Metabolic Disorder

2. There are 11 million Canadians living with diabetes or prediabetes. Every three minutes, another Canadian is diagnosed

3. Metabolic Disorder Abnormally high levels of blood glucose as a result of defects in insulin secretion or defective action of insulin or both.

4. The Two most common types of diabetes are type 1 and type 2.

5. Type 1 – (IDDM)deficiency of insulin secretion (autoimmune destruction of insulin-producing cells in the pancreas Rx- exogenous insulin

6. Type 2 diabetes (NIDDM) insulin resistance with relative insulin deficiency, or a defect in the secretion of insulin, with or without insulin resistance. • usually begins in mid-life but an increase in the frequency of the diagnosis during childhood is being observed. It is the predominant type of diabetes. • - chronic, progressive condition with no known cure, the condition usually can be effectively managed with patient education and regular, appropriate medical care.

7. Gestational Diabetes - temporary condition that occurs during pregnancy. It affects approximately two to four per cent of all pregnancies 

8. Prediabetes – estimated at 6 M.Blood sugars not high enough to be diagnosed as DM. Estimated 50% will become diabetic

9. RISK FACTORS FOR TYPE 2 DIABETES • Age ≥40 years • First-degree relative with type 2 diabetes • Member of high-risk population (e.g. people of Aboriginal, African, Asian Hispanic, or South Asian descent) • History of prediabetes (IGT or IFG or A1C 6.0 to 6.4%) • History of gestational diabetes mellitus • History of delivery of a macrosomic infant

10. Presence of end organ damage associated with diabetes: • Microvascular (retinopathy, neuropathy, nephropathy) • Macrovascular (coronary, cerebrovascular, peripheral) • Presence of vascular risk factors: • HDL cholesterol level <1.0 mmol/L in males, <1.3 mmol/L in females triglycerides ≥1.7 mmol/l • Hypertension • Overweight • Abdominal obesity

11. Presence of associated diseases: • Polycystic ovary syndrome • Acanthosis nigricans • Psychiatric disorders (bipolar disorder, depression, schizophrenia) • HIV infection • Obstructive Sleep Apnea (OSA) • Use of drugs associated with diabetes: • Glucocorticoids • Atypical antipsychotics • Highly Active Antiretroviral Therapy (HAART)

12. WHEN TO SCREEN FOR DIABETES Screen every 3 years in individuals ≥40 years of age Screen every 3 years in individuals at high risk according to the CANRISK calculator Screen earlier and/or more frequently in people with additional risk factors for diabetes (see below) Screen earlier and/or more frequently in people at very high risk using the CANRISK calculator

14. Conditions that lead to misleading A1C include: • hemoglobinopathies • hemolytic anemia • iron deficiency • severe renal or liver disease

15. COMPLICATIONS Long-term complications. Related to duration and control. Complications may be disabling or life-threatening. Possible complications include: Cardiovascular disease - coronary artery disease, heart attack, stroke. Nerve damage (neuropathy). especially the legs. (tingling, numbness, burning or pain) Begins at toes or fingers and gradually spreads upward. Damage to the nerves related to digestion can cause problems with nausea, vomiting, diarrhea or constipation. For men, it may lead to erectile dysfunction.

16. Kidney damage (nephropathy • Eye damage (retinopathy). • Skin conditions. Diabetes may leave you more susceptible to skin problems, including bacterial and fungal infections. • Hearing impairment. Hearing problems are more common in people with diabetes. • Alzheimer's disease. Type 2 diabetes may increase the risk of Alzheimer's disease. The poorer your blood sugar control, the greater the risk appears to be. Although there are theories as to how these disorders might be connected, none has yet been proved.

17. Limitations may be placed on continuous physical exertion, working in extreme temperature or moist areas, working at unprotected heights, and working in isolated areas alone. • If the disease progresses and is associated with visual or sensory impairment, work requiring visual acuity, fine dexterity, prolonged walking, or heavy labor may need to be limited.

18. MAXIMUM MEDICAL IMPROVEMENT In the absence of severe secondary complications (such as MI, stroke, renal failure), MMI can be determined within 90 days, depending on the complexity of the treatment regimen required.

19. Failure to Recover If an individual fails to recover within the expected maximum duration period, one may wish to consider other mitigating factors.

20. Exposure to organochlorine/organophosphate insecticides Organochlorine and organophosphate insecticide exposure over lifetime may be associated with increased risk for diabetes • based on cohort study • 31,787 licensed pesticide applicators in Agricultural Health Study provided medical information in follow-up interview at 5 years • diabetes occurred in 1,176 participants (4%) • exposure to 5 agents significantly associated with increased risk for diabetes • chlordane (ever use) • heptachlor (ever use and cumulative use > 100 days) • trichlorfon (ever use and cumulative use > 100 days) • alachlor (ever use and cumulative use > 100 days) • cyanazine (ever use and cumulative use > 100 days) • Reference - Am J Epidemiol 2008 May 15;167(10):1235

