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Position StatementThe job offer may be conditioned on the considered. Only health care profession- based on sufﬁcient and appropriateresults of the medical inquiry or examina- als tasked with such evaluations should medical data and should never be madetion. An employer may withdraw an offer have access to employee medical informa- based solely on one piece of data. (E)from an applicant with diabetes only if it tion, and this information must be kept ● Screening guidelines and protocols canbecomes clear that he or she cannot do the separate from personnel records (3). be useful tools in making decisionsessential functions of the job or would about employment if they are used inpose a direct threat (i.e., a signiﬁcant risk Screening guidelines an objective way and based on the latestof substantial harm) to health or safety A number of screening guidelines for scientiﬁc knowledge about diabetesand such threat could not be eliminated evaluating individuals with diabetes in and its management. (E)with an accommodation (a workplace various types of high risk jobs have beenchange that enables a worker with a dis- developed in recent years. Examples in- II. EVALUATING THEability to safely and effectively perform clude the American College of Occupa- SAFETY RISK OFjob duties). Another situation in which a tional and Environmental Medicine’s EMPLOYEES WITHmedical evaluation is permissible is when National Consensus Guideline for the DIABETES — Employers who denya problem potentially related to the em- Medical Evaluation of Law Enforcement job opportunities because they perceiveployee’s diabetes arises on the job and Ofﬁcers, the National Fire Protection As- all people with diabetes to be a safety risksuch problem could affect job perfor- sociation’s Standard on Comprehensive do so based on misconceptions, misinfor-mance and/or safety. In this situation, a Occupational Medical Program for Fire mation, or a lack of current informationphysician may be asked to evaluate the Departments, the U.S. Department of about diabetes. The following guidelinesemployee’s ﬁtness to remain on the job Transportation’s Federal Motor Carrier provide information for evaluating an in-and/or his or her ability to safely perform Safety Administration’s Diabetes Exemp- dividual with diabetes who works orthe job. tion Program, and the U.S. Marshall Ser- seeks to work in what may be considered Employers also may obtain medical vice and Federal Occupational Health a safety-sensitive position.information about an employee when Law Enforcement Program Diabetesthe employee has requested an accomo- Protocol. Safety concernsdation and his or her disability or need Such guidelines and protocols can be The ﬁrst step in evaluating safety con-for accommodation is not obvious. An useful tools in making decisions about in- cerns is to determine whether the con-employer should not rely on a medical dividual candidates or employees if they cerns are reasonable in light of the jobevaluation to deny an employment op- are used in an objective way and based on duties the individual must perform. Forportunity to an individual with diabetes the latest scientiﬁc knowledge about dia- most types of employment (such as jobsunless it is conducted by a health care betes and its management. These proto- in an ofﬁce, retail, or food service environ-professional with expertise in diabetes cols should be regularly reevaluated and ment) there is no reason to believe that theand based on sufﬁcient and appropriate updated to reﬂect changes in diabetes individual’s diabetes will put employeesmedical data. The information sought and knowledge and evidence and should be or the public at risk. In other types of em-assessed must be properly limited to data developed and reviewed by health care ployment (such as jobs where the individ-relevant to the individual’s diabetes and professionals with signiﬁcant experience ual must carry a ﬁrearm or operatejob performance (3). The data needed will in diabetes and its treatment. Individuals dangerous machinery) the safety concernvary depending on the type of job and the who do not meet the standards set forth in is whether the employee will become sud-reason for the evaluation, but an evalua- such protocols should be given the op- denly disoriented or incapacitated. Suchtion should never be made based only on portunity to demonstrate exceptional cir- episodes, which are usually due to se-one piece of data, such as a single blood cumstances that would justify deviating verely low blood glucose (hypoglycemia),glucose result or A1C result. Since diabe- from the guidelines. Such guidelines or occur only in people receiving certaintes is a chronic disease in which health protocols are not absolute criteria but treatments such as insulin or secreta-status and management requirements rather the