Faculty/Steering CommitteeSteering Committee: • Pamela Allweiss, MD, MPH

Medical Officer Centers for Disease Control and Prevention Division of Diabetes TranslationAtlanta, GA The findings and conclusions of this presentation are those of the presenter and do not necessarily represent views of the Centers for Disease Control and Prevention

• Roger P. Austin, MS, RPh, CDEClinical Pharmacy Specialist – Diabetes Henry Ford Health SystemSterling Heights, MI

Steering Committee and Speaking Faculty: • Pamella Thomas, MD, MPH, FACPM, FACOEM

Chief Medical OfficerMed MatRx, LLCConsulting Medical DirectorE & P Business Strategy SolutionsLithonia, GA

Pre-Symposium Survey• Located in the front

inside pocket of your syllabus

• A member of our staff will be collecting these shortly

Faculty/Steering Committee DisclosuresThe steering committee/faculty reported the following relevant financial relationships that they or their spouse/partner have with commercial interests: • Pamela Allweiss, MD, MPH: Nothing to disclose.

• Roger P. Austin, MS, RPh, CDE: Dr. Austin’s spouse is a faculty member at: Johnson & Johnson Diabetes Institute.

• Pamella Thomas, MD, MPH, FACPM, FACOEM: Nothing to disclose.

Non-faculty/Reviewer DisclosuresNon-faculty content contributors and/or reviewers reported the following relevant financial relationships that they or their spouse/partner have with commercial interests: • Matthew Horn, MD; Bradley Pine; Blair St. Amand; Jay Katz,

Dana Simpler, MD: Nothing to disclose.

Educational ObjectivesAt the conclusion of this activity, participants should be able to demonstrate the ability to: • Explain the impact of inadequate control of blood glucose levels on

workers’ overall health, work productivity, and safety

• Translate guideline recommendations into individualized therapeutic decisions to manage hyperglycemia, as well as reduce hypoglycemia risk, to best fit an employee’s needs and schedule

• Differentiate the mechanisms of action of diabetic medications, including agents that act on the enteroinsular axis, and explain which agents have a lower risk of hypoglycemia

• Build a partnership with employees by providing individualized counseling (e.g. self-management education) and resources to optimally manage blood glucose levels in the workplace and optimize adherence

Overview

• The landscape of employer health The benefits and framework for worksite health and diabetes initiatives Making the business case for diabetes initiatives at the workplace How do we address the needs of the person with diabetes at the

worksite? How does the worksite keep its employees productive?

• Case studies of employer health and diabetes initiatives• Resources for practitioners• Getting started – worksites are a potential site for education

and diabetes educators can play a role.

Diabetes Is Hitting Hard During TheWorking Years

• Diabetes affects almost 26 million Americans (8.3%), one-quarter of whom don’t know they have it

• Another 79 million Americans have pre-diabetes, which raises their risk of developing type 2 diabetes, heart disease, and stroke

• About 1.9 million new cases of diabetes were diagnosed in people age 20 years or older in 2010

• One-third will have diabetes by 2050 if current trends continue• Cost: $174 billion

Available at: www.ndep.nih.gov or www.DiabetesAtWork.org.

Darwin RulesEvolution of Perceptions and Diabetes

• Endocrine view of the world: normal glucose is the best; NEVER over 140

• Previous occupational medicine view: No reactions at the workplace; Current view: Control and prevent chronic disease

Examples: Why Are We Discussing This?

• Box cutter and hypoglycemia• Short-term use of insulin in type 2 diabetes in an employee

who drives a forklift• Special occupations: Firefighters, law enforcement officers,

drivers• Disposal of needles: pens, ADA guidelines• Shift work

By 2050, if Current Trends Continue, 1 in 3 Americans Will Have Diabetes

Age-adjusted Percentage of US Adults Who Were Obese or Who Had Diagnosed Diabetes

Obesity (BMI ≥30 kg/m2)

Diabetes

1994

1994

2000

2000

No Data <14.0% 14.0-17.9% 18.0-21.9% 22.0-25.9% ≥26.0%

No Data <4.5% 4.5-5.9% 6.0-7.4% 7.5-8.9% ≥9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System. Available at: www.cdc.gov/diabetes/statistics.

