The Impact of Industrial Injury on Diabetes Mellitus

Ira B. Fishman M.D. QMESan Diego, CA

St. Francis Hospital 2013 QME Course

Classification of Diabetes in Adults

• Type 2 diabetes commonly associated with metabolic syndrome(insulin resistance, increased abdominal fat/girth, hyperlipidemia, diminished HDL, hypertension).

• Type 1 diabetes, an autoimmune disorder• Latent autoimmune diabetes of adults (LADA)• Gestational diabetes• Diabetes secondary to other endocrinopathies

e.g. Cushing’s syndrome or chronic pancreatitis

Classification of Diabetes in Adults

• Diabetes secondary to drug side effect e.g. steroids, HIV medications, psychiatric medications

• Diabetes secondary to alterations of glucose metabolism in acute illness

• Diabetes secondary to pancreatic surgery

Scenarios of Diabetes associated with Industrial Injury

• Preexisting diabetes• Onset of diabetes at time of industrial injury

or soon thereafter• Onset of diabetes at variable time after

industrial injury• Transient elevation of blood sugar contiguous

with industrial injury or thereafter

Types of Industrial Injury Commonly Intertwined with Diabetes

• Occupational emotional stress and/or industrial psychiatric illness

• Industrial surgery of any type• Orthopedic industrial injury leading to

diminished physical capacity and exercise pattern

• Treatment of industrial injury with oral or injectable steroids

Potential industrial factors impacting on diabetes by raising blood sugar

• Emotional distress directly impacting blood sugar• Psychiatric illness directly impacting blood sugar• Weight gain due to physical inactivity • Weight gain due to altered dietary patterns and

appetite impacted by chronic pain/medications• Weight gain due to psychiatric medications• Physical inactivity without weight gain• Emotional distress/psychiatric illness reducing

personal capacity for proper diabetes self care

Potential industrial factors impacting on diabetes by raising blood sugar

• Circadian rhythm disturbance• Administration of steroids by any route to

treat industrial injury • Loss of health insurance due to inability to

work after industrial injury• Financial strain after industrial injury causing

inability to purchase medications/test strips for treatment of diabetes

Representative Medical LiteratureSearch terms: “Derivative Diabetes” and “Work-Related Diabetes”

Circulation Research. 2010; 106: 447-462

Circadian Rhythms and Metabolic Syndrome From Experimental Genetics to Human Disease

1. Eleonore Maury,

2. Kathryn Moynihan Ramsey,

3. Joseph Bass

+ Author Affiliations

1. From the Department of Medicine, Division of Endocrinology, Metabolism, and Molecular

Medicine; and Department of Neurobiology and Physiology, Northwestern University,

Evanston, Ill.

1. Correspondence to Joseph Bass, MD, PhD, Northwestern University, Pancoe- ENH Pavilion

Room 4405, 2200 Campus Dr, Evanston, IL 60208. E- mail j- bass@northwestern.edu

Abstract

Abstract: The incidence of the metabolic syndrome represents a spectrum of disorders that continue

to increase across the industrialized world. Both genetic and environmental factors contribute to

metabolic syndrome and recent evidence has emerged to suggest that alterations in circadian

systems and sleep participate in the pathogenesis of the disease. In this review, we highlight studies

at the intersection of clinical medicine and experimental genetics that pinpoint how perturbations of

the internal clock system, and sleep, constitute risk factors for disorders including obesity, diabetes

mellitus, cardiovascular disease, thrombosis and even inflammation. An exciting aspect of the field

has been the integration of behavioral and physiological approaches, and the emerging insight into

both neural and peripheral tissues in disease pathogenesis. Consideration of the cell and molecular

links between disorders of circadian rhythms and sleep with metabolic syndrome has begun to open

new opportunities for mechanism- based therapeutics.

Representative Medical Literature

• Occup Med (Lond). 2008 Jan;58(1):7-14. Epub 2007 Oct 27.

• Does depression increase the risk of developing type 2 diabetes?

• Cosgrove MP, Sargeant LA, Griffin SJ.

