Diabetes and Occupational Health

• By

• Dr.Ashok laddha• Occupational Health

Physician

• MBBS, PGDC ,PGDD, PGDEM, AFIH

• Diploma in Workplace Health and safety. MBA-HA(In –Progress

Diabetes Mellitus

• Diabetes--------siphon-----excessive urination

• Mellitus---------Honey-------passing excessive sweet urine

Indian scenario

• India is Home to over 61 million Diabetic patient

• Expected 100 million –by 2030• Economic burden is very high• Accounted 15% of hospital cost• Every 5th person with diabetes will be Indian

Types of Diabetes

• Type 1 and type2• Type 2• Other specific• Gestational

Diabetes type-1• The body does not produce insulin. Some people may refer to this type

as insulin-dependent diabetes, juvenile diabetes, or early-onset diabetes.

• People usually develop type 1 diabetes before their 40th year, often in early adulthood or teenage years.

• It is autoimmune disorder• Results in total insulin deficiency. • Autoimmunity occurs in islet of Langerhans against the beta cells...• Approximately 10% of all diabetes cases are type 1..• Type 1 diabetes is caused by a T cell–mediated autoimmune destruction

of the pancreatic beta cells • Life long insulin treatment

Future Plan ?• Type-1 Diabetes is currently non-preventable but…

• Drugs?Diet?

• … Mostly in experimental stages. Further research is required.

• Pancreas transplantation?

• Islet cell transplantation?

Diabetes type-2

• Common• Affecting 90 to 95% of all diabetic population • Insulin resistance and relative insulin deficiency• Metabolic disorder• Obesity is the primary cause• Lack of sleep has been linked to type 2• Can be prevented or delayed through proper diet

and structured exercise• Life style intervention is more effective

Diagnosis

• The WHO definition of diabetes (both type 1 and type 2) is for a single raised glucose reading with symptoms, otherwise raised values on two occasions, of either

• Fasting blood sugar 126 mg/dl• Random blood sugar more than 200 mg/dl• Hb1AC more than 6.5

Other specific Type-1

• Genetic defects affecting beta cell function: MODY; mitochondrial DNA mutations; Wolfram’s syndrome

• • Genetic defects affecting insulin action: insulin receptor mutations; lipodystrophies

• • Diseases of pancreas: CF; iron overload syndromes; neoplasia; pancreatitis, trauma

• • Endocrine disorders: glucagonoma, Cushing’s, pheochromocytoma, hyperthyroidism, acromegaly, somatostatinoma

Other specific type-2

• Drugs: calcineurin inhibitors, sirolimus, thiazides, beta-blockers, corticosteroids, niacin, atypical antipsychotics, pentamidine

• Infections: congenital rubella, mumps; CMV• Other immune mediated diabetes: anti-insulin

receptor antibodies• Other genetic syndromes: Down’s, Klinefelter’s,

Turner’s, Friedreich’s ataxia, Myotonia dystrophica, Huntington’s chorea, porphyria, Prader-Willi, Lawrence-Moon-Biedl, Bardet-Biedl

Pre-Diabetic

• High risk of developing diabetes and heart disease

• Blood sugar is high but not enough to labelled as diabetes

• Impaired plasma fasting sugar -100-125 mg/dl• Impaired glucose tolerence-144-199 mg/dl

who should be screened for pre-diabetes

• are habitually physically inactive • have previously been identified as having IFG (impaired fasting glucose)

or IGT (impaired glucose tolerance) • have a family history of diabetes • are members of certain ethnic groups (including Asian American,

African-American, Hispanic American, and Native American) • have had gestational diabetes or have given birth to a child weighing

more than 9 pounds • have elevated blood pressure • have an HDL cholesterol level (the “good” cholesterol) of 35 mg/dl or

lower and/or triglyceride level of 250 mg/dl or higher • have polycystic ovary syndrome • have a history of vascular disease

Gestational Diabetes

• Gestational diabetes is a condition in which women without previously diagnosed diabetes exhibit high blood glucose levels during pregnancy.

• This is likely due to pregnancy-related factors such as the presence of Human placental lactogen that interferes with susceptible insulin receptors. This in turn causes inappropriately elevated blood sugar levels.

• Gestational diabetes generally has few symptoms and it is most commonly diagnosed by screening during pregnancy

• Gestational diabetes affects 3-10% of pregnancies

Risk factors for GDM• Classical risk factors for developing gestational diabetes are:• Polycystic Ovary Syndrome• A previous diagnosis of gestational diabetes or prediabetes, impaired glucose tolerance, or

impaired fasting glycaemia• A family history revealing a first-degree relative with type 2 diabetes• Maternal age - a woman's risk factor increases as she gets older (especially for women over

35 years of age).• Ethnic background (those with higher risk factors include African-Americans, Afro-

Caribbeans, Native Americans, Hispanics, Pacific Islanders, and people originating from South Asia)

• Being overweight, obese or severely obese increases the risk by a factor 2.1, 3.6 and 8.6, respectively.[9]

• A previous pregnancy which resulted in a child with a macrosomia (high birth weight: >90th centile or >4000 g (8 lbs 12.8 oz))

