WORK A Journal of Prevention, Assessment &. Rehabilitation
ELSEVIER
Work 9 (1997) 147-155
Understanding the needs of diabetics in the workplace: a clinician's perspective 1 Bonnie Sanders Polin* 2436 East 47th Place, Tulsa, OK 74105, USA
Abstract The purpose of this article is to acquaint Occupational and Physical therapists with the diabetic client so as to better understand their disease and therefore aid in interventions necessary for their continued performance in the workplace. The article will include sections on self care techniques necessary for control of glucose levels, acute and chronic complications of the disease process, emotional stress, both internal and external, that diabetics face daily plus stress management ideas. Finally, the role of the professional in aiding diabetics through specific modifications in their work environment as mandated by the Americans with Disabilities Act will be addressed as it applies to this diverse population. It is written from the perspective of a diabetic who is trained as a psychologist, started an educational clinic for diabetics, and has written a book with the Joslin Diabetes Center, The Joslin Gourmet Diabetes Cookbook © 1997 Elsevier Science Ireland Ltd. Keywords: Diabetes; Employment; Stress
- - - - - - - - - - - - - - - - - - - - - - - - _....._ - - - -
1. Introduction
On my 41st birthday, I received lovely gifts from my family and a diagnosis of insulin-depen-
1 Diabetes organizations which offer information: American Diabetes Association, 1660 Duke Street, po Box 15757, Alexandria, VA 22314. National Diabetes Information Clearing House, 805 15th Street, NW, Room 500, Washington, DC 20005. Juvenile Diabetes Foundation, 432 Park Avenue South, New York, NY 10016. Joslin Diabetes Center, One Joslin Place, Boston, MA 02115 * Corresponding author. Tel.: + 1 918 7441777; fax: + 1 918 7441777; e-mail: [email protected]
dent diabetes. On that day I became a part of the more than 13 000 000 Americans with diabetes, a disease which is growing in the US each year by 6%. Sadly, only half of this population is aware that they have diabetes. My life changed from one where time could be ignored to a life of regulation and schedules. I also began to see, for the first time, the difficulties of coping with an unseen chronic disease which can ultimately cause death. Although many professionals are rather cavalier about the diagnosis because diabetes is neither an acute disease nor is there a cure, the necessity for self care and education is paramount.
1051-9815/97/$17.00 © 1997 Elsevier Science Ireland Ltd. All rights reserved. PIIS1051-9815(97)00034-X
148
B.S. Polin / Work 9 (1997) 147-155
As Hiss et al. (1991) found, barriers to treatment of type II diabetes are that it is a silent disease with delayed complications whose treatment is neither financially nor intellectually rewarding. It is often mistakenly viewed as a mild disease by both patients and physicians. The lifestyle changes for patients to gain optimal control are very difficult and the technology does not exist to achieve euglycemia, or normal blood glucose levels, for most patients. Diabetics, however, are more than four times as likely to go blind as are non-diabetics. They are 19 times more likely to develop kidney disease, 28 times more likely to be an amputee and two-four times more likely to develop heart disease than non-diabetics. Diabetes accounts for nearly 15% of healthcare expenditures in the US each year (Quickel, 1996). Yet in an investigation comparing diabetics and non-diabetics in the workplace, diabetics' composite job performance, task behaviors, down-time behaviors and hazardous behaviors were all rated better than the norm (Greene and Geroy, 1993). Understanding diabetes is essential to professionals charged with helping persons with this disease so that clients can fulfill their potential for positive contributions in the work place. This paper will review the effects of stress on control of glucose levels, issues of disclosure in the work place, self care guidelines for diabetics, and finally, suggestions geared to occupational and physical therapists for adaptations in the field.
2. Stress and diabetes Before we look at the effect of external stress on diabetics, it is important to understand the scope of intrusion into everyday life that diabetes imposes. Diabetes is a chronic disorder which impedes the metabolism of carbohydrates, protein, and fat, which means that the out of control patient is unable to get sufficient nutriment from meals. I often share that when I first became a diabetic, I felt as if I walked a tight rope, as the very thing I needed to live, i.e. food, wa& making my blood sugars soar. At the present time diabetes mellitus is applied to disorders characterized by fasting plasma glucose levels above de-
fined levels. There are three mutually exclusive classes of diabetes: type I, or insulin-dependent diabetes which makes up about 10% of diabetics in the country, type II, or non-insulin-dependent diabetes, and other types, which includes impaired glucose tolerance and gestational diabetes. Patients with type I diabetes may be of any age but are usually diagnosed before they are 40. The diagnosis peaks at 11 or 12 years of age and almost all are diagnosed before the age of 20. They are usually thin, and have an abrupt onset of symptoms. These patients are prone to ketoacidosis and need exogenous insulin to sustain life. Patients with type II diabetes are typically older than 40 when diagnosed, and tend to be obese. They may have had few symptoms. They are not prone to ketoacidosis except under extreme stress. They are not dependent on exogenous insulin, but, they may require its use when traditional treatments do not control hyperglycemia. The insulin secretory defects and insulin resistance of type II diabetes can be partially reversed, hence the importance of weight loss, exercise and tight control of blood glucose levels. Additional stress on the diabetic is the knowledge that there are long-term chronic complications of both type I and type II diabetes. These include accelerated macrovascular and microvascular diseases, most notably accelerated coronary atherosclerosis, cerebrovascular athereosclerosis, and peripheral vascular disease, retinopathy, and nephropathy. Mixed vascular and neuropathic diseases include both leg and foot ulcers. Neuropathic conditions may be either peripheral or visceral. Acute complications include ketoacidosis and hypoglycemia (Rifkin, 1984). Symptoms of undiagnosed or uncontrolled diabetes include excessive thirst and appetite, blurred vision, frequent urination, slowed healing, weight loss, dry skin and extreme fatigue. In fact, the first question I ask of new patients in our diabetes clinic is, 'How often do you fall asleep after a meal?' Other complications, which we will discuss more fully when we look at how stress impedes glucose control, are psychiatric diagnoses which in part can be linked to coping with a chronic disease like diabetes. Whereas many people go through their days with little thought about exact
B.S. Polin jWork 9 (1997) 147-155
time schedules, mandatory exercise, stress control, medications, medical issues, and food preparation, the diabetic population must concentrate on these as well as family, work, and societal pressures. Stress is normal for all humans, a fact that we, as a society, seem to forget at times. According to Rundell and Wise (1996), there is much speculation based on cross-sectional and retrospective studies that psychosocial stress initiates the attack on beta cells causing diabetes or further alterations of glucose metabolism in diabetics. In some studies, however, results are confounded by factors such as exercise, alcohol and diet. The authors report that there is better research suggesting that a subgroup of diabetics do react to acute emotional stress. Less controversial, and better established is the association of chronic stress such as anxiety, depression, and family dysfunction to poor control, loss of social contacts, and impulsivity. The question here is whether the resultant behavior is due to the stress or the systemic hyperglycemia. There is, however, evidence of both the acute and chronic effect of diabetes on cognitive functioning usually of subclinical intensity. This creates interpersonal problems of misunderstanding others (Cox and Gonder-Frederick, 1992). Improved glucose control has significant benefits on psychosocial functioning in diabetics, an excellent reason for support groups and individual therapy when diabetes is out of control. As long as we exist, we face stress on a daily basis. When it is experienced, the body behaves as if it were under attack either physically, as from illness or injury, or from emotional pressures. The result of this is to release stored energy, i.e. fat and glucose, to the cells so that the person can escape danger. For the diabetic, who may not have insulin available to allow this extra glucose and fat into the cells, there can be a build up of glucose in the blood. In diabetes, stress, either acute or chronic, may affect the body in two ways. First, persons under stress may not take care of themselves, forgetting exercise needs, dietary guidelines, etc. Second, stress hormones may alter glucose levels directly. Diabetes Forecast (December, 1995) in an ex-