• Cherry Hinton Medical Centre, 34 Fishers Lane, Cambridge CB1 9HR, UK.• drmartincosgrove@yahoo.co.uk

• Comment in• Occup Med (Lond). 2008 Jun;58(4):308; author reply 308.

• BACKGROUND: Members of a scheme awarding injury pensions may allege that the• onset of diabetes was precipitated or caused by depression induced by work in• order to claim an injury award.• AIMS: To quantify the association between depression and subsequent development• of type 2 diabetes in order to determine whether an individual in a pension• scheme that awards injury pensions, who develops type 2 diabetes, should be• awarded an injury pension, if the development of the diabetes followed a• work-related depressive episode.• METHODS: Electronic and hand literature searches up to December 2006. Relative• risk estimates from cohort studies of adults were pooled using fixed and random• effects models. Attributable risk fraction was calculated using the Levin• formula.• RESULTS: The presence of depression or depressive symptoms was associated with• increased risk of subsequently developing type 2 diabetes. The pooled fully• adjusted relative risk estimate from the three highest quality studies was 1.25• (95% CI: 1.02-1.48) and was homogenous. However, depression was no more frequent • among those with and without prevalent, but previously undiagnosed, type 2• diabetes.• CONCLUSION: Depression is associated with subsequent development of type 2• diabetes. However, the relative risk estimate is small and only 20% of cases of• diabetes can be attributed to depression in people with both conditions. Further • research is needed to determine possible causal mechanisms for the association• and to ascertain whether depression and diabetes may have a common aetiology.

Representative Medical Literature

• Physical Activity/Exercise and Type 2• Diabetes• • RONALD J. SIGAL, MD, MPH• 1,2,3• GLEN P. KENNY, PHD• 2,3• DAVID H. WASSERMAN, PHD• 4• CARMEN CASTANEDA-SCEPPA, MD, PHD• 5• • DIABETES CARE, VOLUME 27, NUMBER 10, OCTOBER 2004• • • …Therefore, there is firm and consistent• evidence that programs of increased• physical activity and modest weight loss• reduce the incidence of type 2 diabetes in• individuals with IGT. The two strongest• studies, the Finnish Diabetes Prevention• Study (104) and the U.S. DPP (106), do• not permit one to determine the relative• importance of physical activity versus• diet…

Representative Medical Literature • Diabetes Care. 2005 Jul;28(7):1599-603.

• Obesity, inactivity, and the prevalence of diabetes and diabetes-related• cardiovascular comorbidities in the U.S., 2000-2002.

• Sullivan PW, Morrato EH, Ghushchyan V, Wyatt HR, Hill JO.

• Department of Clinical Pharmacy, University of Colorado Health Sciences Center,• Denver, CO 80262, USA. patrick.sullivan@uchsc.edu

• OBJECTIVE: Obesity and physical inactivity are established risk factors for type • 2 diabetes and cardiovascular comorbidities. Whether adiposity or fitness level• is more important to health is controversial. The objective of this research is• to determine the relative associations of physical activity and BMI with the• prevalence of diabetes and diabetes-related cardiovascular comorbidities in the• U.S.• RESEARCH DESIGN AND METHODS: The Medical Expenditure Panel Survey (MEPS) is a• nationally representative survey of the U.S. population. From 2000 to 2002,• detailed information on sociodemographic characteristics and health conditions• were collected for 68,500 adults. Normal weight was defined as BMI 18.5 to <25• kg/m(2), overweight 25 to < or =30 kg/m(2), obese (class I and II) 30 to <40• kg/m(2), and obese (class III) > or =40 kg/m(2). Physical activity was defined as• moderate/vigorous activity > or =30 min > or =3 days per week.• RESULTS: The likelihood of having diabetes and diabetes-related cardiovascular• comorbidities increased with BMI regardless of physical activity and increased• with physical inactivity regardless of BMI. Compared with normal-weight active• adults, the multivariate-adjusted odds ratio (OR) for diabetes was 1.52 (95% CI• 1.25-1.86) for normal-weight inactive adults and 1.65 (1.40-1.96) for overweight • inactive adults; the OR for diabetes and comorbid hypertension was 1.71• (1.32-2.19) for normal-weight inactive adults and 1.84 (1.47-2.32) for overweight• inactive adults.• CONCLUSIONS: Both physical inactivity and obesity seem to be strongly and• independently associated with diabetes and diabetes-related comorbidities. These • results support continued research investigating the independent causal nature of• these factors.