• Previous poor obstetric history• Other genetic risk factors: There are at least 10 genes where certain polymorphism are

associated with an increased risk of gestational diabetes, most notably

MODY• Diabetes result from mutations in a single gene and are called

monogenic• Monogenic forms of diabetes account for about 1 to 5 percent of all

cases of diabetes in young people.• Genetic testing can diagnose most forms of monogenic diabetes• Neonatal diabetes mellitus (NDM) and maturity-onset diabetes of the

young (MODY) are the two main forms of monogenic diabetes.• MODY is much more common than NDM. • People with MODY are generally not overweight • MODY can often be treated with oral diabetes medications• hyperglycemia may only be discovered during routine blood tests• people with MODY typically have a family history of diabetes in

multiple successive generations,

LADA• A proportion of patients ranging from 5-20% with a clinical diagnosis of type 2

diabetes have been found to possess islet auto-antibodies, most typically GADA, and patients in this category progress more rapidly to insulin treatment. This is referred to as Latent Autoimmune Diabetes of the Adult (LADA) and occurs in individuals with a clinical phenotype resembling type 2 diabetes. Immunologically LADA is characterized by islet directed auto-antibodies and is considered a form of type 1 diabetes.

• People with LADA do not require insulin for the first 3 to 6 months following diagnosis, but up to 80% will require insulin within the next five years. Some physicians treat LADA electively with insulin before metabolic decompensation has occurred, but the evidence for this is contested and most patients are treated according to standard management guidelines for type 2 diabetes.

• Latent autoimmune diabetes in adults (LADA) is a form of diabetes that usually affects people who are over 30 years old. People with LADA are often initially thought to have type 2 diabetes, but as the disease progresses, it becomes clear that their condition is actually type 1 diabetes.

Symptoms-1

• frequent urination, especially at night• increased thirst• fatigue• blurred vision• weight loss• itchiness, particularly around the genitals• recurrent infections of the skin and mucous

membranes

Symptoms-2

• Slow-healing sores or cuts• Itching of the skin (usually around the vaginal or groin

area)• Frequent yeast infections• Recent weight gain• Velvety dark skin changes of the neck, armpit and groin,

called acanthosis nigricans• Numbness and tingling of the hands and feet• Decreased vision• Sexual dysfunction, such as erectile dysfunction in men.

Risk factors for diabetes

• Smoking• Tobacco• Alcohol• Chemicals• Drugs• Stress

Risk factors for diabetes• age 45 or older• overweight or obese• physically inactive• parent or sibling with diabetes• family background that is African American, Alaska Native, American Indian, Asian American,

Hispanic/Latino, or Pacific Islander American• history of giving birth to a baby weighing more than 9 pounds• history of gestational diabetes• high blood pressure—140/90 or above—or being treated for high blood pressure• high-density lipoprotein (HDL), or good, cholesterol below 35 milligrams per deciliter (mg/dL), or a

triglyceride level above 250 mg/dL• polycystic ovary syndrome, also called PCOS• prediabetes—an A1C level of 5.7 to 6.4 percent; a fasting plasma glucose test result of 100–125

mg/dL, called impaired fasting glucose; or a 2-hour oral glucose tolerance test result of 140–199, called impaired glucose tolerance

• acanthosis nigricans, a condition associated with insulin resistance, characterized by a dark, velvety rash around the neck or armpits

• history of CVD

Causes of Diabetes

• Type 1 diabetes is a T cell autoimmune disorder

• People with type 2 diabetes have two defects – insulin resistance and relative beta cell Failure.

• Obesity is the main environmental factor for the insulin resistance

Chemical causes

• Medical science has discovered how sensitive the insulin receptor sites are to chemical poisoning.

• Metals such as cadmium, mercury, arsenic, lead, fluoride and possibly aluminum may play a role in the actual destruction of beta cells through stimulating an auto-immune reaction to them after they have bonded to these cells in the pancreas.

• It is because mercury and lead attach themselves at highly vulnerable junctures of proteins that they find their great capacity to provoke morphological changes in the body..

Potential risk factors for type-1 diabetes

• Nitrates, • Nitrites, and • Nitrosoamines• Polychlorinated Biphenyls

Potential risk factors for type-2 diabetes

• 2,3,7,8-Tetrachlorodibenzo-p-dioxin• Aresenic

Facts

• Non-communicable disease• Life long chronic disease• Diet/exercise/health education and team

approach is the foundation of treatment program

• Stay up-to-date with vaccination• Get flu shot every year

Short term complications

• Hypoglycemia• Hyperosmolar coma• Diabetic ketoacidosis• Catabolic State• Susceptibility to infections

Long Term Complications

• Cardiovascular disease• Heart attack—silent—without warning signal• End stage kidney disease• Diabetic foot• Amputation• Gangrene• Blindness• Psychiatric illness• Increases risk of cancer• Increases risk for opportunistic infection-like TB AND MANY

MORE

Mainstay of treatment

• Team approach which consist1. Patient himself2. wife3. Diet/Exercise/weight control4. Family doctor5. Physician6. Diabetologist7. Dietician8. Compliance

Cornerstone of Management

• Vigorous management of hyperglycemia

i.e. High blood sugar should be brought down to normal level within 48 hrs or as early as possible (except in rare cases) will reduce Mortality and morbidity

• Life style modification• Control of cardiovascular risk factors like Blood

pressure ,lipid and smoking

Employment disqualification ?

• Armed forces • Fire service • Ambulance service /rivers• Prison service• Airline pilots and Airline Cabin crew • Air traffic control• Offshore work• Working at height• Working in confined space• Dangerous occupation• Crane operators etc

Why-Concern-Organization point of view

• Cause1. You are important2. They(near and dear) needs you3. Organization needs you

Take home message

• Small step

• Big Rewards

• Prevent type 2 diabetes