FPG Normal IFG DM Chronic Complications of Diabetes

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FPG Normal ≤ IFG ≤ DM

FPG Normal ≤ IFG ≤ DM

Chronic Complications of Diabetes Mellitus Microvascular Eye disease Retinopathy (nonproliferative/proliferative) Macular edema Neuropathy Sensory

Chronic Complications of Diabetes Mellitus Microvascular Eye disease Retinopathy (nonproliferative/proliferative) Macular edema Neuropathy Sensory and motor (mono and polyneuropathy) Autonomic Nephropathy Macrovascular Coronary heart disease Peripheral arterial disease Cerebrovascular disease Other Gastrointestinal (gastroparesis, diarrhea) Genitourinary (uropathy/sexual dysfunction) Dermatologic Infectious Cataracts Glaucoma Periodontal disease Hearing loss

Guidelines for Ongoing Medical Care for Patients with Diabetes Self monitoring of blood glucose

Guidelines for Ongoing Medical Care for Patients with Diabetes Self monitoring of blood glucose (individualized frequency) A 1 C testing (2– 4 times/year) Patient education in diabetes management (annual) Medical nutrition therapy and education (annual) Eye examination (annual) Foot examination (1– 2 times/year by physician; daily by patient) Screening for diabetic nephropathy (annual) Blood pressure measurement (quarterly) Lipid profile and serum creatinine (estimate GFR) (annual) Influenza/pneumococcal immunizations Consider antiplatelet therapy

Treatment Goals for Adults with Diabetes Index Goal Glycemic control A 1 C <7.

Treatment Goals for Adults with Diabetes Index Goal Glycemic control A 1 C <7. 0% Pre prandial capillary plasma glucose 3. 9– 7. 2 mmol/L (70– 130 mg/d. L) Peak postprandial capillary plasma glucose <10. 0 <1. 7 mmol/L (<180 mg/d. L) Blood pressure <130/80 lipids Low density lipoprotein <2. 6 mmol/L (100 mg/d. L) High density lipoprotein >1 mmol/L (40 mg/d. L) in men >1. 3 mmol/L (50 mg/d. L) in women Triglycerides <1. 7 mmol/L (150 mg/d. L)

Diabetes & impairment(1/2) The risk of hypoglycemia and visual impairment may legitimately debar those

Diabetes & impairment(1/2) The risk of hypoglycemia and visual impairment may legitimately debar those with poorly controlled type 1 diabetes from jobs where safety is an important factor,

Diabetes & impairment(2/2) , but people with diabetes are not invalids and most can

Diabetes & impairment(2/2) , but people with diabetes are not invalids and most can work normally and should not be discriminated against in job selection.

Type 1 If untreated, will develop sever hyperglycemia and ketonemia, resulting in dehydration, weight

Type 1 If untreated, will develop sever hyperglycemia and ketonemia, resulting in dehydration, weight loss and sever weakness, progressing into stupor, coma and death. (usually begins in young but may occur at any age)

Type 2 In early years, these peoples do not develop sever hyperglycemia and symptoms.

Type 2 In early years, these peoples do not develop sever hyperglycemia and symptoms. In later when insulin production falls hyperglycemic symptoms become more evident. (generally over 40 years old)

Disability Discrimination Act(1/2) Within the meaning of the DDA, type 1 DM must be

Disability Discrimination Act(1/2) Within the meaning of the DDA, type 1 DM must be regarded as a disability. Type 2 may be different, as this people may be asymptomatic and have no complication.

Disability Discrimination Act(2/2) Where complication such as retinopathy exist, they will be covered by

Disability Discrimination Act(2/2) Where complication such as retinopathy exist, they will be covered by the act.

Disability One is considered disabled only if unable to perform abroad class of occupations

Disability One is considered disabled only if unable to perform abroad class of occupations rather than just one job. Example: LBP, restriction: lifting no more than 50 pounds.

Written medical standards Unfortunately Written medical standards are rarely available for most jobs. Medical

Written medical standards Unfortunately Written medical standards are rarely available for most jobs. Medical standards aid the physician in making decision on whether an applicant can or can not perform the job safely.

restriclimitations & limitations medical restrictions Person with diabetes Should avoid rotating shift work because

restriclimitations & limitations medical restrictions Person with diabetes Should avoid rotating shift work because of the adverse effects of circadian rhythm dis ruptionon glycemic control functional limitations None: Fully capable of performing all tasks

impairment The main chronic complications of DM are associated impairments.

impairment The main chronic complications of DM are associated impairments.