149
cellent article on this subject, reported what I have seen in myself and other diabetics. Type I diabetics have mixed effects under emotional stress, some experiencing lower glucose levels, and some higher. For Type II diabetics, the majority of people experience higher glucose levels. Physical stress such as illness or injury raises blood levels in both types of diabetes. The same article concludes that type A personalities may have higher glucose levels when under stress than type B personalities who are more easy-going and, under similar situations may experience lower glucose elevations. Symptoms of stress include shortness of breath, headaches, indigestion, diarrhea, irritability, tightness of muscles, tiredness, insomnia, overeating, alcohol abuse, difficulty concentrating, drug abuse, and moodiness. Other maladaptive reactions include marital tensions, procrastination, abusive behavior, decreased sexual desire and aggression (Leatz, 1992). Sherbourne et al. (1996) in reporting their recent research on chronically ill patients, found that diabetics with unresolved anxiety were as debilitated as patients with heart disease. There were significant differences in the functioning of patients who did not have comorbid anxiety, thus leading the authors to highlight the social importance of identifying these patients and helping them. Adding to normal developmental stresses experienced throughout the life cycle are the ones unique to diabetes (Beaser and Hill, 1995). Coping with this disease is a 24-h job. The chonicity of diabetes for some people is emotionally draining to begin with, and may become even worse with added external stresses. There are a series of emotional reactions one experiences when first diagnosed with a chronic, life threatening disease. These include shock, denial and then fear, anxiety and depression. When resolved, acceptance of having and living with diabetes is attained. Often patients describe this as finally becoming a person with a problem pancreas, rather then feeling like damaged goods. This mind-body split is an important step in taking control of one's life again, but, stress may cause temporary emotional regression. An additional stress is that diabetes is an invisible disease and for some this causes
150
B.S. Polin / Work 9 (1997) 147-155
significant conflict. While others indulge in forbidden food and drink, the otherwise healthy looking diabetic feels alienated. It is this differentness that at times is overwhelming and must be addressed. When people ask me why I originally decided to write my cookbook, The Joslin Diabetes Gourmet Cookbook, the answer is simple. I could not handle making complicated meals for my family and guests while I ate plain broiled 'something' or salad with lemon juice. This sense of being different and damaged leads to cheating and then guilt which can exacerbate anxiety and depression and further non-compliance. Diabetes, by its seeming unpredictability, is very frustrating. When I first was diagnosed, my physician shared that if one ate the same thing every day, exercised the same way, and had the same stresses, one's glucose levels could still fluctuate. He cautioned not to give in to the frustration of having to be perfect. I have, in fact, spoken to many type A personalities who went through a period of not monitoring their blood levels because they were not perfect. The glucose monitor became an enemy, instead of a tool to help them control diabetes. When I conducted therapy, we would often talk about the additive effect of stresses on our lives, noting that most people can cope with one, some can deal with two, but most feel overwhelmed when the number goes much above a tolerable level. Of course, this depends on the type of stress and its intensity and duration, but reactions are predictable when one knows the person's coping skills and the types of added stresses they experience. listening to your clients and noting their work records will give you excellent clues as to how to propose changes and interventions which will be most beneficial. 3. Employment issues Up to this point we have addressed stresses which emanate from fears and anxiety about long-term and acute complications of the disease process, normal developmental stresses and illness as well as the daily attacks on self worth which stem from coping with a hidden and frustrating disease. Now, we address a most pertinent
area for any person with a chronic disease, that is fear of discrimination in the workplace. This brings up the question of whether to share the truth about having diabetes with one's colleagues and employers. This dilemma can exacerbate other stresses often causing added anxiety for the diabetic. Greene and Geroy (1993), report that despite improvements in diabetes management, people with diabetes have higher unemployment rates, reduced employment prospects, more difficult time during the employment process, higher rate of job denial and a greater frequency of job loss than those without diabetes. One might postulate that with the passage of the Americans with Disabilities Act (ADA), such statistics would improve, but reading Mail Call in Diabetes Forecast, the monthly magazine of the American Diabetes Association, there continues to be reports of employers demoting workers for asking for time to check blood glucose levels (Diabetes Forecast, Jan. 1995). Dickson, in an article, Diabetes and Employment published on the Diabetes Forum (1996), reports on the nurse who sent a resume to 16 institutions including a cover letter mentioning her diabetes. She received no job offers. Mazur (1995) recounts a 7-year legal battle with the government which changed the US Office of Personnel Management regulations effecting all GS-1811 criminal investigator or special agent jobs within the government. Thanks to perseverance, there is no longer a blanket exclusion for people with type I diabetes. Each applicant will be judged on a case-by-case basis. These situations reflect misperceptions about diabetes, but as with any other disability, employers are required by the ADA to look at the actual limitations of employees, not precedents set years before. It is, however, the perseverance of the employee that forces employers to hire and promote them, seeing their assets rather than a disease or disability. The Metabolic Control Matters monograph published by the US Departments of Health and Human Services and the National Institutes of Health (1993), which presents analysis and recommendations stemming from the Diabetes Control and Complications Trials (DCCT), sees the work-
B.S. Polin
I
Work 9 (1997) 147-155
place as pivotal in the care of diabetes. Research cited (Heins et aI., 1993), suggests a relationship between meals missed and supervisors' characteristics of tolerance of freedom, emphasis on production, and job characteristics of work pressure and locus of control over the pace of work. Greater co-worker sensitivity was associated with fewer insulin reactions. The monograph implies that work places which allow for storage places for diabetic supplies and time to check glucose levels positively correlate with lower glycated hemoglobin values. Sadly, in a companion study (Padgett and Heins, 1992), it was reported that human resource managers showed limited knowledge about diabetes and had little interest in gaining more insight into the disease. In general they felt diabetes was not a problem in their workplaces and therefore saw no need to educate themselves or workers about the disease. There are few work restrictions for people who control their diabetes. Some laws prohibit insulin dependent diabetics from serving in the armed forces and occupations such as interstate truck driver and pilot. There are also some police forces which bar diabetics. The American Diabetes Association's position is that employees, their doctors, and employers should work together on an individual basis where dangerous aspects of work are in question. For the most part, people with diabetes will need little help from their supervisors except for those based on an understanding of the worker's needs around issues of scheduling and breaks. It is evident from working with people who live successfully with diabetes that they are self-disciplined, aware and responsible, i.e. the supervisor's dream employee. The question then of when and if to tell employers is a complicated one. Donoguue and Siegel (1992) in a book for patients living with invisible chronic illness discuss this question. Most people, they postulate, want to be fair to employers, but fear for their promotions or ability to keep jobs. Questions to ask oneself revolve around the effect of revealing the secret vs. the anxiety and stress of keeping it, the perceived embarrassment, realistic reading of the boss, and any effects of the person's performance on the company. In most cases I would
151
