PROFESSIONAL PRACTICE
Diabetes Screening in the Workplace Tauna Gulley, PhD, RN, FNP-BC; Dusta Boggs, RN, MSN, FNP-BC; Rebecca Mullins, DNP, RN, FNP; Emily Brock, RN, BSN
The prevalence of diabetes has increased worldwide and the pathophysiological problems associated with diabetes increase the potential for employees’ physical disabilities. These complications, including neuropathy, nephropathy, and visual impairment, negatively impact the job performance of employees and compromise workplace safety. Occupational health nurses can provide diabetes screening programs to employees and identify chronic disease risk factors early. This article describes an occupational diabetes screening program at a major corporation in Belize, Central America, defines diabetes, outlines the diabetes teaching plan, and presents the demographics of the participants and results of the screening. Cultural considerations and recommendations for future occupational diabetes screenings are proposed. [Workplace Health Saf 2014;62(11):444-446.]
N
early 200 million individuals have diabetes (also known as diabetes mellitus) worldwide. By 2025, the number will increase to an estimated 333 million individuals with diabetes if interventions are not undertaken to slow the progression of this epidemic (Katon, 2008; Szosland, 2010). The majority of diabetes cases occur among working adults (Nixon & Robertson, 2008). Research has linked diabetes ABOUT THE AUTHORS
Dr. Gulley is Assistant Professor of Nursing, Ms. Boggs is Instructor of Nursing, Dr. Mullins is Assistant Professor of Nursing, and Ms. Brock is a recent graduate of The University of Virginia’s College at Wise, Wise, Virginia, and is currently practicing as a Registered Nurse. Submitted: May 6, 2014; Accepted: July 9, 2014; Posted online: November 5, 2014 The authors have disclosed no potential conflicts, financial or otherwise. Correspondence: Tauna Gulley, PhD, RN, FNPBC, The University of Virginia’s College at Wise, Wise, VA 24293. E-mail: [email protected] doi:10.3928/21650799-20141014-01
444
to physical disability in adults worldwide (Wong et al., 2013), resulting in increased sick days for employees and increased costs for employers. In 2003, 30% of expenditures for diabetic employees were directly related to absences and disabilities (Akinci, Healey, & Coyne, 2003). Employees with diabetes often exhibit symptoms of depression, potentially resulting in poor adherence to diabetes management (i.e., glucose monitoring, medication adherence, and dietary compliance) and decreases in work productivity (Katon, 2008). The economic impact of employees with diabetes is significant (Akinci et al., 2003). Diabetes is a chronic illness that requires regular health care services and frequent monitoring by occupational health nurses. Occupational health nurses should continually monitor diabetic employees to ensure safe job performance. Specifically, employees
with diabetes should be monitored for hypoglycemic episodes that could result in unexpected incapacity; a hypoglycemic episode may also place other employees at risk for injury. Employees with diabetes and the possibility of sudden incapacity may need to be reassigned if they are working in hazardous areas (Nixon & Robertson, 2008). Employees with diabetes must also be assessed for the possibility of cardiac events, loss of vision, and neuropathies that could adversely affect their job performance and the safety of all employees. Risk of cardiovascular disease is higher among individuals with diabetes (Nixon & Robertson, 2008). A common complication of diabetes is peripheral neuropathy, which results in damage to the peripheral nerves and loss of sensation in the feet of individuals with diabetes. An individual with diabetic neuropathy can injure a foot and develop an ulcer without being aware of the wound on the foot. Occupational health nurses can regularly inspect employees’ feet and teach them to examine their own feet daily for the presence of ulcers (Jarrett, 2013). Screening for diabetes is an excellent way of promoting health and safety in the workplace. At the request of administrative personnel at a major corporation located in Belize, Central America, students and nursing faculty from a regional university in the United States conducted a diabetic screening program for the employees and administrative personnel. Sixty-seven
Copyright © American Association of Occupational Health Nurses, Inc. Downloaded from whs.sagepub.com at Bobst Library, New York University on July 20, 2015
PROFESSIONAL PRACTICE
employees participated, including line workers and administrative staff. Eight participants had been previously diagnosed with diabetes; two of the eight had insulin-dependent diabetes. DIABETES SCREENING PROGRAM Education
The diabetic screening program included teaching participants about the pathophysiology of diabetes, the different types of diabetes (type I and type II), guidelines for the diagnosis of diabetes, prevention and treatment of diabetes, and signs and symptoms of hypoglycemia and hyperglycemia. Participants were also taught the sequelae of prolonged, uncontrolled diabetes such as retinopathy, neuropathy, and nephropathy. The need for an adequate diet and exercise and the importance of foot care for individuals with diabetes were also discussed. Participants were provided with appropriate reading glasses and an explanation about the effects of diabetes on the eyes. Diabetes is the result of an abnormal relationship between glucose and insulin. Normally, insulin opens cells within the body to allow glucose to enter. After entering the cell, glucose is used as a fuel for energy, which results in lower blood glucose. When the body does not produce enough insulin or cells are resistant to insulin, individuals’ blood glucose levels rise, resulting in diabetes. Diabetes can be of two types: type I and type II. Type I diabetes occurs when the pancreas does not produce insulin. As a result, the individual needs insulin injections for the body to use glucose for energy. Type II diabetes occurs when the pancreas secretes inadequate insulin or the action of insulin is inadequate. Type II diabetes is the most common form (Szosland, 2010) and is characterized by insulin resistance, meaning the pancreas produces a sufficient amount of insulin but the body’s cells do not recognize the insulin; therefore, the body does not effectively use the insulin. Unlike type I, type II can occur later in life and may be prevented if certain lifestyle modifications are made.