2009

2009

Diabetes Also Means:

• 2x the risk of high blood pressure

• 2 to 4x the risk of heart disease

• 2 to 4x the risk of stroke• #1 cause of adult blindness • #1 cause of kidney failure• Causes more than 60% of

non-traumatic lower-limb amputations each year

Every 24 hours:• 5205 new cases of

diabetes are diagnosed• 180 non-traumatic lower

limb amputations are performed

• 133 people begin treatment for end-stage renal disease

• 829 people die of diabetes or diabetes is a contributing cause of death

National Institute of Diabetes and Digestive and Kidney Diseases. National Diabetes Statistics Fact Sheet. HHS, NIH, 2011.

Why Pick Diabetes for a Health Promotion Intervention at a Business?

• Effective interventions promote multiple good outcomes

• Loss of productivity due to uncontrolled diabetes may be improved with better glucose control

• Improve quality of life for employees

• Many employees (both current and future) have or may be at risk for developing diabetes

• Unique opportunity for education

• Less time away from work• Improves employer-

employee relations and shows employer cares about employees

Don’t Get Lost in TranslationKnow the Language

• Presenteeism

• Absenteeism

• Timing of shift work

• Short-term disability

• Placement

• Productivity

• CDE, DSME

• Prediabetes vs diabetes

• Timing of insulin

• Acute and chronic complications

Diabetes Education TermsOccupational Medicine Terms

Diabetes in the Workplace

• Knowledge of numbers of diabetic workers

• Specific employment policies

• Employer attitudes toward diabetic workers

• Confidentiality

• Problems in obtaining employment

• Problems in maintaining employment

• Discrimination??

Employee PerspectivesEmployer Perspectives

Why Control Diabetes?

• Better control translates into fewer complications: DCCT in type 1, UKPDS in type 2

• Fewer complications translate into fewer days lost to absenteeism and disability, and future savings on health care expenditures

Diabetes and the WorkplaceGeneral Considerations

• Type of job• Physical activity• Hours• Coworkers• Physical environment

• Desk job• Physically active job• Stress• Supervisor• Handling equipment• Physical requirements• Special license or

qualifications

Concerns

• Hypoglycemia, hypoglycemia, hypoglycemia• Testing logistics• Safety and correct disposal of syringes and other supplies

Job Restrictions

• Job placement• Temporary or permanent restrictions• Health status: temporary or permanent

Complications of Diabetes Issue for Disability

• Balance between appropriate therapies to PREVENT complications and accommodations such as needles at the worksite and breaks for snacks

• Wellness programs to PREVENT and improve control

Tug of War Between Ability to Do Work

• Tug of war between ability to do the job, blanket ban, perceived limitations

• Multiple ADAs: Americans with Disabilities Act and American Diabetes Association

• 2009 amendment: People with diabetes and other chronic illnesses are within the law’s umbrella of protection

• Education of everyone: preconceived notions

Can This Person With Diabetes Do This Job?

The three hallmarks of successful individual assessment are:

• Individual job and the individual applicant – not blanket rules

– In most jobs there is no valid safety issue

• Expertise of both health care professionals with knowledge of occupational medicine and those with knowledge of the medical condition at issue

– Include treating physician

• Realizing there simply is not going to be one test and one cut-off score

Individual Assessment

• LEO (law enforcement officers): ACOEM• Avoid blanket bans!• Focus on specific complications: eyes, neuropathy just like

other physical conditions such as back pain, repetitive motion injuries, etc.

Reasonable Accommodations for People with Diabetes• Usually small, easy to accomplish, little or no cost to employer• Daily care

– Time to check blood glucose and treat by administering insulin or food– Place for blood glucose checking/treatment (work station except in rare

circumstances)– Consistent shift for some people

• Responding to long-term complications– Larger computer screen– Chair– Avoiding walking long distances– Part-time or modified work schedules

Practical Considerations in Current Diabetes Drug

Therapy

Natural History of Type 2 Diabetes

Adapted from: International Diabetes Center (Minneapolis, MN).

Therapy for Type 2 Diabetes: Sites of ActionPancreas

Liver Muscle

Gut

Glucose UptakeHGP

Sulfonylurea

Pioglitazone

Meglitinide

Impaired Insulin Secretion

Insulin Deficiency= Carbohydrate Metabolism

Acarbose

Metformin

Insulin Resistance=

Hyperglycemia

Exogenous Insulin Rx

Insulin Secretagogues Sulfonylureas (SFUs) and Meglitinides

First-generation SFUs (introduced in the 1950s):Chlorpropamide (Diabinese)Tolbutamide (Orinase)Tolazamide (Tolinase)

Seldom used; cause prolonged hypoglycemia

Insulin Secretagogues Sulfonylureas

Second Generation SFUs: Introduced in the 1960sGlyburide (Micronase, Diabeta)Glipizide (Glucotrol)Glimepiride (Amaryl)