agree with the authors that out of fairness to both the diabetic and employer, that information be shared in the best possible light, that is by educating about personal strengths and any handicaps which may need to be addressed. Having information at one's fingertips that any employer might ask about is of importance so that questions can be answered intelligently. Getting defensive will not help. Asking for confidentiality is also important to many people. A boss should be advised of regular doctor's appointments, special working conditions, needed breaks, etc. There are consequences to sharing with superiors at work. One, which we discussed before, is the sense of feeling different, as modifications are made. Some people express feelings of embarrassment around those who know about their diabetes. Old feelings of being damaged goods may reappear for a while. It is important to weigh the positive aspects of letting go of the secret, as the authors state, 'Admitting illness at work can eliminate the defensiveness and self-pity that are consequences of withholding the truth about being ill. Prudent revelation can further more trust between you and your employers, more relief for you, and more understanding from them'. 4. Self care To make appropriate modifications in the work environment, it is important to have an understanding of self care guidelines that diabetics must follow to keep their disease under control. The importance of glucose levels remaining as near to normal as possible cannot be understated. The aforementioned Diabetes Control and Complications Trial made it clear that long-term complications can be forestalled, prevented or minimized by tight control. This involves increased attention to medication, diet and exercise for the diabetic. Current information suggests that this control is important for all diabetics, not just Type I, on which the DCCT research was based. Every treatment plan that a diabetic works out with his health team will involve meal planning, medication, and exercise. Also of importance is the monitoring of blood glucose levels at various times of the day so that effectiveness of
152
B.S. Polin / Work 9 (J997) 147-155
the treatment plan can be monitored and/or changed as needed. Diabetes is a disease which mandates active participation in its control. It is through a partnership with the health team that the diabetic can gain some freedom and control of everyday life. Meal plans are based on the caloric intake designated as appropriate to meet weight goals. Since most type II diabetics are overweight, their caloric intake will be limited to encourage weight loss. Recent findings indicate that for type II diabetics even a modest weight loss of 10-20 Ib may allow cells to become more sensitive to insulin. Thus, they have more energy and feel better. Also, when the type II diabetic follows a meal plan Beta cells will be able to respond more quickly to the body's need for insulin after eating. For type I diabetics, a meal plan is essential because of the exogenous insulin they take. The half lives of the combined insulins most diabetics take peak at different times and therefore, without the proper number of calories at scheduled times, the diabetic may have an insulin reaction, i.e. hypoglycemia. These attacks can be very frightening to both the diabetic and to those around him or her. The person becomes disoriented, breaks into a cold sweat, and often becomes shaky, a potentially dangerous situation in the workplace. Without intelVention coma may ensue. The guidelines for ratios of protein to carbohydrates and fats in the diabetic diet are generally less than 20% protein, no more than 30% fat of which no more than 10% is saturated, and the remainder carbohydrates. The percentage of protein is reduced when renal disease is present. Meal plans are individual and are based on lifestyle, medication, weight goals, other medical conditions, and food preferences. It is false to think that it is not how much a diabetic eats, but only what he or she eats that is important. It is the time, the amount, and the types of foods one dines on which make up a complete meal plan. For type II diabetics medication is considered when blood glucose levels are> 140 mg/dl before breakfast or> 160 mg/dl before bedtime. There are currently three classes of medications used for diabetic control. The sulfonylureas are the most popular and have been available in the
US for 40 years. They work by stimulating the pancreas to make more insulin. Most are given one to two times per day, however, there are long acting formulas. Hypoglycemia can be a problem with these drugs if patients do not follow their me.al plans. People who are allergic to sulfa drugs should be cautioned about this class of medication. Certain Sulfonylureas are of more concern for those with kidney disease. Biguanide (brand name Glucophage), has been used around the world for almost 40 years, and has been available in the US for more than 1 year. It works by lowering the amount of glucose released from the liver, thus lowering the amount in the blood stream. It does not cause hypoglycemia, nor does it cause weight gain. It is taken two to three times a day. Alpha-glucosidase Inhibitor, brand name Precose, went on the market at the beginning of 1996. It interferes with the digestion of carbohydrates. When taken with meals, it slows blood glucose levels from rising quickly after eating (Sherwin, 1996). Persons with type I diabetes must take insulin, as the pancreas no longer produces it. Insulin is measured in units, strengths and types. Most people take U-100 which means that there are 100 units of insulin per cubic centimeter. U-500 is also available. In addition to strength, there are also types of insulin based on how long it takes for the insulin to work, the number of hours until it peaks, and its duration in the body. Many diabetics take a combination of short acting (Regular) and intermediate or long acting types (NPH or Lente) so that the intermediate acting insulin works its hardest as the short acting one subsides. Insulin absorption is affected by the type of insulin, the injection site, depth of injection, temperature of both the skin and surrounding air, variations in meals such as time and amount eaten, illness, and exertion. Most type I diabetics are on a sliding scale for the dosage of insulin they take which is based on their level of blood glucose. Therefore, glucose readings are taken three to four times a day to determine the proper amount of insulin needed for tight control. With the results of the DCCT, it has become more important than ever to test glucose levels for multiple daily injections, thus controlling long-
B.S. Polin / Work 9 (1997) 147-155
term complications. Before these results were reported, two injections per day were a common treatment for diabetes. Hypoglycemia is a problem for insulin-dependent diabetics when they either take too much insulin for the amount of food they eat or they exercise more than usual. They may also develop hyperglycemia when they have too little insulin for the amount of calories they ingest or when they are overstressed physically or mentally. Exercise is important for all people, but for diabetics it has added benefits. It allows cells to become more sensitive to insulin. In fact, it is suggested that regular exercise and remaining slim can forestall the onset of type II diabetes in persons with a family history of the disease. Regular exercise can help lower LDL cholesterol and triglycerides, thus lowering the risk for atherosclerois. It can also raise HDL cholesterol which sweeps fatty deposits from arteries. Exercise can also help in a program of weight loss. Please note that diabetics should not exercise if their blood glucose level is > 240 mg/dl unless the presence of ketones are checked for first. Exercising with a very high level of glucose in the blood can cause ketoacidosis which can result in coma or death. Diabetics need to recognize the importance of post-exercise glucose levels. Type I diabetics should have blood sugar levels of 100-120 mg/ dl, while Type II should not be ~ 80 mg/ dl. All diabetics will need to learn to adjust their food intake and medication depending on the type of exercise and its duration. Working with a health team, the diabetic can learn how to begin an exercise program that is appropriate and how to guard against both high and low blood sugars. Exercise, with meal planning and medication, is vital for the well being of the diabetic. Aside from the physical benefits, the emotional benefits from the production of endorphins gives a sense of well-being which also gives a more positive outlook on life in general (B~aser and Hill, 1995). Care of the eyes and feet, although not often attended to in the workplace, may have to be accommodated sooner or later. The eyes require yearly optical examinations, as diabetics are prone to retinopathy, a disease which causes damage to the retina when small blood vessels are harmed
153
by high levels of glucose in the blood. A diabetic is also twice as likely to develop glaucoma and cataracts than other adults. Laser treatment and surgery can significantly reduce the risk for loss of sight and/or blindness. Secondly, diabetics have a higher incidence of amputation than the normal population as a result of peripheral neuropathy. Checking for unfelt wounds, diabetic ulcers, slow healing sores and wounds and ingrown toenails is part of daily self care. It is said that the physician who does not ask his diabetic patient to remove his socks has not given him a thorough examination. Diabetics should not go barefooted and need comfortable, protective shoes. Feet should be neither too hot nor too cold. Socks need to be clean and dry. Because blood circulation may be impaired, any symptom of pain or cramping needs to be taken care of promptly. S. Workplace accommodations
