham had to answer is unnecessary. The law should be about whether someone is treated unfairly because of their medical condition. There should not be all of this amount of work and effort put into whether somebody has a disability. That is not what Congress intended when it passed the law. So there is a legislation pending which you may have heard about to make sure that the definition of disability, indeed, does include people with diabetes and other chronic diseases so that we can focus on doing what is right and what is fair for folks with diabetes by figuring out who can do what job and what accommodations are necessary. So that is how we approach issues in the workplace and I think it fits in very nicely with what Pam described as the medicine and science behind diabetes management today. So I am done with my introductory remarks, so I think we are now going to open it up to questions, Robin.
That is great. Thank you very much. I know this is a great deal of information in a short period of time for our participants. Just as an FYI for those of you who got kind of a weird noise on your phone, I am not sure where that came from. So if you did get one, we apologize for that interference. Why dont we go ahead, Operator and have you give instructions once again and open up the questions and answers period for participants to direct questions specifically to our speakers.
Yes. Ladies and gentlemen, if you have a question or a comment, please press the 1 key on your touch tone telephone. If your question has been answered, and you wish to be removed from the cue, please press the pound key. Once again, if you have a question, or a comment, please press the 1 key on your touch tone telephone. Our first question.
Go ahead.
I have a question. If you have a medical personnel such as a nurse at a company or a facility, and they know that this patient has diabetes but this patient does not want to reveal that to anyone else, what is the liability of the nurse in this situation? She was hired by the company, but yet she is responsible for the privacy of the patient.
Well, I will start with that. This is Pam, and then Shereen can follow up. First of all, there are always supposed to be two separate records. Okay, the medical records must be separate. So unless there is a cause that will bring up, like if a person, for instance, says I feel dizzy on the job or I cut myself or something, just having the diabetes really is not relevant on whether the person can do the job. And the nurse actually does not need to share it with anybody unless there has been a problem, and then you have to investigate. For instance, let''s say a person is dizzy. Well, maybe it is the diabetes. It could be something else. It could be an irregular heartbeat. The workup has to be done. Now on the other hand, if there is an overall wellness program that a company is doing, sometimes they will get some insurance data from their insurance or whatever, and they will identify people with diabetes but people have to fill out, let''s say, a health risk assessment and then must say, okay, I am filling out this health risk assessment and then I give permission for you to, you know, intervene or do whatever. But if that nurse just knows that the person has diabetes, but the job performance is just fine and there has not been a problem with anything, then that nurse is not responsible to tell anybody because it means that it has not really affected the person''s job or productivity or job performance. As I say, if a question comes up at the person''s performance of the job is in question, then the whole differential has to be worked up and then the medical history needs to be examined. Shereen any comments?
I would agree with that. My question to questioner would be what is the nurse wondering about, what does he or she feels she needs to share with other people? I will go back just a little bit to say that in the hiring process, as I am sure as most folks know, you cannot ask someone a question about a medical condition until they have been given a conditional offer of employment. And that means condition on you passing your physical, you have the job. At that point, a physical can be required but only if it is required of everyone. And that is where you get into the kinds of physicals that are not or medical evaluations that are not appropriate that happened in Gary Branham''s case. And then once the person is on the job, you can ask for another physical if something has come up that raises a question about the person''s ability to do the job. But otherwise, it is inappropriate.
Great, thank you. Again, complicated issues. Our next question please.
Our next question.
Go ahead.
Hi. My question goes for employers out there, how can they be proactive with their workforce? For employees who are kind of the opposite of a Branham, someone who does not pay attention. They are clearly obese, they do not pay attention to the risk signs. It is bringing the horse to the water but you cannot make them drink kind of thing. They are in denial of a condition. What do we do about employees that way and how can we be proactive to draw them to be, you know, to be better employees when you can see all the risk factors there? And that, you know, the train has left the station and then they become, you know, disabled as a result of not paying attention to a diabetic condition.