Representative Medical Literature • Occup Med (Lond). 2012 Apr;62(3):167-73. Epub 2012 Feb 14.

• Work-related stress and Type 2 diabetes: systematic review and meta-analysis.

• Cosgrove MP, Sargeant LA, Caleyachetty R, Griffin SJ.

• Cherry Hinton Medical Centre, 34 Fishers Lane, Cambridge, Cambridgeshire CB1 9HR,• UK. drmartincosgrove@yahoo.co.uk

• BACKGROUND: Work-related psychosocial stress has been hypothesized to increase• the individual risk of Type 2 diabetes; however, observational epidemiological• studies investigating the association between work-related psychosocial stress• and Type 2 diabetes have provided an inconsistent picture.• AIMS: To evaluate whether work-related psychosocial stress (defined by a• work-related stress model or by long work hours) is associated with the risk of• Type 2 diabetes.• METHODS: A systematic review of the literature was conducted until March 2010.• Studies eligible for inclusion were published observational epidemiological• studies of adult participants in community or occupational settings if they had a• measure of work-related stress on a validated scale or a measure of work hours or• overtime assessed prior to, or at the same time as, assessment of Type 2 diabetes• status. Where possible, meta-analysis was conducted to obtain summary odds ratios• of the association.• RESULTS: We located nine studies (four prospective, one case-control and four• cross-sectional). The meta-analyses did not show any statistically significant• associations between any individual aspect of work-related psychosocial stress or• job strain and risk of Type 2 diabetes.• CONCLUSIONS: The specific hypothesis that a working environment characterized by • high psychosocial stress is directly associated with increased risk of Type 2• diabetes could not be supported from the meta-analysis.

Representative Medical Literature

Obesity (Silver Spring). 2012 Feb;20(2):428-33. doi: 10.1038/oby.2011.95. Epub 2011 May 19. Work stress, obesity and the risk of type 2 diabetes: gender-specific bidirectional effect in the Whitehall II study. Heraclides AM, Chandola T, Witte DR, Brunner EJ. Source Department of Epidemiology and Public Health, Royal Free and University College London Medical School, London, UK. axhr@steno.dk Abstract Psychosocial work stress has been linked to higher risk of type 2 diabetes (T2DM), with the effect being consistently higher among women than men. Also, work stress has been linked to prospective weight gain among obese men but weight loss among lean men. Here, we aimed to examine the interaction between work stress and obesity in relation to T2DM risk in a gender-specific manner. We studied 5,568 white middle-aged men and women in the Whitehall II study, who were free from diabetes at analysis baseline (1993). After 1993, diabetes was ascertained at six consecutive phases by an oral glucose tolerance test supplemented by self-reports. Cox regression analysis was used to assess the association between job strain (high job demands/low job control) and 18-year incident T2DM stratifying by BMI (BMI <30 kg/m(2) vs. BMI ≥30 kg/m(2)). Overall, work stress was associated with incident T2DM among women (hazard ratio (HR) 1.41: 95% confidence intervals: 1.02; 1.95) but not among men (HR 0.87: 95% confidence interval 0.69; 1.11) (P(INTERACTION) = 0.017). Among men, work stress was associated with a lower risk of T2DM in nonobese (HR 0.70: 0.53; 0.93) but not in obese individuals (P(INTERACTION) = 0.17). Among women, work stress was associated with higher risk of T2DM in the obese (HR 2.01: 1.06; 3.92) but not in the nonobese (P(INTERACTION) = 0.005). Gender and body weight status play a critical role in determining the direction of the association between psychosocial stress and T2DM. The potential effect-modifying role of gender and obesity should not be ignored by future studies looking at stress-disease associations.