During the screening, signs and symptoms of hyperglycemia and hypoglycemia were provided. Signs and symptoms of hyperglycemia include high levels of glucose in the urine (ketones), frequent urination (polyuria), and increased thirst (polydipsia). Signs and symptoms of hypoglycemia include shakiness, nervousness or anxiety, sweating, chills and clamminess, irritability, dizziness, hunger, and headache. Type I diabetes is characterized by polyuria (frequent urination), polydipsia (increased thirst), and polyphagia (frequent hunger). These same manifestations can occur with type II diabetes, although fatigue, visual changes, and recurrent infections may be the symptoms experienced by employees with type II diabetes. Employees who urinate often and have frequent hunger and thirst need numerous breaks throughout the shift, resulting in impaired performance; recurrent infections or visual changes may increase sick days. Visual changes could also result in altered product quality. Participants also learned the side effects of prolonged uncontrolled diabetes, such as retinopathy, neuropathy, and nephropathy. The primary language of Belize is English; however, many Belizeans indicate they prefer Spanish or Creole as their primary language. With the latter, interpreters were used to convey information during the health education and screening phases of the program. Screening
After participating in the educational component of the program, employees learned about the procedure for diabetes screening. Every employee elected to participate in the screening. The normal values for glucose were set between 70 and 110 mg/dL. After conducting 67 nonfasting glucose screenings, approximately half of the participants had glucose levels of 150 to 190 mg/dL, above the normal values. These employees had eaten lunch at noon and the screening took place at 3 p.m. Two of the employees with known insulin-dependent diabetes melli-
tus had levels in the 200 to 300 mg/ dL range; these two employees had taken their regular medications and eaten lunch. One participant, with undiagnosed diabetes, had a blood glucose reading of 581 mg/dL. This particular participant was a middleaged, normal weight man who rode a bike around the perimeter of the huge compound several times a day as part of his security job. He stated that he was unaware of anyone in his family having diabetes. He was active, but did consume a small to moderate amount of alcohol each week. He followed a diet consistent with his Belizean coworkers, a diet consisting mainly of carbohydrates. After the diabetes screening and educational activity, a drawing was held for a door prize. The door prize (a glucometer, testing strips, and lancets) was won by one of the employees who had insulin-dependent diabetes. He gave himself insulin every day but did not have a glucometer to check his blood glucose level. RESULTS Education
After each participant was screened, the result of the glucose screening was discussed with the employee immediately. If the glucose result was considerably high, the participant received education on the probable causes for the elevated results and lifestyle modifications were suggested, including dietary changes, appropriate exercise, and reduction in sugar intake. If the glucose result was abnormally high (> 190 mg/dL), participants were encouraged to see their primary health care provider for further evaluation. Cultural Considerations
The Central America Diabetes Initiative reported the prevalence of diabetes among Belizeans to be 12.9% (Barcelo et al., 2012). The typical Belizean diet consists of rice, fryjacks, tortillas, and plantains; this high starch, carbohydrate diet may contribute to the development of type II diabetes (Hu, van Dam, & Liu, 2001). Better nutrition sources include protein, complex carbohy-
WORKPLACE HEALTH & SAFETY • VOL. 62, NO. 11, 2014 Downloaded from whs.sagepub.com at Bobst Library, New York University on July 20, 2015
445
PROFESSIONAL PRACTICE