Criteria for Rating Permanent Impairment Due to DM(5 th) Class 1(0 -5%) Type 2

Criteria for Rating Permanent Impairment Due to DM(5 th) Class 1(0 -5%) Type 2 DM can be controlled by diet & May or may not have microangiopathy as retinopathy or albuminuria >30 mg/dl Class 2(6 -10%) Type 2 DM & Satisfactory control requires both diet+ medication (oral or insulin) & Microangiopathy, may or may not visual impairment Class 3(11 -20%) Type 1 DM, with or without Microangiopathy Class 4(21 -40%) Type 1 DM & Hypoglycemia or hyperglycemia occurs frequently despite efforts of both patient & physician

Example 4 o years old woman. History: Onset of DM 1 20 years earlier.

Example 4 o years old woman. History: Onset of DM 1 20 years earlier. Originally presented with polydypsia, polyuria, weigh loss, BS=350. Current symptoms: Occasional visual changes with floaters, flashes & decreased visual acuity.

 PX: Ophthalmologic exam: Background retinopathy. Lab: Hb. A 1 c: 10. 5% DX:

PX: Ophthalmologic exam: Background retinopathy. Lab: Hb. A 1 c: 10. 5% DX: DM 1 with diabetic microangiopathy.

Impairment? Impairmenting rate: 20% Impairment of the whole person. Comment: Referral to ophthalmologist (combine

Impairment? Impairmenting rate: 20% Impairment of the whole person. Comment: Referral to ophthalmologist (combine any visual impairment & with endocrine impairment)

Criteria for Rating Impairment Due to DM(6 th) class 0 1 2 3 4

Criteria for Rating Impairment Due to DM(6 th) class 0 1 2 3 4 WPI(%) 0 1 5 6 10 11 15 16 28 1. 2. 3. 4. 5 ( ABCDE ) 6. 7. 8. 9. 10 ( ABCDE ) History of IFG, dose not require treat DM &/or metabolic Syn treated with a single oral DM well controlled with 2 3 oral agents or insulin <6 6 6. 5 6. 6 8 8. 1 10 >10 0 point 1 5 6 10 11 15 ≥ 16 Severity grade(%) History Hb. A 1 c(%) BOTC* 11. 12. 13. 14. 15 (ABCDE) 16. 19. 22. 25. 28 (ABCDE) DM well controlled DM that is not with ≥ 4 oral consistently agents or use of controlled despite use insulin with oral of any treatment agents * (Burden Of Treatment Compliance)

Example Subject: 40 year old man HX: DM discovered on a routine medical exam.

Example Subject: 40 year old man HX: DM discovered on a routine medical exam. Current symptoms: Feels well, lost 24. 5 Kg in the last year. Able to perform all desired activities. Weight has been stable over the past 6 months. PX : Moderately obese. No diabetic retinopathy. Reminder of exam: normal. Lab: 1+ glycosuria. No albuminuria. FBS=160. after 6 months on a special diet, weight: normal, FBS= 110, 12 months after diet, FBS=90, Hb. A 1 c=5. 5%.

 DX: Type 2 DM controlled by diet, without microangiopathy. BOTC: No points for

DX: Type 2 DM controlled by diet, without microangiopathy. BOTC: No points for medication, but 2 points for dietary modification. Impairment: BTOC: class 1 but Hb. A 1 c: class 0, WPI: 2%.

Agent Orange AO=Herbicide Orange + Agent LNX Used by U. S military in Vietnam

Agent Orange AO=Herbicide Orange + Agent LNX Used by U. S military in Vietnam Warfare U. S military army helicopter spraying A. O over the Vietnamese agricultural lands.

Association with occupation & environment Rodenticide Vacur After human ingestion Anti islet cell antibodies

Association with occupation & environment Rodenticide Vacur After human ingestion Anti islet cell antibodies

The work record of people with DM An individual basis for DM considered jointly

The work record of people with DM An individual basis for DM considered jointly by an occupational physician and diabetologist. (FFW)

Advisory services The diabetologist can profiled detailed medical information, While the occupational physician is

Advisory services The diabetologist can profiled detailed medical information, While the occupational physician is best placed to assess the suitability for particular occupation. For especially difficult decisions, the combine opinion of diabetologist and occupational medicine are particularly useful.

Suitability(periodic exam) Suitability for employment should be re assessed annually by both an occupational

Suitability(periodic exam) Suitability for employment should be re assessed annually by both an occupational physician and a diabetologist.

pre post %change FVC 4 4. 26 +7 FEV 1 2. 91 3. 32

pre post %change FVC 4 4. 26 +7 FEV 1 2. 91 3. 32 +14 FEV 1/ FVC 72. 8 77. 9 +7 Thanks for your FEF 25 -75 2. 32 3. 09 +31 attention