framework for a thorough indi- gogues such as sulfonylureas and evennaturally change over time, it is inappro- vidualized assessment. then occur infrequently. Workplace ac-priate—and medically unnecessary—for commodations can be made that are min-examiners to collect all past laboratory Recommendations imal yet effective in helping the individualvalues or information regarding ofﬁce vis- ● People with diabetes should be individ- to manage his or her diabetes on the jobits whether or not related to diabetes. ually considered for employment based and avoid severe hypoglycemia.Only medical information relevant to on the requirements of the speciﬁc jobevaluating an individual’s current capac- and the individual’s medical condition, Hypoglycemiaity for safe performance of the particular treatment regimen, and medical his- Hypoglycemia is deﬁned as a blood glu-job at issue should be collected. For ex- tory. (E) cose level 70 mg/dl (4,6). It is a poten-ample, in some circumstances a review of ● When questions arise about the medi- tial side effect of some diabetesan individual’s hypoglycemia history may cal ﬁtness of a person with diabetes for treatments, including insulin and sulfo-be relevant to the evaluation and should a particular job, a health care profes- nlyureas. It can usually be effectively self-be collected. sional with expertise in treating diabe- treated by ingestion of glucose Information about the individual’s di- tes should perform an individualized (carbohydrate) and is not often associatedabetes management (such as the current assessment; input from the treating with loss of consciousness or a seizure.treatment regimen, medications, and physician should always be included. Severe hypoglycemia, requiring the assis-blood glucose logs), job duties, and work (E) tance of another person, is a medicalenvironment are all relevant factors to be ● Employment evaluations should be emergency. Symptoms of severe hypogly-care.diabetesjournals.org DIABETES CARE, VOLUME 34, SUPPLEMENT 1, JANUARY 2011 S83
Diabetes and Employmentcemia may include confusion or, rarely, thy), eyes (retinopathy), kidneys (ne- careful changes to their diabetes manage-seizure or loss of consciousness (6). Most phropathy), or heart, not all individuals ment regimen (for example, more fre-individuals with diabetes never experi- with diabetes develop these long-term quent blood glucose testing or frequentence an episode of severe hypoglycemia complications. Such complications be- meals).because either they are not on medication come relevant in employment decisions Presence of diabetes-related complica-that causes it or they recognize the early only when they are established and inter- tions. Chronic complications that maywarning signs and can quickly self-treat fere with the performance of the actual result from long-term diabetes involve thethe problem by drinking or eating. Also, job being considered. Evaluations should blood vessels and nerves. These compli-with self-monitoring of blood glucose lev- not be based on speculation as to what cations may involve nerve (neuropathy),els, most people with diabetes can man- might occur in the future. Job evaluations eye (retinopathy), kidney (nephropathy),age their condition in such a manner that should take high blood glucose levels into and heart disease. In turn, these problemsthere is minimal risk of incapacitation account only if they have already caused can lead to amputation, blindness orfrom hypoglycemia because mildly low long-term complications such as visual other vision problems, including visionglucose levels can be easily detected and impairment that interfere with perfor- loss, kidney failure, stroke, or heart at-treated (4,7). mance of the speciﬁc job. tack. As these complications could poten- A single episode of severe hypoglyce- tially affect job performance and safety,mia should not per se disqualify an indi- Aspects of a safety assessment such complications should be evaluatedvidual from employment. Rather, an When an individual with diabetes is as- by a specialist in the speciﬁc area relatedappropriate evaluation should be under- sessed for safety risk there are several as- to the complication. If complications aretaken by a health care professional with pects that must be considered. not present, their possible future develop-expertise in diabetes to determine the Blood glucose test results. A single ment should not be addressed, both be-cause of the low blood glucose, the cir- blood glucose test result only gives infor- cause of laws prohibiting suchcumstances of the episode, whether it was mation about an individual’s blood glu- consideration and because with medicalan isolated incident, whether adjustment cose level at one particular point in time. monitoring and therapies, long-termto the insulin regimen may mitigate this Because blood glucose levels ﬂuctuate complications