The Americans with Disabilities Act was enacted to take advantage of the skills and talents of the disabled. It guarantees equal opportunity in public accommodations, employment, transportation, State and local government services and telecommunications. It requires employers to 'reasonably accommodate' the limitations imposed by known mental or physical disabilities. This means that changes must be made to allow a qualified employee to work. It requires the employer to accommodate unless doing so would cause undo heartship to the employer. If the changes are too expensive the employer can assist the employee in gaining funds, or allow the employee to pay for them personally. The most common impairment for the diabetic may be the loss of vision. This is usually a slow process with exacerbations. The professional can help by modifying lighting, or suggesting magnification and/or larger print. Sometimes the employee may need to take a leave of absence for vocational rehabilitation to learn compensatory skills to continue at his or her job or to train for another position. In our experience in the diabetes clinic, one worrisome complication of diabetes is 'pins and needles' or numbness of the fingers and hands. This has resulted in modifications in equipment used
154
B.S. Polin / Work 9 (1997) 147-J55
on the job for some and retraining at vocational centers for others. When the employee is to be retrained for a different position, whether within the corporation or at a vocational training center, the employee may need alterations to this environment such as being given time for glucose monitoring, snacks, large print, time out for exercise, tape recorder so that notes can be filled in at a later time and a known schedule beforehand so that modifications in the treatment plan can be anticipated and addressed. Employers may rightfully assume that diabetics have the same career goals and aspirations as other employees. Most will be employed for years without complications which affect their work or necessitate accommodations. However, because they are individuals with individual needs and different chronic conditions resulting from the disease, the role of the allied health professional who is hired to make even minor corrective modifications in the work environment will vary. What is self evident is that the vast majority of people with diabetes need few special accommodations. They would, however, benefit from a private place to monitor blood glucose levels, regular meals and breaks to control hypo and hyperglycemia, stress management seminars or classes, smoke cessation classes, nutritional education, regular exercise, and protection from extreme heat and cold. Although classes sponsored by large corporations have various names, such as the Life for Life Program at Johnson and Johnson or the Center for Health Help at Metropolitan Ufe Insurance, the results have been positive with respect to employee health and productivity. The program at Metropolitan Life focuses on prevention, but also helps those with existing health problems such as hypertension and diabetes. Companies like Sentry Life Insurance Company have seen rewards from having a fitness center on grounds, while United Healthcare Corporation adds nutritional classes, stop smoking seminars and stress management (Parkinson et al. 1982). These programs have in common the very things that the diabetic needs to perform at his or her maximum level, i.e. stress management, nutrition and weight loss programs as well as fitness facilities. If these programs do not exist in-house, the
diabetic suffering from stress related disorders, as well as those with micro and macrovascular disease should be referred out to support groups in local hospitals or those given by the American Diabetes Association. The American Diabetes Association, Juvenile Diabetes Foundation and Joslin Diabetes Center have publications available with a great deal of information for the professional and patient. When stress is causing disruption of the patient's work, a consult with his or her physician may be necessary to modify the treatment plan with an additional referral to a psychiatrist for diagnosis and treatment especially when medication is indicated. It is well documented that antidepressants may impact the management of diabetes. It has also been reported that anxiety disorders, eating disorders, and depression occur more often in type I diabetics than in the general population (Jacobson, 1996). A team approach is therefore necessary to treat the entire person. When there are no stress reducing classes available, teaching methods for reducing anxiety by the professional can be important. After the locus of control has been established, if the client feels helpless to change his environment, assertiveness training has been shown to reduce tension and consequently reduce physical reactions to stress due to unexpressed anger or anxiety. Helping the client to focus on overreactions and reading stresses accurately is important in decreasing stress, especially with diabetics where the locus of stress is the permanence and frustration of coping with the fickleness of diabetes. Here, relaxation techniques, biofeedback, meditation, and guided imagery can be used with the goal of reducing autonomic arousal. As stated before, exercise is extremely important for the diabetic in controlling the effects of anxiety. Understanding the way medications control glucose levels makes it necessary that exercise times remain consistent during the work day to protect against hypoglycemia. Professionals helping their clients can be of great help making sure that schedules match individual treatment plans or that the plan is changed by the treatment team to meet the needs of both the employer and employee. The allied health professional who is responsi-
B.S. Polin / Work 9 (1997) 147-155
ble for attending to the needs of disabled employees resultant from diabetes has the opportunity to make a significant impact on this individual. As we have seen in this article, diabetes can make a person more susceptible to anxiety and depression due to continual frustrations of living with a chronic disease and/or not controlling glucose levels. He or she may, over time, develop chronic diseases secondary to diabetes. Knowledgeable allied health professionals can help clients get involved in support groups, therapy, exercise programs, nutrition classes - as well as teach relaxation and/or assertiveness techniques to help control emotional responses. They can make physical accommodations and help set up rehabilitation services when needed. Most of all, the allied health professional can be an educator who dispels myths, one who can be used as a source of strength for change. As the secrets melt away and people do not fear loss of their livelihood, they can become free to take better care of themselves, reach out socially, and attain life goals. Freud said that to love and to work are the simplified components for mental health. With effective interventions, the allied health professional can give these as a gift to the diabetic experiencing difficulties in the workplace References Beaser RS, Hill lVe. The 10slin guide to diabetes. New York: Fireside, 1995:254-264, 70-84. Cox 01, Gonder·Frederick L. Major developments in behavioral diabetes research. 1 Consult Clin Psychol 1992;60:628-638.
155
Diabetes Forecast. Stress 1995;48(12):56-58. Diabetes Forecast. Mail Call 1995;48(1):8. Donogue Pl, Siegel, ME. Sick and tired of feeling sick and tired. New York: WW Norton, 1992:184-186. Fisher EB, Heins 1M, Hiss RG et al. Metabolic control matters. Washington, DC: US Dept. of Health and Human Services and National Institutes of Health, 1993. Greene OS, Geroy GO. Diabetes and job performance: an empirical investigation. Diabetes Educator 1993; 19(4):293-198. Heins 1, Arfken C, Westfall B. Diabetes and employment. Diabetes 1993:42. Hiss RG, Anderson RM, Stepien CJ, Hess GE. Diabetes care and education in American communities. Diabetes 1991 ;40 Suppl:499A. Jacobson AM. The psychological care of patients with insulin-dependent diabetes mellitus. N Engl 1 Med 1996;334(19):1250-1252. Leatz CA, Stolar MW. Career success/personal stress. New York: McGraw-Hill, 1992:30-42. Mazur ML. Fighting back. Diabetes Forecast 1995;48(8):16-22. Moe B. Coping with chronic illness. New York: Rosen, 1992. Padgett 0, Heins 1, Nord W. Perceptions of workers with Diabetes. Diabetes 1992;41:197A. Parkinson RS. Managing health promotion in the workplace. Pal a Alto: Mayfield, 1982:63-116. Quickel KE lr. Diabetes in a managed care system. Ann Int Med 1996;124(1 pt.2):160-3. Rifkin H, editor. The physician's guide to type II diabetes. New York: The American Diabetes Association, 1984:69. Rifkin H, Porte 0 lr. Diabetes mellitus. New York: Elsevier, 1990. Rundell lR, Wise MG. Textbook of consultation·liaison psy· chiatry. Washington, DC: The American Psychiatric Press, 1996:1096. Sherwin R. Pill time. Diabetes Forecast 1996;49(3):36-40. Sherbourne CD, Wells KB, Meredith LS, lackson CA, Camp P. Comorbid anxiety disorder and the functioning and well.being of chronically ill patients of general medical providers. Arch Gen Psychiatry 1996;53:889-895.