drates, and multi-grains, but economic constraints often inhibit inclusion of these foods in the Belizean diet. Economic issues also affect access to chronic disease management in this country. An anecdotal report of an individual who had diabetes with limited resources for purchasing oral diabetic medication stated she would check for high glucose levels by tasting her urine; only when her urine tasted sweet would she take her diabetic medications. This anecdotal report is a reflection of the economic conditions affecting access to medications and other resources for managing diabetes. Effective communication is essential when implementing any health education program. Employees often need to learn individual strategies to prevent the development of diabetes, thus strengthening the culture of health and safety for all employees. FUTURE RECOMMENDATIONS Future recommendations are to partner with the Belize Diabetes Association and the International Diabetes Association to develop culturally appropriate intervention strategies to prevent diabetes and optimize blood glucose control for those employees already diagnosed with diabetes. Diabetes screening and education will continue to be offered to industries in Belize. However, securing funding for teaching supplies and equipment needed for screenings, such as glucometers and test strips, presents a challenge for continuing these screenings. For the employer, the benefits of diabetic screening is to identify those individuals who have diabetes and eliminate the negative outcomes at-
446
tributed to this disease, including work absences, frequent health care visits, and lost productivity. More than 30% of the health-related costs attributed to diabetic employees are due to disability and work absences (Akinci et al., 2003). Given the positive response to this program from employees and administrative staff, the authors hope the employer may provide funding for future screenings. Documentation of the services provided, along with written, quantitative tools that assess knowledge regarding the prevention and control of diabetes, are essential components of a health promotion program (Akinci et al., 2003). Recommendations for future diabetic education programs for employees include a thorough vision examination and access to eyeglasses, including prescription glasses or reading glasses. Impaired vision is a safety issue that must be addressed. Enhancing the visual ability of employees could improve the overall safety of employees and enhance their work performance. CONCLUSIONS Employer-promoted health and wellness programs to enhance employee productivity and performance are beneficial for the employer and employee. Education about disease prevention and health promotion is essential when creating programs to promote health and safety in the workplace. This educational process can inform employees about ways they can positively impact their own health and safety and should lead to a sense of empowerment for employees. This empowerment may translate into absences for employees,
which makes sound economic sense for both employees and employer. Healthy employees are safer employees, and safe employees enhance overall safety for the organization. Finally, with knowledge about chronic disease management, employees should experience a sense of overall well-being, knowing that health promotion is not just a personal concern but also a concern for the employer. REFERENCES
Akinci, F., Healey, B., & Coyne, J. (2003). Improving the health status of US working adults with type 2 diabetes mellitus: A review. Disease Management & Health Outcomes, 11, 489-498. Barcelo, A., Gregg, E. W., Gerzoff, R. B., Wong, R., Perez Flores, E., Ramirez-Zea, M., . . . Villagra, L. (2012). Prevalence of diabetes and intermediate hyperglycemia among adults from the first multinational study of noncommunicable diseases in six Central American countries: The Central America Diabetes Initiative. Diabetes Care, 35, 738-740. Hu, F. B., van Dam, R. M., & Liu, S. (2001). Diet and risk of type II diabetes: The role of types of fat and carbohydrates. Diabetologia, 44, 805-817. Jarrett, L. (2013). Prevention and management of neuropathic diabetic foot ulcers. Nursing Standard, 28, 55-65. Katon, W. J. (2008). The comorbidity of diabetes mellitus and depression. American Journal of Medicine, 121, S8-S15. Nixon, H., & Robertson, D. (2008). The role of occupational health in diabetes management. Occupational Health, 60, 29-30. Szosland, D. (2010). Shift work and metabolic syndrome, diabetes mellitus and ischemic heart disease. International Journal of Occupational Medicine & Environmental Health, 23, 287-291. Wong, E., Backholer, K., Gearon, E., Harding, J., Freak-Poli, R., Stevenson, C., & Peeters, A. (2013). Diabetes and risk of physical disability in adults: A systematic review and meta-analysis. Lancet Diabetes Endocrinology, 1, 106-114.