can now often be avoidedrisk, and the likelihood of such an episode throughout the day (this is also true for or delayed. Thus, many people with dia-happening again. Some episodes of severe people without diabetes), one test result is betes never develop any of these compli-hypoglycemia can be explained and cor- of no use in assessing the overall health of cations, and those that do generallyrected with the assistance of a diabetes a person with diabetes. The results of a develop them over a period of years.health care professional. series of self-monitored blood glucose However, recurrent episodes of se- measurements over a period of time, how- Inappropriate assessmentsvere hypoglycemia may indicate that an ever, can give valuable information about The following tools and terms do not ac-individual may in fact not be able to safely an individual’s diabetes health. Blood glu- curately reﬂect the current state of diabe-perform a job, particularly jobs or tasks cose records should be assessed by a tes treatment and should be avoided in aninvolving signiﬁcant risk of harm to em- health care professional with expertise in assessment of whether an individual withployees or the public, especially when diabetes (7). diabetes is able to safely and effectivelythese episodes cannot be explained. The History of severe hypoglycemia. Of- perform a particular job.person’s medical history and details of ten, a key factor in assessing employment Urine glucose tests. Urine glucose re-any history of severe hypoglycemia safety and risk is documentation of inci- sults are no longer considered to be anshould be examined closely to determine dents of severe hypoglycemia. An individ- appropriate and accurate methodologywhether it is likely that such episodes will ual who has managed his or her diabetes for assessing diabetes control (8). Beforerecur on the job. In all cases, job duties over an extended period of time without the mid-1970s, urine glucose tests wereshould be carefully examined to deter- experiencing severe hypoglycemia is un- the best available method of monitoringmine whether there are ways to minimize likely to experience this condition in the blood glucose levels. However, the urinethe risk of severe hypoglycemia (such as future. Conversely, multiple incidents of test is not a reliable or accurate indicatoradjustment of the insulin regimen or pro- severe hypoglycemia may in some situa- of blood glucose levels and is a poor mea-viding additional breaks to check blood tions be disqualifying for high-risk occu- sure of the individual’s current health sta-glucose levels). pations. However, the circumstances of tus. Blood glucose monitoring is a more each incident should be examined, as accurate and timely means to measureHyperglycemia some incidents can be explained due to glycemic control. Urine glucose testsIn contrast to hypoglycemia, high blood changes in insulin dosage, illness, or other should never be used to evaluate the em-glucose levels (hyperglycemia) can cause factors and thus will be unlikely to recur ployability of a person with diabetes.long-term complications over years or de- or have already been addressed by the in- A1C and estimated average glucosecades but does not normally lead to any dividual through changes to his or her di- (eAG). Hemoglobin A1C (A1C) test re-adverse effect on job performance. The abetes treatment regimen or education. sults reﬂect average glycemia over severalsymptoms of hyperglycemia generally de- Hypoglycemia unawareness. Some in- months and correlate with mean plasmavelop over hours or days and do not occur dividuals over time lose the ability to rec- glucose levels (4). An eAG is directly re-suddenly. Therefore, hyperglycemia does ognize the early warning signs of lated to A1C and also provides an individ-not pose an immediate risk of sudden in- hypoglycemia. These individuals are at ual with an estimate of average bloodcapacitation. While over years or decades, increased risk for a sudden episode of se- glucose over a period of time, but it useshigh blood glucose may cause long-term vere hypoglycemia. Some of these indi- the same values and units that are ob-complications to the nerves (neuropa- viduals may be able to lessen this risk with served when using a glucose meter or re-S84 DIABETES CARE, VOLUME 34, SUPPLEMENT 1, JANUARY 2011 care.diabetesjournals.org