ELSEVIER
Work 9 (1997) 147-155
Understanding the needs of diabetics in the workplace: a clinician's perspective 1 Bonnie Sanders Polin* 2436 East 47th Place, Tulsa, OK 74105, USA
Abstract The purpose of this article is to acquaint Occupational and Physical therapists with the diabetic client so as to better understand their disease and therefore aid in interventions necessary for their continued performance in the workplace. The article will include sections on self care techniques necessary for control of glucose levels, acute and chronic complications of the disease process, emotional stress, both internal and external, that diabetics face daily plus stress management ideas. Finally, the role of the professional in aiding diabetics through specific modifications in their work environment as mandated by the Americans with Disabilities Act will be addressed as it applies to this diverse population. It is written from the perspective of a diabetic who is trained as a psychologist, started an educational clinic for diabetics, and has written a book with the Joslin Diabetes Center, The Joslin Gourmet Diabetes Cookbook © 1997 Elsevier Science Ireland Ltd. Keywords: Diabetes; Employment; Stress
- - - - - - - - - - - - - - - - - - - - - - - - _....._ - - - -
1. Introduction
On my 41st birthday, I received lovely gifts from my family and a diagnosis of insulin-depen-
1 Diabetes organizations which offer information: American Diabetes Association, 1660 Duke Street, po Box 15757, Alexandria, VA 22314. National Diabetes Information Clearing House, 805 15th Street, NW, Room 500, Washington, DC 20005. Juvenile Diabetes Foundation, 432 Park Avenue South, New York, NY 10016. Joslin Diabetes Center, One Joslin Place, Boston, MA 02115 * Corresponding author. Tel.: + 1 918 7441777; fax: + 1 918 7441777; e-mail: [email protected]
dent diabetes. On that day I became a part of the more than 13 000 000 Americans with diabetes, a disease which is growing in the US each year by 6%. Sadly, only half of this population is aware that they have diabetes. My life changed from one where time could be ignored to a life of regulation and schedules. I also began to see, for the first time, the difficulties of coping with an unseen chronic disease which can ultimately cause death. Although many professionals are rather cavalier about the diagnosis because diabetes is neither an acute disease nor is there a cure, the necessity for self care and education is paramount.
1051-9815/97/$17.00 © 1997 Elsevier Science Ireland Ltd. All rights reserved. PIIS1051-9815(97)00034-X
148
B.S. Polin / Work 9 (1997) 147-155
As Hiss et al. (1991) found, barriers to treatment of type II diabetes are that it is a silent disease with delayed complications whose treatment is neither financially nor intellectually rewarding. It is often mistakenly viewed as a mild disease by both patients and physicians. The lifestyle changes for patients to gain optimal control are very difficult and the technology does not exist to achieve euglycemia, or normal blood glucose levels, for most patients. Diabetics, however, are more than four times as likely to go blind as are non-diabetics. They are 19 times more likely to develop kidney disease, 28 times more likely to be an amputee and two-four times more likely to develop heart disease than non-diabetics. Diabetes accounts for nearly 15% of healthcare expenditures in the US each year (Quickel, 1996). Yet in an investigation comparing diabetics and non-diabetics in the workplace, diabetics' composite job performance, task behaviors, down-time behaviors and hazardous behaviors were all rated better than the norm (Greene and Geroy, 1993). Understanding diabetes is essential to professionals charged with helping persons with this disease so that clients can fulfill their potential for positive contributions in the work place. This paper will review the effects of stress on control of glucose levels, issues of disclosure in the work place, self care guidelines for diabetics, and finally, suggestions geared to occupational and physical therapists for adaptations in the field.
2. Stress and diabetes Before we look at the effect of external stress on diabetics, it is important to understand the scope of intrusion into everyday life that diabetes imposes. Diabetes is a chronic disorder which impedes the metabolism of carbohydrates, protein, and fat, which means that the out of control patient is unable to get sufficient nutriment from meals. I often share that when I first became a diabetic, I felt as if I walked a tight rope, as the very thing I needed to live, i.e. food, wa& making my blood sugars soar. At the present time diabetes mellitus is applied to disorders characterized by fasting plasma glucose levels above de-
fined levels. There are three mutually exclusive classes of diabetes: type I, or insulin-dependent diabetes which makes up about 10% of diabetics in the country, type II, or non-insulin-dependent diabetes, and other types, which includes impaired glucose tolerance and gestational diabetes. Patients with type I diabetes may be of any age but are usually diagnosed before they are 40. The diagnosis peaks at 11 or 12 years of age and almost all are diagnosed before the age of 20. They are usually thin, and have an abrupt onset of symptoms. These patients are prone to ketoacidosis and need exogenous insulin to sustain life. Patients with type II diabetes are typically older than 40 when diagnosed, and tend to be obese. They may have had few symptoms. They are not prone to ketoacidosis except under extreme stress. They are not dependent on exogenous insulin, but, they may require its use when traditional treatments do not control hyperglycemia. The insulin secretory defects and insulin resistance of type II diabetes can be partially reversed, hence the importance of weight loss, exercise and tight control of blood glucose levels. Additional stress on the diabetic is the knowledge that there are long-term chronic complications of both type I and type II diabetes. These include accelerated macrovascular and microvascular diseases, most notably accelerated coronary atherosclerosis, cerebrovascular athereosclerosis, and peripheral vascular disease, retinopathy, and nephropathy. Mixed vascular and neuropathic diseases include both leg and foot ulcers. Neuropathic conditions may be either peripheral or visceral. Acute complications include ketoacidosis and hypoglycemia (Rifkin, 1984). Symptoms of undiagnosed or uncontrolled diabetes include excessive thirst and appetite, blurred vision, frequent urination, slowed healing, weight loss, dry skin and extreme fatigue. In fact, the first question I ask of new patients in our diabetes clinic is, 'How often do you fall asleep after a meal?' Other complications, which we will discuss more fully when we look at how stress impedes glucose control, are psychiatric diagnoses which in part can be linked to coping with a chronic disease like diabetes. Whereas many people go through their days with little thought about exact
B.S. Polin jWork 9 (1997) 147-155
time schedules, mandatory exercise, stress control, medications, medical issues, and food preparation, the diabetic population must concentrate on these as well as family, work, and societal pressures. Stress is normal for all humans, a fact that we, as a society, seem to forget at times. According to Rundell and Wise (1996), there is much speculation based on cross-sectional and retrospective studies that psychosocial stress initiates the attack on beta cells causing diabetes or further alterations of glucose metabolism in diabetics. In some studies, however, results are confounded by factors such as exercise, alcohol and diet. The authors report that there is better research suggesting that a subgroup of diabetics do react to acute emotional stress. Less controversial, and better established is the association of chronic stress such as anxiety, depression, and family dysfunction to poor control, loss of social contacts, and impulsivity. The question here is whether the resultant behavior is due to the stress or the systemic hyperglycemia. There is, however, evidence of both the acute and chronic effect of diabetes on cognitive functioning usually of subclinical intensity. This creates interpersonal problems of misunderstanding others (Cox and Gonder-Frederick, 1992). Improved glucose control has significant benefits on psychosocial functioning in diabetics, an excellent reason for support groups and individual therapy when diabetes is out of control. As long as we exist, we face stress on a daily basis. When it is experienced, the body behaves as if it were under attack either physically, as from illness or injury, or from emotional pressures. The result of this is to release stored energy, i.e. fat and glucose, to the cells so that the person can escape danger. For the diabetic, who may not have insulin available to allow this extra glucose and fat into the cells, there can be a build up of glucose in the blood. In diabetes, stress, either acute or chronic, may affect the body in two ways. First, persons under stress may not take care of themselves, forgetting exercise needs, dietary guidelines, etc. Second, stress hormones may alter glucose levels directly. Diabetes Forecast (December, 1995) in an ex-
149