Well, that is where a lot of the wellness programs come in, and there are many, oh, ideas, on how to get people to participate. Some companies are giving incentives in the form of money. Some are giving people incentives in the form of decreased premiums on their insurance. Of course, there was just an article a couple of weeks ago in the paper about some companies that are taking away money, all right? They are doing negative reinforcement for people who do not participate in some of the wellness programs as well. So that really depends on the company. If you look at the American College of Occupational Medicine, ACOEM website, there is a whole health and productivity site that talks about programs that are effective and how to motivate people at the work site to participate in them. So that sometimes becomes a culture of the company to promote better health. The environment having healthier food, having it cheaper, having places to walk, things like that, having lay coaches, having like lunch and learns at the site where you have a champion who is a worker there. Because sometimes peer pressure is better than the doctor, nurse or whatever telling the patient. So that is been one thing. The companies are either rewarding people for participating or taking away if they do not. Shereen, any comments?
I like the innovations, the various kinds of ideas that Pam and the folks that she has worked with have come up with. What makes me a little nervous is the concept of the better employee. I mean, I stayed up way too late last night watching the Eagles lose to the Redskins and being depressed over that. And maybe I would be a little sharper for this thing today if I had not done that. There are a lot of things we do outside of the workplace that may cause not as healthy as we could be. Now we want to encourage people to be healthy for all the reasons that Pam said. But if a person can do the job, and maybe my example of watching tv too long was a bad one, but the person can do the job, the fact that they are bringing themselves down eventually, ultimately is not something that employers can or should take into account. In other words, the fact that I see that you are obese and obesity can lead to all of those things is simply an impermissible factor in deciding whether the person can do the job today assuming that the person has diabetes or something else that is protected under discrimination law. So it is the water that takes the horse. You know, it is having the water there and doing all the things to get people to realize what good health is about, but it is not about using the force of the employer to require somebody to have a healthier lifestyle. The question is for the employer is, can this employee do this job today?
Now, that being said, the work site is a wonderful opportunity to promote wellness and it has become a very hot place to do it because people are there for a long time.
Oh, and I am all in favor of all the carrots that we can make that happen. I think where I worry about -
Is the discrimination aspect of it.
Right, yeah. I look at you, you have diabetes. I figure you are going to lose your sight in 10 years so I am going to not give you this promotion today.
And I think that is something that we do hear from people, a big concern about that disclosure about that retribution issue.
Exactly, and that is why studies have shown that people do not tell their supervisors, et cetera.
Definitely. Next question please.
Thank you. Our next question.
Can you hear me?
Yes, we can. Go ahead.
My question is for Shereen and has to do with the second prong of the definition of the ADA which you did not cover but whether having a record or a history of an impairment that substantially limit has been used in many diabetes legal cases?
Actually, as you point out, there are three prongs, there is actual disability, there is record of and there is being regarded as having a disability. You know, one record of case that I recall is a guy who had been on Social Security Disability for about 20 years, really had a hard time with diabetes management, turned his life around, and sought a job, was turned down for the job because of his diabetes and he -- one of the prongs that he successfully used was that he was discriminated because he had this record of diabetes and the fact that he had it. Frankly, it does not come up as much as regarded as. And the argument with regarded as, folks with diabetes do not like to say they have a disability. It is a term that has negative connotations and what I say to people is that it is a word, and if you are not covered by it, then you are not protected from overt discrimination because of your diabetes. And because sometimes it is difficult to prove because of the problems with the law that I talked about that you have a disability, you go with the regarded as. You can see in for example Gary Branham''s case, you could say he was regarded as by the IRS as not being able to do the job. And that has been successful and I can name a number of cases although there are actually problems in the law in which trying to prove that the employer regarded you as substantially limited in working is difficult because you have to show that not only do they think you could not be an IRS agent with a gun but it was that you could not do anything, could not do a range of jobs. That actually can be shown because if in Gary Branham''s case they felt that he could not do anything which required him to be able to be alert all the time. So that is sometimes useful. And, in fact, it really is the essence of these laws is that someone is, whether they can do the job or not is being regarded as unable to do it. So as Robin say, there is complicated legal issues in that. But I do see record of sometimes used to establish but more often I see regarded as well as actual disability.