Stimulate insulin secretion, but unlike normal physiology: risk of unpredictable hypoglycemia

Glyburide use has been associated with cardiac ischemia

Insulin SecretagoguesMeglitinides (Glinides)

Examples: Repaglinide (Prandin) Nateglinide

Increase pancreatic insulin production (like SFUs)

Short-acting secretagogues: decrease post-meal hyperglycemia

Less potential for prolonged hypoglycemia compared to sulfonylureas

Biguanide(s)

Example: Metformin (Glucophage)

Decreases hepatic glucose production

Does not cause hypoglycemia when used as monotherapy

May decrease appetite; weight loss or weight-neutral

Long durability of effect (as contrasted w/ SFUs)

Thiazolidinediones (TZDs) Examples: Pioglitazone (Actos)

Rosiglitazone (Avandia)

Enhance insulin sensitivity in muscle, adipose tissue

Inhibit hepatic gluconeogenesis

Do not increase insulin production, but rather reduce insulin resistance (low risk of hypoglycemia as monotherapy)

Star-crossed class of drugs: Rezulin removed from US market in 1997; Avandia severely restricted in use in the US in 2008

Alpha-Glucosidase Inhibitors

Examples: Acarbose (Precose)Meglitol

Decrease or slow carbohydrate absorption in the intestine

Infrequently used in the US d/t GI s/e’s

Low risk of hypoglycemia when used as monotherapy

GLP-1 Agonists

GLP-1 (glucagon-like peptide 1) is a hormone produced in the small intestine in response to food entering the stomach

GLP-1 signals the pancreas to produce insulin and to decrease glucagon in a glucose-dependent manner

GLP-1 agonists are biosynthetic peptides that mimic native GLP-1 actions

Examples: Exenatide (Byetta)Liraglutide (Victoza)

Exenatide long-acting (Bydureon)

GLP-1 Agonists

Diabetes Education TermsOccupational Medicine Terms

• Increases mealtime insulin production and down-regulates glucagon production• Earlier satiety• Slows gastric emptying time• Cardioprotective• Weight loss• May slow apoptosis of

pancreatic beta cells• Once daily dosing (Victoza)

• Nausea (dose and time dependent, decreases over time)• Injectable• Expensive• Twice daily dosing w/ 45-60 min

lead time prior to meals (Byetta)

Dipeptidyl-Peptidase-4 Inhibitors (DPP-4 Inhibitors)

Examples: Sitagliptin (Januvia)Saxagliptin (Onglyza)

Inhibit enzyme (DPP-4) that deactivates endogenous GLP-1

Increase insulin secretion (beta cells) & decrease glucagon secretion (alpha cells) in the pancreas

Low risk of hypoglycemia when used as monotherapy

Insulin Therapy

No longer the option of last resort; in many cases, may be necessary at time of diagnosis

Several options:Basal insulin (glargine, detemir)Mealtime insulin (aspart, lispro)Mixtures (Novolog Mix 70/30; Novolin 70/30;

Humalog Mix 75/25)

Byetta (exenatide) now has an FDA-approved indication in combination with basal insulin glargine (Lantus)

Type 2 DiabetesA Failure of Mealtime Insulin Secretion (as Hyperglycemia Worsens, Insulin Secretion Is further Impaired)

Adapted from Caotes PA et al. Diabetes Res Clin Pract. 1994;26:177-187.

Practical Aspects of Insulin Therapy

• Timing of dose in relationship to meals is critical

• Mixtures (70/30) work best for patients who eat on a regular schedule

• Rapid-acting insulins (Novolog, Humalog, Apidra) must be given at start of meals

• Matching dose to carbohydrate content of meals is critical

Blood Glucose Testing (SMBG)

• General Targets:– Pre-meal and Fasting: 80 to 140 mg/dl– 2 hours post-meal: 140 to 180 mg/dl

• Dangers of “insulin sliding scale” dosing• Risks of skipped/missed meals• Importance of BG testing at the worksite, especially for

workers who use insulin

Landscape of Employer Health and Business Case

for Diabetes Initiatives

Population Changes

• Aging

• Changing Ethnic Mix

• Obesity

• Unhealthy Lifestyles

• Caregiving Demands

Impact on Employers

• Depletion of human capital

• Productivity losses- Presenteeism

- Absenteeism

- FMLA

- Disability: Short-term and Long-term

- Workers’ compensation cost, liability

- Double-digit increase in health care expenditure

- Loss of highly skilled employees

It’s More Than Health Care Costs…The Economic Toll of Poor Health Includes Direct and Indirect Costs

Source: National Business Group on Health.