cellent article on this subject, reported what I have seen in myself and other diabetics. Type I diabetics have mixed effects under emotional stress, some experiencing lower glucose levels, and some higher. For Type II diabetics, the majority of people experience higher glucose levels. Physical stress such as illness or injury raises blood levels in both types of diabetes. The same article concludes that type A personalities may have higher glucose levels when under stress than type B personalities who are more easy-going and, under similar situations may experience lower glucose elevations. Symptoms of stress include shortness of breath, headaches, indigestion, diarrhea, irritability, tightness of muscles, tiredness, insomnia, overeating, alcohol abuse, difficulty concentrating, drug abuse, and moodiness. Other maladaptive reactions include marital tensions, procrastination, abusive behavior, decreased sexual desire and aggression (Leatz, 1992). Sherbourne et al. (1996) in reporting their recent research on chronically ill patients, found that diabetics with unresolved anxiety were as debilitated as patients with heart disease. There were significant differences in the functioning of patients who did not have comorbid anxiety, thus leading the authors to highlight the social importance of identifying these patients and helping them. Adding to normal developmental stresses experienced throughout the life cycle are the ones unique to diabetes (Beaser and Hill, 1995). Coping with this disease is a 24-h job. The chonicity of diabetes for some people is emotionally draining to begin with, and may become even worse with added external stresses. There are a series of emotional reactions one experiences when first diagnosed with a chronic, life threatening disease. These include shock, denial and then fear, anxiety and depression. When resolved, acceptance of having and living with diabetes is attained. Often patients describe this as finally becoming a person with a problem pancreas, rather then feeling like damaged goods. This mind-body split is an important step in taking control of one's life again, but, stress may cause temporary emotional regression. An additional stress is that diabetes is an invisible disease and for some this causes
150
B.S. Polin / Work 9 (1997) 147-155
significant conflict. While others indulge in forbidden food and drink, the otherwise healthy looking diabetic feels alienated. It is this differentness that at times is overwhelming and must be addressed. When people ask me why I originally decided to write my cookbook, The Joslin Diabetes Gourmet Cookbook, the answer is simple. I could not handle making complicated meals for my family and guests while I ate plain broiled 'something' or salad with lemon juice. This sense of being different and damaged leads to cheating and then guilt which can exacerbate anxiety and depression and further non-compliance. Diabetes, by its seeming unpredictability, is very frustrating. When I first was diagnosed, my physician shared that if one ate the same thing every day, exercised the same way, and had the same stresses, one's glucose levels could still fluctuate. He cautioned not to give in to the frustration of having to be perfect. I have, in fact, spoken to many type A personalities who went through a period of not monitoring their blood levels because they were not perfect. The glucose monitor became an enemy, instead of a tool to help them control diabetes. When I conducted therapy, we would often talk about the additive effect of stresses on our lives, noting that most people can cope with one, some can deal with two, but most feel overwhelmed when the number goes much above a tolerable level. Of course, this depends on the type of stress and its intensity and duration, but reactions are predictable when one knows the person's coping skills and the types of added stresses they experience. listening to your clients and noting their work records will give you excellent clues as to how to propose changes and interventions which will be most beneficial. 3. Employment issues Up to this point we have addressed stresses which emanate from fears and anxiety about long-term and acute complications of the disease process, normal developmental stresses and illness as well as the daily attacks on self worth which stem from coping with a hidden and frustrating disease. Now, we address a most pertinent
area for any person with a chronic disease, that is fear of discrimination in the workplace. This brings up the question of whether to share the truth about having diabetes with one's colleagues and employers. This dilemma can exacerbate other stresses often causing added anxiety for the diabetic. Greene and Geroy (1993), report that despite improvements in diabetes management, people with diabetes have higher unemployment rates, reduced employment prospects, more difficult time during the employment process, higher rate of job denial and a greater frequency of job loss than those without diabetes. One might postulate that with the passage of the Americans with Disabilities Act (ADA), such statistics would improve, but reading Mail Call in Diabetes Forecast, the monthly magazine of the American Diabetes Association, there continues to be reports of employers demoting workers for asking for time to check blood glucose levels (Diabetes Forecast, Jan. 1995). Dickson, in an article, Diabetes and Employment published on the Diabetes Forum (1996), reports on the nurse who sent a resume to 16 institutions including a cover letter mentioning her diabetes. She received no job offers. Mazur (1995) recounts a 7-year legal battle with the government which changed the US Office of Personnel Management regulations effecting all GS-1811 criminal investigator or special agent jobs within the government. Thanks to perseverance, there is no longer a blanket exclusion for people with type I diabetes. Each applicant will be judged on a case-by-case basis. These situations reflect misperceptions about diabetes, but as with any other disability, employers are required by the ADA to look at the actual limitations of employees, not precedents set years before. It is, however, the perseverance of the employee that forces employers to hire and promote them, seeing their assets rather than a disease or disability. The Metabolic Control Matters monograph published by the US Departments of Health and Human Services and the National Institutes of Health (1993), which presents analysis and recommendations stemming from the Diabetes Control and Complications Trials (DCCT), sees the work-
B.S. Polin
I
Work 9 (1997) 147-155
place as pivotal in the care of diabetes. Research cited (Heins et aI., 1993), suggests a relationship between meals missed and supervisors' characteristics of tolerance of freedom, emphasis on production, and job characteristics of work pressure and locus of control over the pace of work. Greater co-worker sensitivity was associated with fewer insulin reactions. The monograph implies that work places which allow for storage places for diabetic supplies and time to check glucose levels positively correlate with lower glycated hemoglobin values. Sadly, in a companion study (Padgett and Heins, 1992), it was reported that human resource managers showed limited knowledge about diabetes and had little interest in gaining more insight into the disease. In general they felt diabetes was not a problem in their workplaces and therefore saw no need to educate themselves or workers about the disease. There are few work restrictions for people who control their diabetes. Some laws prohibit insulin dependent diabetics from serving in the armed forces and occupations such as interstate truck driver and pilot. There are also some police forces which bar diabetics. The American Diabetes Association's position is that employees, their doctors, and employers should work together on an individual basis where dangerous aspects of work are in question. For the most part, people with diabetes will need little help from their supervisors except for those based on an understanding of the worker's needs around issues of scheduling and breaks. It is evident from working with people who live successfully with diabetes that they are self-disciplined, aware and responsible, i.e. the supervisor's dream employee. The question then of when and if to tell employers is a complicated one. Donoguue and Siegel (1992) in a book for patients living with invisible chronic illness discuss this question. Most people, they postulate, want to be fair to employers, but fear for their promotions or ability to keep jobs. Questions to ask oneself revolve around the effect of revealing the secret vs. the anxiety and stress of keeping it, the perceived embarrassment, realistic reading of the boss, and any effects of the person's performance on the company. In most cases I would
151