Position Statementcording a fasting glucose value on a lab are relevant in employment decisions care tasks that should be provided when-report (5). A1C/eAG values provide only when they are established and in- ever feasible.health care providers with important in- terfere with the performance of the ac- Administering insulin. Employees mayformation about the effectiveness of an in- tual job being considered. (E) need short breaks during the workday todividual’s treatment regimen (4) but are ● Proper safety assessments should in- administer insulin when it is needed. In-often misused in assessing whether an in- clude review of blood glucose test re- sulin can be safely administered whereverdividual can safely perform a job. Because sults, history of severe hypoglycemia, the employee happens to be. The em-they identify only averages and not presence of hypoglycemia unaware- ployee may also need a place to store in-whether the person had severe extreme ness, and presence of diabetes-related sulin and other supplies if workblood glucose readings, A1C/eAG results complications and should not include conditions (such as extreme tempera-are of no value in predicting short-term urine glucose or AIC/eAG tests or be tures) prevent the supplies from beingcomplications of diabetes and thus have based on a general assessment of level carried on the person (10).no use in evaluating individuals in em- of control. (E) Food and drink. Employees may needployment situations. access to food and/or beverages during The American Diabetes Association III. ACCOMMODATING the workday. This is particularly impor-recommends that in most patients A1C EMPLOYEES WITH tant in the event that the employee needslevels be kept below 7% (4), or eAG below DIABETES — Individuals with diabe- to quickly respond to low blood glucose154 mg/dl. This recommendation sets a tes may need certain changes or accom- levels or maintain hydration if glucosetarget in order to lessen the chances of modations on the job in order to perform levels are high. Employees should be per-long-term complications of high blood their work responsibilities effectively and mitted to consume food or beverages asglucose levels but does not provide useful safely. Federal and state laws require the needed at their desk or work station (ex-information on whether the individual is provision of “reasonable accommoda- cept in an extremely rare situation inat signiﬁcant risk for hypoglycemia or tions” to help an employee with diabetes which this would pose a hazard and cre-suboptimal job performance and is not a to perform the essential functions of the ate a safety issue, and if this is the case, anmeasure of “compliance” with therapy. job (3). Additional laws provide for leave alternative site should be provided).An A1C or eAG cut off score is not med- for an employee to deal with his or her Leave. Employees may need leave or aically justiﬁed in employment evaluations medical needs or those of a family mem- ﬂexible work schedule to accommodateand should never be a determinative fac- ber (9). Although there are some typical medical appointments or other diabetestor in employment. accommodations that many people with care needs. Occasionally, employees may“Uncontrolled” or “brittle” diabetes. diabetes use, the need for accommoda- need to miss work due to unanticipatedSometimes an individual’s diabetes is de- tions must be assessed on an individual- events (severe hypoglycemic episode) orscribed as “uncontrolled,” “poorly con- ized basis (2). illness.trolled,” or “brittle.” These terms are not Work schedules. Certain types of workwell deﬁned and are not relevant to job Accommodating daily diabetes schedules, such as rotating or split shifts,evaluations. As such, giving an opinion management needs can make it especially difﬁcult for someon the level of “control” an individual has Many of the accommodations that em- individuals to manage diabetesover diabetes is not the same as assessing ployees with diabetes need on a day-to- effectively.whether that individual is qualiﬁed to day basis are those that allow them toperform a particular job and can do so manage their diabetes in the workplace as Accommodating complications ofsafely. Such an individual assessment is they would elsewhere. They are usually diabetesthe only relevant evaluation. simple accommodations, can be provided In addition to accommodating the day-to- without any cost to the employer, and day management of diabetes in the work-Recommendations should cause little or no disruption in the place, for some individuals it is also● Evaluating the safety risk of employees workplace. Most employers are required necessary to seek modiﬁcations for long- with diabetes includes determining to provide accommodations unless those term diabetes-related complications. whether the concerns are reasonable in accommodations would create an undue Such people can remain productive em- light of the job duties the individual burden (3). Some accommodations that ployees if appropriate accommodations must perform. (E) may be needed include the following. are implemented.