Economic Benefits of Improved Glycemic Control

• Workers with better A1c have fewer days lost to absenteeism*

• Fewer days of restricted activity

* Testa MA, Simonson DC. JAMA. 1998;280:1490-1496.

A1c Glucose mg/dL

Avg Charge/PatientNo Complications

Avg Charge/PatientComplications

6% 100 $8,576 $38,726

7% 135 $8,954 $40,230

8% 170 $9,555 $42,230

9% 205 $10,424 $42,467

10% 240 $11,629 $49,673

Gilmer TP et al. Diabetes Care. 1997;20:1847-1853.

~ $30,000

~ $31,000

~ $32,000

~ $32,000

$38k

Access to Diabetes Management

• Time, cost, distance

• Adult learning theories

• Workplace culture

• Employee empowerment

• Impact of low health literacy

Adult Learning Theories for Health Behavior Change

• Need to feel actions will lead to outcomes

• Hands-on interactive sessions

• Role-play exercises

• Small groups

• Readiness to change

Workplace Culture

• Capture senior level support and leadership• CEO leading charge• Benefit design to support efforts and reduce barriers,

also pay for value, not just care• Educate employees on their benefit coverage• Create teams• Choose appropriate interventions• Create a supportive environment• Solicit employee input• Make health behavior change fun!!

Employee Empowerment

• Known barriers to disease management compliance• Leads to

– Poor problem-solving skills

– Needs assessment

– Poor health outcomes

– Little or no knowledge of benefit-plan coverage

Health Literacy

• Definition from IOM: the degree to which an individual has the capacity to obtain, process, and understand basic health information and services needed to make appropriate health care decisions

• In the US

– Proficient: 12%

– Intermediate: 53%

– Basic: 22%

– Below Basic: 14%

• Cost $106-$238 billion dollars per year

Patient Recall After MD Visit

• Truth is stranger than fiction

• Forget 40%-83% of what they hear before leaving the office

• Only 50% of what is remembered is correct

Examples of Programs and Resources

Worksite Diabetes Intervention Programs at Chrysler Corporation 2005-2008

The “Diabetes Coach”Coaching vs Counseling vs Consulting: A Single Role, or a Blend of All Three?

Chrysler HQ Diabetes InterventionA1c Data (Pre-/Post-Intervention)

A1c Aug-05 Feb-06

>9% 6 ( 5%) 2 (2.3%)

>8% <8.9% 18 (14%) 6 (7%)

>7% <7.9% 21 (17%) 15 (18%)

>6% <6.9% 45 (35%) 25 (30%)

>5% <5.9% 37 (29%) 33 (39%)

<5% 3 (3.6%)

Total 127 84

Assembly Plant Pilot Data (Feb 2007 to Apr 2008)

n = 22 A1c (%) RBG (mg/dl) DBP (mmHg) SBP (mmHg) Total Chol (mg/dl)

Pre- 8.5 195.8 132.1 81.6 198.9

Post- 7.2 139.0 122.5 79.6 172.0

Avg Diff 1.3 56.8 9.6 2.0 26.9

Lost Hours 2006 2872.2

Lost Hours 2007 1435.3

Difference 1436.9

n = 18

www.DiabetesAtWork.org

• www.diabetesatwork.org can help businesses and managed care companies assess the impact of diabetes in the workplace, and provide intuitive information to help employees manage their diabetes and take steps toward reducing risks for related complications

www.DiabetesAtWork.org Content

• General diabetes education• Managing diabetes complications• Cardiovascular disease risk factors• Nutrition, physical activity, and weight

control• Emotional well-being • Feet care• Guide to choosing a health plan• “Lunch and Learns” topics• Shift work• Supervisor’s guide• Links to NDEP websites

Resource List

American Diabetes Association www.diabetes.org

American College of Occupational Environmental Medicine www.acoem.org

Centers for Disease Control (CDC) www.cdc.gov/workplacehealthpromotion www.cdc.gov/NationalHealthyWorksite

Diabetes at work www.diabetetesatwork.org

Healthy People 2020 www.healthypeople.gov

National Business Coalition on Health www.nbch.org

National Business Group on Health www.businessgroup.org

National Diabetes Education program www.ndep.nih.gov

Partnership for Prevention www.prevent.org

Wellness Councils of America www.welcoa.org