agree with the authors that out of fairness to both the diabetic and employer, that information be shared in the best possible light, that is by educating about personal strengths and any handicaps which may need to be addressed. Having information at one's fingertips that any employer might ask about is of importance so that questions can be answered intelligently. Getting defensive will not help. Asking for confidentiality is also important to many people. A boss should be advised of regular doctor's appointments, special working conditions, needed breaks, etc. There are consequences to sharing with superiors at work. One, which we discussed before, is the sense of feeling different, as modifications are made. Some people express feelings of embarrassment around those who know about their diabetes. Old feelings of being damaged goods may reappear for a while. It is important to weigh the positive aspects of letting go of the secret, as the authors state, 'Admitting illness at work can eliminate the defensiveness and self-pity that are consequences of withholding the truth about being ill. Prudent revelation can further more trust between you and your employers, more relief for you, and more understanding from them'. 4. Self care To make appropriate modifications in the work environment, it is important to have an understanding of self care guidelines that diabetics must follow to keep their disease under control. The importance of glucose levels remaining as near to normal as possible cannot be understated. The aforementioned Diabetes Control and Complications Trial made it clear that long-term complications can be forestalled, prevented or minimized by tight control. This involves increased attention to medication, diet and exercise for the diabetic. Current information suggests that this control is important for all diabetics, not just Type I, on which the DCCT research was based. Every treatment plan that a diabetic works out with his health team will involve meal planning, medication, and exercise. Also of importance is the monitoring of blood glucose levels at various times of the day so that effectiveness of
152
B.S. Polin / Work 9 (J997) 147-155
the treatment plan can be monitored and/or changed as needed. Diabetes is a disease which mandates active participation in its control. It is through a partnership with the health team that the diabetic can gain some freedom and control of everyday life. Meal plans are based on the caloric intake designated as appropriate to meet weight goals. Since most type II diabetics are overweight, their caloric intake will be limited to encourage weight loss. Recent findings indicate that for type II diabetics even a modest weight loss of 10-20 Ib may allow cells to become more sensitive to insulin. Thus, they have more energy and feel better. Also, when the type II diabetic follows a meal plan Beta cells will be able to respond more quickly to the body's need for insulin after eating. For type I diabetics, a meal plan is essential because of the exogenous insulin they take. The half lives of the combined insulins most diabetics take peak at different times and therefore, without the proper number of calories at scheduled times, the diabetic may have an insulin reaction, i.e. hypoglycemia. These attacks can be very frightening to both the diabetic and to those around him or her. The person becomes disoriented, breaks into a cold sweat, and often becomes shaky, a potentially dangerous situation in the workplace. Without intelVention coma may ensue. The guidelines for ratios of protein to carbohydrates and fats in the diabetic diet are generally less than 20% protein, no more than 30% fat of which no more than 10% is saturated, and the remainder carbohydrates. The percentage of protein is reduced when renal disease is present. Meal plans are individual and are based on lifestyle, medication, weight goals, other medical conditions, and food preferences. It is false to think that it is not how much a diabetic eats, but only what he or she eats that is important. It is the time, the amount, and the types of foods one dines on which make up a complete meal plan. For type II diabetics medication is considered when blood glucose levels are> 140 mg/dl before breakfast or> 160 mg/dl before bedtime. There are currently three classes of medications used for diabetic control. The sulfonylureas are the most popular and have been available in the
US for 40 years. They work by stimulating the pancreas to make more insulin. Most are given one to two times per day, however, there are long acting formulas. Hypoglycemia can be a problem with these drugs if patients do not follow their me.al plans. People who are allergic to sulfa drugs should be cautioned about this class of medication. Certain Sulfonylureas are of more concern for those with kidney disease. Biguanide (brand name Glucophage), has been used around the world for almost 40 years, and has been available in the US for more than 1 year. It works by lowering the amount of glucose released from the liver, thus lowering the amount in the blood stream. It does not cause hypoglycemia, nor does it cause weight gain. It is taken two to three times a day. Alpha-glucosidase Inhibitor, brand name Precose, went on the market at the beginning of 1996. It interferes with the digestion of carbohydrates. When taken with meals, it slows blood glucose levels from rising quickly after eating (Sherwin, 1996). Persons with type I diabetes must take insulin, as the pancreas no longer produces it. Insulin is measured in units, strengths and types. Most people take U-100 which means that there are 100 units of insulin per cubic centimeter. U-500 is also available. In addition to strength, there are also types of insulin based on how long it takes for the insulin to work, the number of hours until it peaks, and its duration in the body. Many diabetics take a combination of short acting (Regular) and intermediate or long acting types (NPH or Lente) so that the intermediate acting insulin works its hardest as the short acting one subsides. Insulin absorption is affected by the type of insulin, the injection site, depth of injection, temperature of both the skin and surrounding air, variations in meals such as time and amount eaten, illness, and exertion. Most type I diabetics are on a sliding scale for the dosage of insulin they take which is based on their level of blood glucose. Therefore, glucose readings are taken three to four times a day to determine the proper amount of insulin needed for tight control. With the results of the DCCT, it has become more important than ever to test glucose levels for multiple daily injections, thus controlling long-
B.S. Polin / Work 9 (1997) 147-155
term complications. Before these results were reported, two injections per day were a common treatment for diabetes. Hypoglycemia is a problem for insulin-dependent diabetics when they either take too much insulin for the amount of food they eat or they exercise more than usual. They may also develop hyperglycemia when they have too little insulin for the amount of calories they ingest or when they are overstressed physically or mentally. Exercise is important for all people, but for diabetics it has added benefits. It allows cells to become more sensitive to insulin. In fact, it is suggested that regular exercise and remaining slim can forestall the onset of type II diabetes in persons with a family history of the disease. Regular exercise can help lower LDL cholesterol and triglycerides, thus lowering the risk for atherosclerois. It can also raise HDL cholesterol which sweeps fatty deposits from arteries. Exercise can also help in a program of weight loss. Please note that diabetics should not exercise if their blood glucose level is > 240 mg/dl unless the presence of ketones are checked for first. Exercising with a very high level of glucose in the blood can cause ketoacidosis which can result in coma or death. Diabetics need to recognize the importance of post-exercise glucose levels. Type I diabetics should have blood sugar levels of 100-120 mg/ dl, while Type II should not be ~ 80 mg/ dl. All diabetics will need to learn to adjust their food intake and medication depending on the type of exercise and its duration. Working with a health team, the diabetic can learn how to begin an exercise program that is appropriate and how to guard against both high and low blood sugars. Exercise, with meal planning and medication, is vital for the well being of the diabetic. Aside from the physical benefits, the emotional benefits from the production of endorphins gives a sense of well-being which also gives a more positive outlook on life in general (B~aser and Hill, 1995). Care of the eyes and feet, although not often attended to in the workplace, may have to be accommodated sooner or later. The eyes require yearly optical examinations, as diabetics are prone to retinopathy, a disease which causes damage to the retina when small blood vessels are harmed
153
by high levels of glucose in the blood. A diabetic is also twice as likely to develop glaucoma and cataracts than other adults. Laser treatment and surgery can significantly reduce the risk for loss of sight and/or blindness. Secondly, diabetics have a higher incidence of amputation than the normal population as a result of peripheral neuropathy. Checking for unfelt wounds, diabetic ulcers, slow healing sores and wounds and ingrown toenails is part of daily self care. It is said that the physician who does not ask his diabetic patient to remove his socks has not given him a thorough examination. Diabetics should not go barefooted and need comfortable, protective shoes. Feet should be neither too hot nor too cold. Socks need to be clean and dry. Because blood circulation may be impaired, any symptom of pain or cramping needs to be taken care of promptly. S. Workplace accommodations
