1. Diabetes and occupational hazards AH Mehrparvar,MD Occupational Medicine department Yazd University of Medical Sciences

2. Disease & Workplace Workplace: Physical Hazards Chemical Hazards Ergonomic Hazards Psychological Hazards Biological Hazards Safety Hazards Employee Affect work (quality,safety,productivity, essential job functions Affect worker ( induce disease or Aggravate pre-existing diseases

3. Importance of diabetics in workplace  High incidence of diabetes in general population (our country)  High incidence of diabetes in working population  Workers spend more than 30% of their time in the workplace

4. Impact of diabetes on work and worker  Uncontrolled diabetes: high level of absenteeism  Uncontrolled diabetes: reduced productivity  Uncontrolled diabetes: job limitations  Interaction between diabetes and job tasks

5. Important questions regarding the job when assessing patient  Is the disease work-induced?  Is the disease work-aggravated  Can the disease or its complications make the patient prone to other occupational diseases?  Can the worker perform its main tasks?  Does the disease or its complications affect safety in the workplace (for the patient or others)?

6. Cont.  Is there any job limitation for the diabetic?  Is there any job restriction for the diabetic?  How we can assess the fitness for work in diabetics?  How we can prevent diabetes or its complications in workers?

7. Important questions regarding the job when assessing diabetic patients  Is diabetes work-induced or work- aggravated?  Can diabetes or its complications make the patient prone to other occupational diseases?  Can the diabetic worker perform its main tasks?  Does diabetes affect safety in the workplace?

8. Cont.  What are job limitations or restrictions in a diabetic patient?  Which clinical or paraclinical tests for assessment of fitness for work?  Recommendations for diabetics in the workplace?  Diabetics and high-standard jobs?

9. Is diabetes work-induced? ??

10. Is diabetes work-aggravated?  Shift work  Job stress  Diabetic foot  CTS  Peripheral neuropathies

11. Diabetes and other occupational diseases  Local hypothermia and frost bite

12. Diabetes and main tasks  Cardiac disease  Vascular disease  Eye diseases  Neurologic diseases

13. Diabetes and safety  High-standard jobs: Drivers, Firefighters, Divers, Police, Seafarers, Offshore, Pilots, Train driver, Crane operator, Forklift, …  Potentially hazardous jobs (Safety-sensitive jobs):  کاربا ماشینهای صنعتی متحرک و دوار ( برش مکانیکی، اره برقی،....)  کارکردن در نزدیکی مواد مذاب و سوزان  کار انفرادی  کارکردن نزدیک حوضچه های بزرگ مایع  کاردرارتفاع ( دکل ها - آنتن های مخابراتی یا.....)  کار در نزدیگ لبه های یا پرتگاه مثل سکو های دریایی یا اسکله یا.....  کار در مناطق پررفت و آمد ( وسایل نقلیه متحرک )  کار با الکتریسیته ولتاژبالا

14. Diabetes and high-standard jobs  Hypoglycemia Sudden incapacitation Rapid deterioration

15. High-standard jobs  Be competent and safe to carry out their duties  Have their diabetes under regular specialist review  Have their diabetes under stable control  Have no disabling hypoglycemia in previous 3-6 months ago  awareness of hypoglycemia symptoms  Have no advanced proliferative retinopathy or nephropathy, nor peripheral or autonomic neuropathy

16. Diabetes and fitness for work  Fitness depends on:  Job and its requirements  Diabetes control state  Diabetes complications  Treatment measures

17. Clinical and paraclinical assessments  Occupational history  Medical history  Type of diabetes  Drugs  Hypoglycemic events  Ph. Exam: cardiovascular, neurologic, eye  Paraclinical tests: FBS, U/A, Creat, HbA1c, ETT

18. Recommendations for high – standard jobs  Check BS at least twice a day  1 hour before work and then every 4 hours  BS< 108 (can not work)  Education  Tight control

19. Work-Site Accommodation Ideas for Individuals with Diabetes  If person with diabetes experiences Hypo/Hyperglycemia: Allow for storage of medications such as insulin, and/or food Supply an area to test blood sugar levels Supply an area to administer medications (insulin) Provide appropriate containers for needles/syringe disposal Provide a rest area for reorientation after hypo/hyperglycemic episode Frequent breaks for food as needed

20. Work-Site Accommodation Ideas for Individuals with Diabetes  If person with diabetes experiences Fatigue or Weakness (May be due to cardiovascular disease): Frequent rest breaks Reduce or eliminate strenuous activities Anti-fatigue mats or padded carpeting Provide rest area Flexibility to sit or stand Job sharing Shorten work day and extend work week

21. Work-Site Accommodation Ideas for Individuals with Diabetes  If person with diabetes has Vision Impairment: If benefit from magnification, consider options to enlarge with magnification devices or computer screen magnification software If does not benefit from magnification, consider options for accessing information through Braille, tactile graphics, or voice output technology Provide a tape recorder

22. Work-Site Accommodation Ideas for Individuals with Diabetes  If person with diabetes has Neuropathy (Nerve damage): Modify job tasks requiring fine finger dexterity Provide protective clothing and equipment Eliminate or reduce the need to use sharp objects Anti-fatigue mats or padded carpeting  If there are other Medical Considerations” Flexible or modified work schedule Work a steady shift schedule Avoid temperature extremes (poor circulation) Reassignment

23. Diabetes and shift work  Risk of hypoglycemia Effect of shift work on circadian rhythms  Risk of hyperglycemia High CRH (stress) Modified habits and activities Modified eating habits and time

24. Diabetes and shift work  Counseling with a nutrition  Evenly spaced meals (each 4 to 5 hours) and snacks  Afternoon shift: larger afternoon snack  Midnight shift: change the drugs  Availability of packaged food

25. Shift work considerations  When changing shifts, monitor at various times to assess blood glucose patterns while working  For example, test before a 'new' meal or snack times, when physically active and when insulin or diabetes pills are working the hardest  Record the results and situations in a logbook to help make appropriate adjustments

26. Shift work considerations  Adjustments in insulin, diabetes pills, exercise plan and meal pattern may be necessary  Generally, working days to nights with two or three weeks on each shift presents the fewest problems  The midnight shift is the most challenging.

27. Shift work considerations  Physical Activity:  Generally, the best time to exercise is after a meal when blood glucose tends to be higher  If working an evening shift, you may want to exercise after lunch  When returning home from the midnight shift, exercising after the morning meal is often a good time

28. Shift work considerations  Insulin adjustments are usually necessary when working shifts  Insulin can be delayed one to two hours without affecting diabetes control  This may be all that is required to manage the afternoon shift  If extra food is consumed later in the day, a slight increase in the suppertime insulin may be needed

29. Shift work considerations  The goals for adjusting insulin over the midnight shift are to provide the right amount of insulin to match the change in food consumed: to avoid excess insulin to prevent hypoglycemia to try to avoid insulin peaks during physical activity and to reduce the amount of insulin during the sleep period