Copyright © American Association of Occupational Health Nurses, Inc. Downloaded from whs.sagepub.com at Bobst Library, New York University on July 20, 2015
Diabetes Screening in the Workplace Tauna Gulley, PhD, RN, FNP-BC; Dusta Boggs, RN, MSN, FNP-BC; Rebecca Mullins, DNP, RN, FNP; Emily Brock, RN, BSN
The prevalence of diabetes has increased worldwide and the pathophysiological problems associated with diabetes increase the potential for employees’ physical disabilities. These complications, including neuropathy, nephropathy, and visual impairment, negatively impact the job performance of employees and compromise workplace safety. Occupational health nurses can provide diabetes screening programs to employees and identify chronic disease risk factors early. This article describes an occupational diabetes screening program at a major corporation in Belize, Central America, defines diabetes, outlines the diabetes teaching plan, and presents the demographics of the participants and results of the screening. Cultural considerations and recommendations for future occupational diabetes screenings are proposed. [Workplace Health Saf 2014;62(11):444-446.]
N
early 200 million individuals have diabetes (also known as diabetes mellitus) worldwide. By 2025, the number will increase to an estimated 333 million individuals with diabetes if interventions are not undertaken to slow the progression of this epidemic (Katon, 2008; Szosland, 2010). The majority of diabetes cases occur among working adults (Nixon & Robertson, 2008). Research has linked diabetes ABOUT THE AUTHORS
Dr. Gulley is Assistant Professor of Nursing, Ms. Boggs is Instructor of Nursing, Dr. Mullins is Assistant Professor of Nursing, and Ms. Brock is a recent graduate of The University of Virginia’s College at Wise, Wise, Virginia, and is currently practicing as a Registered Nurse. Submitted: May 6, 2014; Accepted: July 9, 2014; Posted online: November 5, 2014 The authors have disclosed no potential conflicts, financial or otherwise. Correspondence: Tauna Gulley, PhD, RN, FNPBC, The University of Virginia’s College at Wise, Wise, VA 24293. E-mail: [email protected] doi:10.3928/21650799-20141014-01
444
to physical disability in adults worldwide (Wong et al., 2013), resulting in increased sick days for employees and increased costs for employers. In 2003, 30% of expenditures for diabetic employees were directly related to absences and disabilities (Akinci, Healey, & Coyne, 2003). Employees with diabetes often exhibit symptoms of depression, potentially resulting in poor adherence to diabetes management (i.e., glucose monitoring, medication adherence, and dietary compliance) and decreases in work productivity (Katon, 2008). The economic impact of employees with diabetes is significant (Akinci et al., 2003). Diabetes is a chronic illness that requires regular health care services and frequent monitoring by occupational health nurses. Occupational health nurses should continually monitor diabetic employees to ensure safe job performance. Specifically, employees
with diabetes should be monitored for hypoglycemic episodes that could result in unexpected incapacity; a hypoglycemic episode may also place other employees at risk for injury. Employees with diabetes and the possibility of sudden incapacity may need to be reassigned if they are working in hazardous areas (Nixon & Robertson, 2008). Employees with diabetes must also be assessed for the possibility of cardiac events, loss of vision, and neuropathies that could adversely affect their job performance and the safety of all employees. Risk of cardiovascular disease is higher among individuals with diabetes (Nixon & Robertson, 2008). A common complication of diabetes is peripheral neuropathy, which results in damage to the peripheral nerves and loss of sensation in the feet of individuals with diabetes. An individual with diabetic neuropathy can injure a foot and develop an ulcer without being aware of the wound on the foot. Occupational health nurses can regularly inspect employees’ feet and teach them to examine their own feet daily for the presence of ulcers (Jarrett, 2013). Screening for diabetes is an excellent way of promoting health and safety in the workplace. At the request of administrative personnel at a major corporation located in Belize, Central America, students and nursing faculty from a regional university in the United States conducted a diabetic screening program for the employees and administrative personnel. Sixty-seven
Copyright © American Association of Occupational Health Nurses, Inc. Downloaded from whs.sagepub.com at Bobst Library, New York University on July 20, 2015
PROFESSIONAL PRACTICE
employees participated, including line workers and administrative staff. Eight participants had been previously diagnosed with diabetes; two of the eight had insulin-dependent diabetes. DIABETES SCREENING PROGRAM Education
The diabetic screening program included teaching participants about the pathophysiology of diabetes, the different types of diabetes (type I and type II), guidelines for the diagnosis of diabetes, prevention and treatment of diabetes, and signs and symptoms of hypoglycemia and hyperglycemia. Participants were also taught the sequelae of prolonged, uncontrolled diabetes such as retinopathy, neuropathy, and nephropathy. The need for an adequate diet and exercise and the importance of foot care for individuals with diabetes were also discussed. Participants were provided with appropriate reading glasses and an explanation about the effects of diabetes on the eyes. Diabetes is the result of an abnormal relationship between glucose and insulin. Normally, insulin opens cells within the body to allow glucose to enter. After entering the cell, glucose is used as a fuel for energy, which results in lower blood glucose. When the body does not produce enough insulin or cells are resistant to insulin, individuals’ blood glucose levels rise, resulting in diabetes. Diabetes can be of two types: type I and type II. Type I diabetes occurs when the pancreas does not produce insulin. As a result, the individual needs insulin injections for the body to use glucose for energy. Type II diabetes occurs when the pancreas secretes inadequate insulin or the action of insulin is inadequate. Type II diabetes is the most common form (Szosland, 2010) and is characterized by insulin resistance, meaning the pancreas produces a sufficient amount of insulin but the body’s cells do not recognize the insulin; therefore, the body does not effectively use the insulin. Unlike type I, type II can occur later in life and may be prevented if certain lifestyle modifications are made.