The Americans with Disabilities Act was enacted to take advantage of the skills and talents of the disabled. It guarantees equal opportunity in public accommodations, employment, transportation, State and local government services and telecommunications. It requires employers to 'reasonably accommodate' the limitations imposed by known mental or physical disabilities. This means that changes must be made to allow a qualified employee to work. It requires the employer to accommodate unless doing so would cause undo heartship to the employer. If the changes are too expensive the employer can assist the employee in gaining funds, or allow the employee to pay for them personally. The most common impairment for the diabetic may be the loss of vision. This is usually a slow process with exacerbations. The professional can help by modifying lighting, or suggesting magnification and/or larger print. Sometimes the employee may need to take a leave of absence for vocational rehabilitation to learn compensatory skills to continue at his or her job or to train for another position. In our experience in the diabetes clinic, one worrisome complication of diabetes is 'pins and needles' or numbness of the fingers and hands. This has resulted in modifications in equipment used
154
B.S. Polin / Work 9 (1997) 147-J55
on the job for some and retraining at vocational centers for others. When the employee is to be retrained for a different position, whether within the corporation or at a vocational training center, the employee may need alterations to this environment such as being given time for glucose monitoring, snacks, large print, time out for exercise, tape recorder so that notes can be filled in at a later time and a known schedule beforehand so that modifications in the treatment plan can be anticipated and addressed. Employers may rightfully assume that diabetics have the same career goals and aspirations as other employees. Most will be employed for years without complications which affect their work or necessitate accommodations. However, because they are individuals with individual needs and different chronic conditions resulting from the disease, the role of the allied health professional who is hired to make even minor corrective modifications in the work environment will vary. What is self evident is that the vast majority of people with diabetes need few special accommodations. They would, however, benefit from a private place to monitor blood glucose levels, regular meals and breaks to control hypo and hyperglycemia, stress management seminars or classes, smoke cessation classes, nutritional education, regular exercise, and protection from extreme heat and cold. Although classes sponsored by large corporations have various names, such as the Life for Life Program at Johnson and Johnson or the Center for Health Help at Metropolitan Ufe Insurance, the results have been positive with respect to employee health and productivity. The program at Metropolitan Life focuses on prevention, but also helps those with existing health problems such as hypertension and diabetes. Companies like Sentry Life Insurance Company have seen rewards from having a fitness center on grounds, while United Healthcare Corporation adds nutritional classes, stop smoking seminars and stress management (Parkinson et al. 1982). These programs have in common the very things that the diabetic needs to perform at his or her maximum level, i.e. stress management, nutrition and weight loss programs as well as fitness facilities. If these programs do not exist in-house, the
diabetic suffering from stress related disorders, as well as those with micro and macrovascular disease should be referred out to support groups in local hospitals or those given by the American Diabetes Association. The American Diabetes Association, Juvenile Diabetes Foundation and Joslin Diabetes Center have publications available with a great deal of information for the professional and patient. When stress is causing disruption of the patient's work, a consult with his or her physician may be necessary to modify the treatment plan with an additional referral to a psychiatrist for diagnosis and treatment especially when medication is indicated. It is well documented that antidepressants may impact the management of diabetes. It has also been reported that anxiety disorders, eating disorders, and depression occur more often in type I diabetics than in the general population (Jacobson, 1996). A team approach is therefore necessary to treat the entire person. When there are no stress reducing classes available, teaching methods for reducing anxiety by the professional can be important. After the locus of control has been established, if the client feels helpless to change his environment, assertiveness training has been shown to reduce tension and consequently reduce physical reactions to stress due to unexpressed anger or anxiety. Helping the client to focus on overreactions and reading stresses accurately is important in decreasing stress, especially with diabetics where the locus of stress is the permanence and frustration of coping with the fickleness of diabetes. Here, relaxation techniques, biofeedback, meditation, and guided imagery can be used with the goal of reducing autonomic arousal. As stated before, exercise is extremely important for the diabetic in controlling the effects of anxiety. Understanding the way medications control glucose levels makes it necessary that exercise times remain consistent during the work day to protect against hypoglycemia. Professionals helping their clients can be of great help making sure that schedules match individual treatment plans or that the plan is changed by the treatment team to meet the needs of both the employer and employee. The allied health professional who is responsi-
B.S. Polin / Work 9 (1997) 147-155
ble for attending to the needs of disabled employees resultant from diabetes has the opportunity to make a significant impact on this individual. As we have seen in this article, diabetes can make a person more susceptible to anxiety and depression due to continual frustrations of living with a chronic disease and/or not controlling glucose levels. He or she may, over time, develop chronic diseases secondary to diabetes. Knowledgeable allied health professionals can help clients get involved in support groups, therapy, exercise programs, nutrition classes - as well as teach relaxation and/or assertiveness techniques to help control emotional responses. They can make physical accommodations and help set up rehabilitation services when needed. Most of all, the allied health professional can be an educator who dispels myths, one who can be used as a source of strength for change. As the secrets melt away and people do not fear loss of their livelihood, they can become free to take better care of themselves, reach out socially, and attain life goals. Freud said that to love and to work are the simplified components for mental health. With effective interventions, the allied health professional can give these as a gift to the diabetic experiencing difficulties in the workplace References Beaser RS, Hill lVe. The 10slin guide to diabetes. New York: Fireside, 1995:254-264, 70-84. Cox 01, Gonder·Frederick L. Major developments in behavioral diabetes research. 1 Consult Clin Psychol 1992;60:628-638.
155
Diabetes Forecast. Stress 1995;48(12):56-58. Diabetes Forecast. Mail Call 1995;48(1):8. Donogue Pl, Siegel, ME. Sick and tired of feeling sick and tired. New York: WW Norton, 1992:184-186. Fisher EB, Heins 1M, Hiss RG et al. Metabolic control matters. Washington, DC: US Dept. of Health and Human Services and National Institutes of Health, 1993. Greene OS, Geroy GO. Diabetes and job performance: an empirical investigation. Diabetes Educator 1993; 19(4):293-198. Heins 1, Arfken C, Westfall B. Diabetes and employment. Diabetes 1993:42. Hiss RG, Anderson RM, Stepien CJ, Hess GE. Diabetes care and education in American communities. Diabetes 1991 ;40 Suppl:499A. Jacobson AM. The psychological care of patients with insulin-dependent diabetes mellitus. N Engl 1 Med 1996;334(19):1250-1252. Leatz CA, Stolar MW. Career success/personal stress. New York: McGraw-Hill, 1992:30-42. Mazur ML. Fighting back. Diabetes Forecast 1995;48(8):16-22. Moe B. Coping with chronic illness. New York: Rosen, 1992. Padgett 0, Heins 1, Nord W. Perceptions of workers with Diabetes. Diabetes 1992;41:197A. Parkinson RS. Managing health promotion in the workplace. Pal a Alto: Mayfield, 1982:63-116. Quickel KE lr. Diabetes in a managed care system. Ann Int Med 1996;124(1 pt.2):160-3. Rifkin H, editor. The physician's guide to type II diabetes. New York: The American Diabetes Association, 1984:69. Rifkin H, Porte 0 lr. Diabetes mellitus. New York: Elsevier, 1990. Rundell lR, Wise MG. Textbook of consultation·liaison psy· chiatry. Washington, DC: The American Psychiatric Press, 1996:1096. Sherwin R. Pill time. Diabetes Forecast 1996;49(3):36-40. Sherbourne CD, Wells KB, Meredith LS, lackson CA, Camp P. Comorbid anxiety disorder and the functioning and well.being of chronically ill patients of general medical providers. Arch Gen Psychiatry 1996;53:889-895.