21. Exposure to polychlorinated biphenyls (PCB) PCB exposure associated with increased incidence of diabetes in women in Taiwan • based on case control study of 378 Taiwanese from cohort poisoned by rice-bran cereal oil containing PCBs in the 1970s, and 370 matched controls • increased odds of diabetes in women of poisoned cohort (odds ratio [OR] 2.1) • increased odds of diabetes (OR 5.5) in poisoned women with chloracne • Reference - Diabetes Care 2008 Aug;31(8):1574

22. Arsenic Arsenic may be associated with increased risk for diabetes type 2 • based on cross-sectional cohort study • 788 adults ≥ 20 years old from NHANES study evaluated for arsenic in urine samples • 7.7% prevalence of diabetes type 2 • arsenic levels significantly higher in adults with diabetes compared to adults without diabetes • no significant differences in levels of dimethylarsenate or arsenobetaine • Reference - JAMA 2008 Aug 20;300(7):814, editorial can be found in JAMA 2008 Aug 20;300(7):845, commentary can be found in JAMA 2008 Dec 17;300(23):2728

23. Risk: Once diabetes is established, there is no occupation that would directly worsen the condition. Capacity: Diabetes will not usually affect capacity. Lost work time may be needed during periods of significant medication adjustment. Tolerance: Education is the mainstay of encouraging diabetic treatment and compliance.

24. CAPACITY Individuals with very irregular diabetes control may be precluded from driving, flying, working at unprotected heights or in safety sensitive positions.

25. WHAT S DIABETES CANADA”S POSITION ON EMPLOYMENT? Diabetes Canada believes that a person with diabetes should be eligible for employment in any occupation for which he or she is individually qualified. In being considered for employment in safety-sensitive positions, a person with diabetes has the right to be assessed for specific job duties on his or her own merits based on reasonable standards applied consistently. Employers have the duty to accommodate employees with diabetes unless the employer can show it to cause undue hardship to the organization.

26. What is workplace discrimination for people living with diabetes? Discrimination can come in many forms. It is possible that an employer may refuse to hire you after an employment medical, limit your job responsibilities or promotions, or terminate your services.

27. EXAMPLES OF DISCRIMINATION IN THE WORKPLACE You inquire about applying to be an officer with the city police department and are told they do not hire people with diabetes. After experiencing a hypoglycemic reaction at your workplace, you are terminated from your job. Despite requesting a regularly scheduled morning coffee break to test your blood glucose and eat a snack, your employer makes you work through until lunchtime. After the employment medical, your job offer is rescinded because your have type 1 diabetes.

28. EXAMPLES OF BLANKET DISCRMINATORY POLICIES “We do not hire people with diabetes.” “People with diabetes do not meet the medical requirements for this job.” “People with diabetes using insulin are unfit for employment in this job.”

29. It is a discriminatory practice for an employer to establish a policy that denies employment opportunities on a prohibited ground of discrimination (i.e. diabetes) unless the employer can establish the practice to be a bona fide occupational requirement and therefore impossible to accommodate.

30. Many blanket policies are a result of long-standing practices, often the result of outdated ideas about diabetes. Although there are fewer blanket policies these days, some still remain for people with diabetes using insulin. The federal parliament and provincial legislatures in Canada have enacted human rights legislation prohibiting discrimination on the basis of physical disability. As defined within the context of human rights law, diabetes is a disability for which discrimination is prohibited. Although employers and others are not permitted to discriminate against people with diabetes, sometimes it occurs because of a lack of correct information about diabetes or assumptions made about diabetes.

31. Human rights legislation specifies that an employer must accommodate a person with diabetes up to the point of “undue hardship”. This means that an employer must do what is necessary in the workplace to enable a person with diabetes to perform the essential duties of a job unless the employer would suffer undue hardship in terms of health, safety and cost. For example, if an employee with diabetes requires regularly scheduled breaks during the day to have a snack or to administer insulin, the employer would be legally obligated in the vast majority of cases to permit such a break.

32. Other requests for accommodation might include: • A private area to test blood sugar levels or to take insulin • A place to rest until blood sugar levels become normal after treating low blood glucose • A place to store snacks for treatment of hypoglycemia • Time off to attend medical appointments • If a request for reasonable accommodation is declined, an employee can file a human rights complaint against his or her employer.

33. Employers have the duty to accommodate employees with diabetes unless the employer can show it to cause undue hardship to the organization.

34. DEFINITION OF UNDUE HARDSHIP Undue hardship arises as part of the legislative requirement that employers must change workplace policies, rules, practices and operations that result in discrimination, and provide individual accommodation unless it would lead to “undue” or unreasonable hardship on the part of the employer.

35. The question of what constitutes undue hardship varies; however, courts have made it clear that employers must expect to experience some cost in eliminating barriers and providing accommodation. Questions arise over when the threshold of undue hardship has been reached. The Canadian Human Rights Act provides that undue hardship must be assessed considering “health, safety and cost.” The mere fact that some cost, financial or otherwise, will be incurred is insufficient to establish undue hardship. (Source: A Place for All: A Guide to Creating an Inclusive Workplace, The Canadian Human Rights Commission)

36. POSITION STATEMENT People with diabetes have the right to be assessed for a license to drive a motor vehicle on an individual basis in accordance with Canadian Diabetes Association recommendations for private and commercial driving.