● Most people with diabetes can manage Testing blood glucose. Breaks may be For example, an employee with dia- their condition in such a manner that needed to allow an individual to test betic retinopathy or other vision impair- there is no or minimal risk of incapaci- blood glucose levels when needed. Such ments may beneﬁt from using a big screen tation from hypoglycemia at work. A checks only take minutes to complete. computer or other visual aids, while an single episode of severe hypoglycemia Some individuals use continuous glucose employee with nerve pain may beneﬁt should not per se disqualify an individ- monitors but will still need an opportu- from reduced walking distances or having ual from employment, but an individ- nity to check blood glucose with a meter. the ability to sit down on the job. Individ- ual with recurrent episodes of severe Blood glucose can be checked wherever uals with kidney problems may need to hypoglycemia may be unable to safely the employee is without putting other have ﬂexibility to take time off work for perform certain jobs, especially when employees at risk, and employers should dialysis treatment. those episodes cannot be explained. (E) not limit where employees with diabetes It is impossible to provide an exhaus-● Hyperglycemia does not pose an imme- are permitted to manage their diabetes. tive list of potential accommodations. The diate risk of sudden incapacitation on Some employees may prefer to have a pri- key message in accommodating an em- the job, and long-term complications vate location for testing or other diabetes ployee with diabetes is to ensure that ac-care.diabetesjournals.org DIABETES CARE, VOLUME 34, SUPPLEMENT 1, JANUARY 2011 S85
Diabetes and Employmentcommodations are tailored to the jobs. The therapies for, and effects of, di- 2. Equal Employment Opportunity Com-individual and effective in helping the in- abetes vary greatly from person to person, mission, “Questions and Answers Aboutdividual perform his or her job. Input so employers must consider each person’s Diabetes in the Workplace and the Amer-from health care professionals who spe- capacities and needs on an individual ba- icans with Disabilities Act (ADA)” Oct.cialize in the particular complication, or sis. People with diabetes should always be 29, 2003. Available from http://wwwfrom vocational rehabilitation specialists evaluated individually with the assistance .eeoc.gov/facts/diabetes.html. Accessed 26 May 2008or organizations, may help identify ap- of experienced diabetes health care pro- 3. Americans with Disabilities Act of 1990,propriate accommodations. fessionals. The requirements of the spe- 42 U.S.C. §12101 et seq. ciﬁc job and the individual’s ability to 4. American Diabetes Association: Stan- perform that job, with or without reason- dards of medical care in diabetes—2011Recommendations able accommodations, always need to be● Individuals with diabetes may need ac- (Position Statement). Diabetes Care 34 considered. (Suppl. 1):S11–S61, 2011 commodations on the job in order to 5. Nathan DM, Kuenen J, Borg R, Zheng H, perform their work responsibilities ef- Schoenfeld D, Heine R: Translating the A1C fectively and safely; these include ac- Acknowledgments — The American Diabe- assay into estimated average glucose values. commodating daily diabetes needs and, tes Assocation thanks the members of the Diabetes Care 31:1473–1478, 2008 when present, the complications of di- volunteer writing group for this updated state- 6. American Diabetes Association: Deﬁning abetes. All such accommodations must ment: John E. Anderson, MD; Michael A. and reporting hypoglycemia in diabetes, a be tailored to the individual and effec- Greene, JD; John W. Grifﬁn, Jr., JD; Daniel B. report from the American Diabetes Asso- Kohrman, JD; Daniel Lorber, MD, FACP, tive in helping the individual perform ciation Workgroup on Hypoglycemia. Di- CDE; Christopher D. Saudek, MD; Desmond his or her job. (E) Schatz, MD; and Linda Siminerio, RN, PhD, abetes Care 28:1245–1249, 2005 CDE. 7. American Diabetes Association: Self-moni- toring of blood glucose (Consensus State-CONCLUSION — Individuals with ment). Diabetes Care 17:81– 86, 1994diabetes can and do serve as highly pro- 8. American Diabetes Association: Tests of gly-ductive members of the workforce. While References 1. Centers for Disease Control and Preven- cemia in diabetes (Position Statement). Di-not every individual with diabetes will be tion: National Diabetes Fact Sheet: General abetes Care 27 (Suppl. 1):S91–S93, 2004qualiﬁed for, nor can perform, every Information and National Estimates on Dia- 9. Family Medical Leave Act of 1993, 29available job, reasonable accommoda- betes in the U.S., 2007. Atlanta, GA, U.S. U.S.C. §2601 et seq.tions can readily be made that allow the Department of Health and Human Ser- 10. American Diabetes Association: Insulin ad-vast majority of people with diabetes to vices, Centers for Disease Control and ministration (Position Statement). Diabeteseffectively perform the vast majority of Prevention, 2008 Care 27 (Suppl. 1):S106 –S109, 2004S86 DIABETES CARE, VOLUME 34, SUPPLEMENT 1, JANUARY 2011 care.diabetesjournals.org