During the screening, signs and symptoms of hyperglycemia and hypoglycemia were provided. Signs and symptoms of hyperglycemia include high levels of glucose in the urine (ketones), frequent urination (polyuria), and increased thirst (polydipsia). Signs and symptoms of hypoglycemia include shakiness, nervousness or anxiety, sweating, chills and clamminess, irritability, dizziness, hunger, and headache. Type I diabetes is characterized by polyuria (frequent urination), polydipsia (increased thirst), and polyphagia (frequent hunger). These same manifestations can occur with type II diabetes, although fatigue, visual changes, and recurrent infections may be the symptoms experienced by employees with type II diabetes. Employees who urinate often and have frequent hunger and thirst need numerous breaks throughout the shift, resulting in impaired performance; recurrent infections or visual changes may increase sick days. Visual changes could also result in altered product quality. Participants also learned the side effects of prolonged uncontrolled diabetes, such as retinopathy, neuropathy, and nephropathy. The primary language of Belize is English; however, many Belizeans indicate they prefer Spanish or Creole as their primary language. With the latter, interpreters were used to convey information during the health education and screening phases of the program. Screening
After participating in the educational component of the program, employees learned about the procedure for diabetes screening. Every employee elected to participate in the screening. The normal values for glucose were set between 70 and 110 mg/dL. After conducting 67 nonfasting glucose screenings, approximately half of the participants had glucose levels of 150 to 190 mg/dL, above the normal values. These employees had eaten lunch at noon and the screening took place at 3 p.m. Two of the employees with known insulin-dependent diabetes melli-
tus had levels in the 200 to 300 mg/ dL range; these two employees had taken their regular medications and eaten lunch. One participant, with undiagnosed diabetes, had a blood glucose reading of 581 mg/dL. This particular participant was a middleaged, normal weight man who rode a bike around the perimeter of the huge compound several times a day as part of his security job. He stated that he was unaware of anyone in his family having diabetes. He was active, but did consume a small to moderate amount of alcohol each week. He followed a diet consistent with his Belizean coworkers, a diet consisting mainly of carbohydrates. After the diabetes screening and educational activity, a drawing was held for a door prize. The door prize (a glucometer, testing strips, and lancets) was won by one of the employees who had insulin-dependent diabetes. He gave himself insulin every day but did not have a glucometer to check his blood glucose level. RESULTS Education
After each participant was screened, the result of the glucose screening was discussed with the employee immediately. If the glucose result was considerably high, the participant received education on the probable causes for the elevated results and lifestyle modifications were suggested, including dietary changes, appropriate exercise, and reduction in sugar intake. If the glucose result was abnormally high (> 190 mg/dL), participants were encouraged to see their primary health care provider for further evaluation. Cultural Considerations
The Central America Diabetes Initiative reported the prevalence of diabetes among Belizeans to be 12.9% (Barcelo et al., 2012). The typical Belizean diet consists of rice, fryjacks, tortillas, and plantains; this high starch, carbohydrate diet may contribute to the development of type II diabetes (Hu, van Dam, & Liu, 2001). Better nutrition sources include protein, complex carbohy-
WORKPLACE HEALTH & SAFETY • VOL. 62, NO. 11, 2014 Downloaded from whs.sagepub.com at Bobst Library, New York University on July 20, 2015
445
PROFESSIONAL PRACTICE