Great. Thank you. Next question please.
Thank you. Our next question.
Go ahead, please.
Yes, I wanted to request that the second speaker read the list that was in slide 16 I believe because those of us who are just listening did not get access to that information.
Ok, what Slide 16 was, this is Gary Branham''s Disability versus the Average Person, is that the slide you are referring to?
I believe that you said there was a list of things that we could look at on the slide and I thought that you had said 16. I am not sure if that was accurate but there was a list of characteristics I think.
Yes, that is the right slide. This actually comes from the trial from Gary Branham''s trial and again trying to show that he meets the definition of disability. So it is a chart that says has a list of 10 things, and then after it says Branham and the average person. Constant blood sugar vigilance, Branham, yes, he has to do the average person, no, monthly quarterly doctors visits and lab tests, Branham yes, average person no, multiple insulin shots, each day, Branham yes, average person no, frequent changes in how much insulin every day, Branham yes, average person no. Side-effects from insulin, Branham yes, average person no, multiple blood tests each day, all these are Branham yes, and average person no. Calculate food quality and quantity. Limits on types and quantity of food consumed. Adjust food for insulin and diet, adjust exercise for insulin and diet, adjust insulin for exercise and diet. Basically what they were trying to show to the jury is despite the fact that he was successful in doing it that he did live his life again in a very different way. He was substantially limited in how he ate. He does not eat whatever he wants to, he does not exercise whenever he wants to, without thinking about balancing those things. And that is the way that you work through with a judge or a jury understanding the people with diabetes should indeed be protected from discrimination.
Okay, thank you. And for those of you who did not get the materials, the individuals who registered on behalf of your site, had access to those materials. So if you are having a problem with getting those or accessing those materials, please feel free to contact our office at, I will give you a website gldbtac@uic.edu. And we will make sure that you get a copy of the handouts that were provided, the power point presentations. Ok. Operator, can we get another question please.
Yes, the next question.
Hi, my question is regarding the complications that diabetes brings with it and the healthcare costs that it brings. And I am wondering what ADA (American Diabetes Association) is doing to educate not just employers and persons with diabetes but what are we doing to help educate the insurance providers to develop wellness programs and allow people with diabetes to have better control.
Well, one of the things that the American Diabetes Association did was get laws passed in 46 states which would required insurance except self-insured but I will not go into details of that, to provide for diabetes education and supplies. Because the problem is that you can even be insured and not be able to get what you need to take care of your diabetes. Pam might be able to talk about it in sort of a positive programs that insurance companies are doing. But I know it is a struggle for many folks with diabetes and I think that in the workplace, if the workplace offers insurance, it so behooves the employer to make sure it is comprehensive coverage because if you want a healthy workforce, you have to give them the tools to be able to do that. If the employers does not provide insurance, realize that while you may have vision of what perfect diabetes management might be, that may be completely unaffordable to an employee.
There are also, what is interesting is now many employer groups are making a push. The National Business Group on Health, the National Business Coalition on Health, both represent employers, and the employers realize that many of their employees either have diabetes or are at risk for developing diabetes and they are actually pushing the managed care organizations to improve their outcomes on diabetes education, on monitoring A1C levels, on flu vaccines, all of these types of measures because they know that they will have more productive employees. So they are working with the managed care organizations. If you go on the National Business Group on Health''s work site, the National Business Coalition on Healths work site, and that those are two resources that the websites are listed on at the end of my talk, both will show you some of the initiatives that they have. A lot now is going on with pay-for-performance. If the employers and the managed care organizations, the health insurance groups are advocating now. I am not sure that is a magic bullet, but the employers are now pushing the health plans into having different models of care. So we will see how that goes.
Thank you. Next question please.
Thank you. Ladies and gentlemen, if you have a question or a comment, please press the 1 key on your touch tone telephone. Our next question.
Go ahead.
