Missing millions

A lack of awareness of diabetes symptoms can lead to
misunderstandings, so when it comes to dealing with staff sufferers, experts
recommend a softly, softly approach.  By
Vicki Madden

The importance of screening people at work for diabetes has been highlighted by
a recent report which estimates there are currently as many as 1 million people
who unknowingly have the disease.

The report, Diabetes in the UK – The Missing Million, by Diabetes UK
(previously the British Diabetic Association) commissioned Mori to conduct a
survey of public awareness of the risks and potential long-term effects of
diabetes1.

Diabetes is a leading cause of heart disease, blindness, kidney disease and
stroke, and there are currently 1.4 million people diagnosed with the condition
in the UK.

The prevalence of Type 2 diabetes (non-insulin dependent diabetes mellitus),
which usually affects the middle aged or elderly, now comprises around 75 per
cent of all newly diagnosed cases.

In some ethnic groups such as Asians, the disease has reached almost
epidemic proportions, with one in five over the age of 40 suffering from Type 2
diabetes2. The numbers affected are set to rise as the numbers of elderly and
ethnic groups rise.

Although well over a million people are affected by Type 1 and Type 2
diabetes, the Mori survey found a poor level of knowledge about the disease and
its serious consequences.

Alarmingly, ethnic minorities, who are at higher risk of developing
diabetes, show lower levels of awareness than white people, with just 24 per
cent aware that diabetes can result in heart disease, compared with 35 per cent
amongst white people.

A substantial proportion of people surveyed continue to believe that
diabetes is only serious if you inject yourself with insulin, despite the fact
that Type 2 diabetes is a serious and progressive condition.

On average, there is a gap of seven years between onset of Type 2 diabetes
and its diagnosis3.

Diabetes control

This lack of recognition of the condition has serious clinical implications.
Around half of those newly diagnosed already have early signs of complications
such as diabetic retinopathy which can lead to blindness (see box ).

The importance of glycaemic control in the development of complications has
been established by two recent landmark trials.

The first of these, the Diabetes Control and Complications Trial (DCCT),
compared conventional treatment with intensive therapy in insulin-dependent
diabetics. Results showed that the risk of vascular complications was reduced
in the intensive therapy group, which received three or more insulin injections
per day plus frequent diet and exercise counselling.

The second trial, the UK Prospective Diabetes Study (UKPDS) looked at
whether the numbers of life-threatening complications of Type 2 diabetes could
be decreased significantly by appropriate treatment.

Results showed that lowering blood pressure and glucose levels and making
more use of effective treatments could reduce the risk of death from heart
disease, stroke, diabetic retinopathy and early kidney damage.

As a result of these findings, Diabetes UK recommends treatment which aims
for the following:

– Blood pressure levels of 140/80mm Hg or below,

– HbA1c levels of 7 per cent or below,

– Fasting blood glucose levels of 4-7mmols/litre,

– Self-monitored blood glucose levels before meals between 4-7mmols/litre

Despite the need to identify the "missing million" with diabetes,
OH nurses should adopt a softly, softly approach, according to independent
occupational health adviser Cynthia Atwell.

"A full health assessment will include a urine test and this would
identify those with diabetes," she said.

A paper screening test, however, will not necessarily identify those with
diabetes, and employees will need to understand why they are being asked
questions which they feel might not relate to the job in hand.

Symptoms of diabetes to look out for include weight loss, unexplained
fatigue and lethargy, thirst, visual disturbances, increased infections and
polyuria (see case study).

A full explanation of why these questions are being asked is necessary to
allay people’s fears.

Employer’s duty

The Disability Discrimination Act (DDA), which came into effect in 1996, now
makes it illegal for any employer of 20 or more people to discriminate against
employees because of their disability, and the employers also have a duty to
make adjustments to the working environment to accommodate disadvantages
experienced by any disabled worker.

According to Atwell, under the DDA, people with diabetes would have the
right to have:

– Shift hours that accommodate suitable working hours and meals at regular
intervals

– Canteens that provide suitable good quality low-fat food

– A suitable environment for self injection of insulin

"OH nurses should be able to offer support and education to staff with
diabetes," added Atwell, and help to ensure that the environment is
suitable.

Many people with well-controlled diabetes know far more about their
condition than many doctors and nurses, but an identified key worker, such as
the first aid officer, should be told (with the consent of the person with
diabetes) what to do in the event of a hypo occurring.

This is important as sometimes the symptoms are similar to drunkenness and
this can cause unnecessary problems for the employee concerned.

The advent of the DDA has not been altogether a success, however. Because
the DDA forbids exclusion on the basis of a disability, many employers simply
do not carry out full screening medicals, and some companies continue to
discriminate against employees with a disability.

One thorny issue where employees are not judged on their individual fitness
for a job is who can and cannot drive.

Driving regulations that came into force in 1998 allow Type 1 diabetics who
drive C1 and C1 +E (8.25 tonnes) vehicles for a living to renew their licences
provided they meet the health requirements.

In order to obtain a licence, diabetes sufferers must:

– Have held a licence since 31 December 1996

– Have notified the DVLA by 31 December 1997 of their insulin requirements

– Not have had a hypo while driving

– Produce a consultant’s report confirming their history of good diabetic
control and a minimal risk of hypoglycaemia during normal working hours

– Regularly monitor their blood sugar levels

The regulations do not allow the following Type 1 diabetics to obtain or
renew either C1 or D1 licences:

– Those who require a C1 licence outside work

– Those who have never held a C1 licence

– Those who currently hold a licence for a D1 vehicle

Even the Government now recognises that a blanket ban such as this does not
take into account an individual’s fitness to drive, according to a spokesperson
at Diabetes UK.

"One government minister went as far as to say that the 1998
regulations were ill-considered, illogical and arbitrary.

"After a great deal of lobbying and pressure by interested groups the
Government has recently announced that there is to be a full review of the
regulations."

Following publication of the Missing Million report, Diabetes UK now calls
for action by both the Government and all who work within the health system.

"There are rapidly expanding numbers of people with diabetes, both
those who are diagnosed and those who are falling through the net, but who will
be diagnosed when the long term effects have already begun to take their toll.

"At the heart of the problem is a lack of awareness and understanding
of diabetes."

References

1 Diabetes in the UK – the missing million, report by Diabetes UK, May 2000

2 McKeigue PM, Shah B and Marmot MG relation of central obesity and insulin
resistance with high diabetes prevalence and CV risk in south Asians. Lancet
1991 337(8738): 382-6

3 UK Prospective Diabetes Study Group. Tight blood pressure control and risk
of macrovascular and microvascular complications in Type 2 diabetes. UKPDS 38:
BMJ; 1998; 317:703-713

Key Points

Two or more characteristics indicates a higher risk of Type 2 diabetes

– Aged over 40
– Overweight
– Asian or Afro-Caribbean
– Family history of diabetes

Relative risk of morbidity associated with types of diabetes

– Blindness 20
– End-stage renal disease 25
– Amputation 40
– Myocardial infarction 2-5
– Stroke 2-3

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