drates, and multi-grains, but economic constraints often inhibit inclusion of these foods in the Belizean diet. Economic issues also affect access to chronic disease management in this country. An anecdotal report of an individual who had diabetes with limited resources for purchasing oral diabetic medication stated she would check for high glucose levels by tasting her urine; only when her urine tasted sweet would she take her diabetic medications. This anecdotal report is a reflection of the economic conditions affecting access to medications and other resources for managing diabetes. Effective communication is essential when implementing any health education program. Employees often need to learn individual strategies to prevent the development of diabetes, thus strengthening the culture of health and safety for all employees. FUTURE RECOMMENDATIONS Future recommendations are to partner with the Belize Diabetes Association and the International Diabetes Association to develop culturally appropriate intervention strategies to prevent diabetes and optimize blood glucose control for those employees already diagnosed with diabetes. Diabetes screening and education will continue to be offered to industries in Belize. However, securing funding for teaching supplies and equipment needed for screenings, such as glucometers and test strips, presents a challenge for continuing these screenings. For the employer, the benefits of diabetic screening is to identify those individuals who have diabetes and eliminate the negative outcomes at-
446
tributed to this disease, including work absences, frequent health care visits, and lost productivity. More than 30% of the health-related costs attributed to diabetic employees are due to disability and work absences (Akinci et al., 2003). Given the positive response to this program from employees and administrative staff, the authors hope the employer may provide funding for future screenings. Documentation of the services provided, along with written, quantitative tools that assess knowledge regarding the prevention and control of diabetes, are essential components of a health promotion program (Akinci et al., 2003). Recommendations for future diabetic education programs for employees include a thorough vision examination and access to eyeglasses, including prescription glasses or reading glasses. Impaired vision is a safety issue that must be addressed. Enhancing the visual ability of employees could improve the overall safety of employees and enhance their work performance. CONCLUSIONS Employer-promoted health and wellness programs to enhance employee productivity and performance are beneficial for the employer and employee. Education about disease prevention and health promotion is essential when creating programs to promote health and safety in the workplace. This educational process can inform employees about ways they can positively impact their own health and safety and should lead to a sense of empowerment for employees. This empowerment may translate into absences for employees,
which makes sound economic sense for both employees and employer. Healthy employees are safer employees, and safe employees enhance overall safety for the organization. Finally, with knowledge about chronic disease management, employees should experience a sense of overall well-being, knowing that health promotion is not just a personal concern but also a concern for the employer. REFERENCES
Akinci, F., Healey, B., & Coyne, J. (2003). Improving the health status of US working adults with type 2 diabetes mellitus: A review. Disease Management & Health Outcomes, 11, 489-498. Barcelo, A., Gregg, E. W., Gerzoff, R. B., Wong, R., Perez Flores, E., Ramirez-Zea, M., . . . Villagra, L. (2012). Prevalence of diabetes and intermediate hyperglycemia among adults from the first multinational study of noncommunicable diseases in six Central American countries: The Central America Diabetes Initiative. Diabetes Care, 35, 738-740. Hu, F. B., van Dam, R. M., & Liu, S. (2001). Diet and risk of type II diabetes: The role of types of fat and carbohydrates. Diabetologia, 44, 805-817. Jarrett, L. (2013). Prevention and management of neuropathic diabetic foot ulcers. Nursing Standard, 28, 55-65. Katon, W. J. (2008). The comorbidity of diabetes mellitus and depression. American Journal of Medicine, 121, S8-S15. Nixon, H., & Robertson, D. (2008). The role of occupational health in diabetes management. Occupational Health, 60, 29-30. Szosland, D. (2010). Shift work and metabolic syndrome, diabetes mellitus and ischemic heart disease. International Journal of Occupational Medicine & Environmental Health, 23, 287-291. Wong, E., Backholer, K., Gearon, E., Harding, J., Freak-Poli, R., Stevenson, C., & Peeters, A. (2013). Diabetes and risk of physical disability in adults: A systematic review and meta-analysis. Lancet Diabetes Endocrinology, 1, 106-114.
Copyright © American Association of Occupational Health Nurses, Inc. Downloaded from whs.sagepub.com at Bobst Library, New York University on July 20, 2015