I have two questions. One, I am interested in what the actual reference for the study that people do not tell their supervisors that they have diabetes.
Okay. I am find it. If you e-mail me, I will find it for you, okay?
Great. And the e-mail?
It is pca8@cdc.gov.
Thank you. And my second question was could you tell us a little bit about that Small Steps Big Rewards program?
Oh, I would love to, okay. We have a whole tool kit if you go on to the National Diabetes Education Program website. It is ndep.nih.gov alright, and there is a whole campaign for both providers and for patients. And it is a whole tool kit that shows how if you walk 30 minutes, five days a week, it could be 10 minutes, three times a day, and lose let''s say 5% to 7% of your body weight, you can help to prevent diabetes. We also have it for different ethnic groups. So we have some materials for the African-American population, for the Native American population and for the Hispanic population as well for primary prevention which is what we are calling it. But the Small Steps Big Rewards as whole tool kit that you may order, it is free if you go on the NDEP website, you can order it and they will deliver it to your door. It has programs that you can do anywhere at your work site or with just a support group. But that is where it all comes from. It also has campaigns and it has PSAs all in the tool kit.
Thank you very much.
Thank you. Next question please.
The next question.
Go ahead.
My question is how to go about finding local diabetes support groups throughout the country?
Oh, just call your local ADA (American Diabetes Association) chapter and that 1-800-DIABETES actually will hook you up with your local chapter. Shereen isnt that correct?
Well actually ADA (American Diabetes Association) does not do support group per se but we have resources about support groups. In addition, people''s healthcare providers often know about support groups as well. So those are two sources to find out about support groups.
Also your local Health Department. CDC sponsors diabetes prevention and control programs in all of the states. So if you call your local Health Department, you can find it. Also there is different diabetes coalitions in various states that will have diabetes -- that may have diabetes support groups as well.
Thank you.
Next question, please.
Ladies and gentlemen, if you have a question or a comment, please press the 1 key on your touch tone telephone. Once again, if you have a question or a comment, please press the 1 key on your touch tone telephone.
Okay, we are in between questions at this point.
Yes, Ma''am, we are. Actually we have a question now.
Okay, great, go ahead.
Thank you. Yes. I have a question possibly, for legal interpretation but also medical. I have become aware in researching medication for Type 2 Diabetes that some of the medications they are proliferating so fast that even the research data cannot keep up with them, yet doctors seem to know about them. And I am kind of wondering if in your cases that you had, if Type 2 Diabetes is changing these medications might preclude the disability status to some degree. And I had one other question, I am interested in any websites that you would have that would give me the information on these drugs that are rapidly developing.
Okay. We have to divide that, okay? One, is it the evidence from different studies, the Diabetes Control and Complications Trial that was in Type 1 Diabetes and the UKPDS (United Kingdom Prospect of Diabetes Studies) in Type 2 Diabetes, basically showed that better control of the glucose and blood pressure too, led to fewer complications in the eyes and in the kidneys. For instance, in Type 1 Diabetes, dropping the hemoglobin A1C which is a measure of glucose control, decreased the risk by 56%, I believe that was the number of eye disease. Now, whatever your combination of drugs to drop the hemoglobin A1C, that is an individual medical decision. The American Association of Clinical Endocrinologists and the ADA (American Diabetes Association) both have some information. AACE is AACE and if you look at the guidelines for diabetes, it will show you a chart that has how much each medication will drop the hemoglobin A1C, so how much each medication will improve glucose control. Every January in Diabetes Care, the American Diabetes Association also publishes some guidelines. So if you go on the Diabetes on the American Diabetes Association website, it will give you that information as well. So it is a combination of medications that will lower the hemoglobin A1C. It is not a particular medication but especially I know that the AACE guidelines has a wonderful chart that looks at the old and the new medications and how, what percentage it drops the hemoglobin A1C which is the degree of control. So those would be two resources that could show you that information.
