Diabetes and worker safety

Diabetes has been called an epidemic in America. A 2014 report from the Centers for Disease Control and Prevention estimates that 29.1 million people in the United States – almost 10 percent of the population – have the disorder. Of those, 8.1 million are undiagnosed.

The seventh leading cause of death in the nation, diabetes can lead to heart disease, stroke, kidney disease, vision problems and lower limb amputation if not controlled. So what are the implications for worker safety?

Concerns

The blood of a person with diabetes has too much glucose, resulting in possible health issues. In people with type 1 diabetes, the pancreas makes little or no insulin, which is needed to turn sugar and other food into energy. With type 2 diabetes – the most common type – the body improperly uses insulin, leading to abnormal blood glucose levels.

Concerns about worker safety focus mainly on hypoglycemia, a state of low blood glucose. Symptoms of hypoglycemia range from hunger and dizziness to confusion and unconsciousness. In contrast, hyperglycemia occurs when blood glucose is high because the body has too little insulin or is improperly using insulin, resulting in symptoms such as hunger, thirst and frequent urination. Left untreated, hyperglycemia can lead to diabetic coma.

“When sugar gets very high, it can affect their cognitive abilities, it can affect vision,” said Dr. Daniel Samo, member of the American College of Occupational and Environmental Medicine board of directors and medical director of health promotion, and corporate services and public safety medicine divisions, at Northwestern Medical Group in Chicago.

Control

Experts say that, regardless of type, an individual with diabetes can work safely as long as he or she can effectively control the disorder and perform the job’s essential functions. “It’s very dependent on the person’s job duties,” said Wendy Strobel Gower, director of the Ithaca, NY-based Northeast Americans with Disabilities Act Center. “Diabetes can be very mild and it can be very significant. It really depends on how you experience it and how you manage it.”

Amendments to the Americans with Disabilities Act that went into effect in 2009 clarify that people with diabetes are protected under anti-discrimination laws.

“There’s definitely been progress – [but] still lots of work to do,” said Greg Paul, vice chair of the American Diabetes Association’s legal advocacy subcommittee.

The association states that, in most jobs, diabetes likely would not put a worker or the public at risk. If the condition is well managed, Samo said, the individual is unlikely to have a hypoglycemic reaction.

“Some have horrible diabetes. That’s the minority,” Samo said. “Let’s talk about the bulk of them. You see your doctor, use the most modern way of managing it that helps reduce risk of sudden incapacitation, and monitor yourself carefully and exercise – being good about your disease.”

Employers and employees

By law, in most cases, workers with diabetes do not have to disclose the condition to their employer. “I would never say someone should definitely disclose,” Strobel Gower said. “If you need to do something differently on your job, because of your diabetes to do your job effectively, you should probably say something so you can ask for what you need, but it’s a personal choice.”

Workers who have diabetes may choose to disclose their condition to request “reasonable accommodations.” The employer may then require proof of disability and need for accommodations, the American Diabetes Association states. According to law, an employer cannot retaliate against a worker for requesting such accommodations.

Reasonable accommodations may include breaks to eat, take medicine and test blood sugar levels; and larger computer screens.

Accommodations also can involve protective equipment. In a 2012 OSHA interpretation of standards 1910.132 and 1910.136, the agency states that workers who cannot wear certain PPE required by their employer should discuss possible alternatives or reasonable accommodations. For example, some people with diabetes develop foot problems such as poor circulation and ulcers. OSHA notes that some PPE manufacturers offer footwear designed for people with diabetes, featuring extra wide steel or non-metallic toe caps.

Performance

An employer can exclude someone with diabetes from a job when the worker poses a “direct threat” – what the Equal Employment Opportunity Commission calls “a significant risk of substantial harm to the individual or others that cannot be eliminated or reduced through reasonable accommodation.” According to the commission, an employer who knows about a worker’s disability can require the worker to undergo a medical evaluation if the employer has observed performance issues and “reasonably believes” the issues are connected to the medical condition.

The National Diabetes Education Program’s “Diabetes at Work” project offers the following scenario as an example: A supervisor may ask an ironworker to undergo an exam or submit information from his doctor stating that he can safely do his job after the worker, who said he has diabetes, sweats and shakes during a break from hoisting iron beams.

In certain industries, guidance and standards help determine whether workers with diabetes can perform a job. For example, law enforcement officers with diabetes are expected to be evaluated on an individual basis. And the Federal Motor Carrier Safety Administration currently requires commercial motor vehicle drivers with insulin-treated diabetes mellitus to obtain an exemption every two years. However, the agency issued a notice of proposed rulemaking in May that would ease the exemption requirements for CMV drivers who can show they have their diabetes under control.

Safety-sensitive work

For safety-sensitive jobs – such as those involving a firearm or heavy machinery – concern has revolved around whether the worker will become disoriented or incapacitated, according to the American Diabetes Association.

This may be changing in some industries. FMCSA’s recent proposal to ease exemption requirements states that commercial motor vehicle drivers with insulin-treated diabetes mellitus “are as safe as other drivers when their condition is well-controlled.” Drivers with ITDM would be allowed to operate CMVs if they are cleared yearly by a medical examiner listed in the National Registry of Certified Medical Examiners. The risk posed by drivers with controlled diabetes is “very low in general,” the agency states in the rule, which was published in the May 4 Federal Register. FMCSA also believes a yearly doctor visit would allow physicians to promote awareness about hypoglycemia’s effect on driving.

“It’s really great progress,” Paul said. “There’s still plenty of protections. You have to have the treating health care provider provide his or her opinion about qualification. There’s a registry of doctors who have to be certified to provide the Department of Transportation exams. Those are at least two separate medical providers that have to weigh in on the qualification issue or safety issue.”

Similarly, opportunities have expanded for law enforcement officers with diabetes. ACOEM’s National Consensus Guidance for the Medical Evaluation of Law Enforcement Officers states that “blanket bans” of people with diabetes are illegal and inconsistent with medical information. And for firefighters, any disqualification due to diabetes or insulin use must be made on an individual basis.

“The concept is a well-controlled, well-educated, well-motivated diabetic can pretty much do anything,” Samo said.

For pilots, the Federal Aviation Administration states that a history of “diabetes mellitus requiring hypoglycemic medication” is a disqualifying condition, although diabetic pilots who use insulin can apply for a third-class certificate that allows them to fly privately or recreationally. However, the American Diabetes Association wants FAA to change its policy to allow people who treat diabetes with insulin to be medically certified for commercial airline operations.

Additional guidance to clear workers with diabetes for other safety-sensitive jobs would be beneficial, Samo said.

“If someone can be a firefighter and drive an emergency vehicle, why would you say, ‘I’m not going to hire you to drive a forklift in my factory because you’re diabetic,’” Samo said. “It’s irrational. I’d be hard put to think of a job that wouldn’t be able to use the same criteria as the police and fire criteria for other safety-sensitive jobs.”