I would approach the legal part of that, first, in a sort of practical way. Let''s imagine that someone that you are working in HR and someone comes to you and says, "I am on this new med that requires me to check my blood glucose three times a day, that is really important for me right now to make sure that even though it is an oral med, it might make my blood glucose too low and I would like to do that." And the employer can take one of two responses. One is they can say, "well, you are not covered by the American with Disabilities Act because the drugs are doing such a good job that you are no longer substantially limited in major life activity," and you can get into that discussion. But the better thing is to do, say hey I have got a good employee here, needs something that is going to take a few minutes a day, going to make the employee more loyal to my company, going to make the employee healthier, just do it. So that is hopefully where most of the problems get resolved. But I think you asked the question of given the legal issue of whether someone is substantially limited in major life activity, could different medications make that harder to prove. And under the current state of the law, the answer is yes. If everything is working out well with these drugs, it is going to be harder to show that you are substantially limited in major life activity but that does not mean that you are not. And I think I go back to the chart that I talked about earlier with Gary which is that person''s life still is not the same. But now we are into the difficult legal issues, and we are into the employer and the employee both spending a whole lot of money and getting a whole lot of experts together to go through the issues of whether someone is covered by the law which we hope can be resolved in the first way I talk about, which is what do you need and can we as a company do it and is it going to be a win-win for both of us. So that is a legal answer and what I hope will be the real answer.
Okay, any other questions at this time?
I am showing no further questions at this time Maam.
Okay, thank you. Well obviously from the series of the questions that were asked by participants, there is a wide array of interests and issues for people around the topic of diabetes in the workplace and obviously people are coming from different places depending on possibly the role that they play in an organization or their own personal experience, the individual with the disability or are they someone who is trying to work with the workforce and manage those particular issues. I think that our speakers today have brought to us a wealth of information, a broad range of resources and activities that are out there that can potentially help employers, help advocates and individuals themselves in some of these areas. And I would really highly recommend that people look at the resources, some of the websites that have been provided by both of our speakers as well as contact agencies and organizations like the American Diabetes Association. Whenever we talk about the ADA and diabetes, there is also confusion about the acronyms because, of course, we use ADA to reference both the Americans with Disabilities Act as well as the American Diabetes Association. So just as a word of caution to anyone who is looking at materials that may have been part of this session, make a differentiation between whether or not we are talking about or they are talking about the American Diabetes Association or the Americans with Disabilities Act with those abbreviations. I want to take this opportunity to thank our speakers for the time that they have spent with us today and their willingness to share this information. As a reminder to people, this particular session will be archived. A digital audio recording as well as a written manuscript including the power point presentations will be posted to the www.ada-audio.org website within 10 business days following the end of this particular session today. So you will be able to go to that site and access this information for further reference. This session also concludes the 12 month series of sessions that we have held as part of the ADA Audio Conference Series. In October, we will begin another 12 month series. We will start out the series with the same similar session we have held in the last couple of years which is a legal overview to run through a variety of where we stand in the cases and such. Barry Taylor, an attorney with Equip for Equality who again has been a speaker with us for a couple of years will be joining us once again for that session. All of the sessions for the next 12 months will be posted to the ada-audio.org website in the next couple of days, so you will be able to take a look at the planned sessions. We have a variety of topics that will be made available including addressing specific disabilities in the workplace and in educational settings as well such as psychiatric disability and learning disability. We will be looking at issues related to hiring and employer attitudes around people with disabilities and how that impacts both from the customer''s side as well as the employer''s side, as well as looking at some best practice issues in regards to recruitment and hiring of people with disabilities. We will also in the next year have our traditional favorites of opportunities to have a one-on-one session with staff from the Equal Employment Opportunity Commission as well as the U.S. Department of Justice. So keep checking back to the www.ada-audio.org website for a full complement of the sessions for the next 12 months. And again, we want to thank our speakers for today and we want thank all of you for joining us. And we hope that you have a good rest of your day. So thank you, everyone, and take care.
Ladies and gentlemen, thank you for your participation in today''s conference. This concludes the program. You may all disconnect. Thank you, and have a nice day.