Representative Medical Literature • J Indian Med Assoc. 2011 Apr;109(4):238-40.• Study of occupational stress as a risk factor for various morbidities among policemen.• Kamble SV, Phalke DB.• Source• Department of Community Medicine, Rural Medical College, Loni 413736.• Abstract• Police work is widely considered to be among the most stressful occupations. There is increased

prevalence of cardiovascular diseases risk factors and type 2 diabetes among policemen in many countries. There is limited data on health status of policemen in India. Hence a cross-sectional study was conducted during the period April 2007 to September 2007 at three police stations in Rahata taluka of Ahmednagar district. Study was done to assess the level of stress and source of stress among policemen and to study the stress as a risk factor for hypertension, diabetes, obesity and depression. All available 90 policemen were interviewed and their occupational stress was assessed by occupational stress index. Clinical examination and necessary investigations were done. Depression among them was diagnosed with the help of Hamilton depression rating scale. Majority of policemen (88.89%) were having moderate level of stress. Role overload and responsibility for person were moderately stress producing factors among all ranks. Stress score was significantly high among overweight (137), diabetes (142), hypertensive (137) and depressed (118) policemen. Thus occupational stress is the risk factor for development of obesity, diabetes, hypertension and depression.

Representative Medical Literature • Diabetes Res Clin Pract. 2008 Jul;81(1):2-12. doi: 10.1016/j.diabres.2008.04.025.

• Sleep-disordered breathing and type 2 diabetes: a report from the International• Diabetes Federation Taskforce on Epidemiology and Prevention.

• Shaw JE, Punjabi NM, Wilding JP, Alberti KG, Zimmet PZ; International Diabetes• Federation Taskforce on Epidemiology and Prevention.

• Collaborators: Alberti G, Zimmet P, Amiel S, Cohen M, Ficker J, Fulcher G,• Goldberg LR, Groop L, Hillman D, Ip M, Laakso M, Lefebvre P, Matsuzawa Y, Mbanya • JC, Punjabi N, Rossner S, Sadikot S, Shaw J, Silink M, Standl E, Sullivan C,• Wilding J.

• International Diabetes Institute, 250 Kooyong Road, Caulfield, Melbourne, VIC• 3162, Australia. jshaw@idi.org.au

• Sleep-disordered breathing (SDB) has been associated with insulin resistance and • glucose intolerance, and is frequently found in people with type 2 diabetes. SDB • not only causes poor sleep quality and daytime sleepiness, but has clinical• consequences, including hypertension and increased risk of cardiovascular• disease. In addition to supporting the need for further research into the links• between SDB and diabetes, the International Diabetes Federation Taskforce on• Epidemiology and Prevention strongly recommends that health professionals working• in both type 2 diabetes and SDB adopt clinical practices to ensure that a patient• presenting with one condition is considered for the other.

Systematic Medical Legal Approach to an Industrial Diabetes Claim

• Insist on review of pre-injury medical records• Was diabetes preexisting?• Potential nonindustrial factors impacting on

diabetes:• Obesity• Psychiatric illness• Emotional stress• Intercurrent illness• Hyperlipidemia and metabolic syndrome

Systematic Medical Legal Approach to an Industrial Diabetes Claim

• Age• Gender• Ethnicity• Family history• Obstructive sleep apnea• Alcohol consumption• Cigarette smoking• Dietary history, pre-injury exercise pattern

Systematic Medical Legal Approach to an Industrial Diabetes Claim

• Review post-injury diabetic/medical treatment records

• Is there objective evidence of weight gain?• Carefully query applicant about pre and post

injury patterns of exercise, eating patterns citing specific examples

• Document pre and post injury levels of emotional stress

• Review pre and post injury Hemoglobin A1C

Systematic Medical Legal Approach to an Industrial Diabetes Claim

• Carefully consider apportionment• However, future medical care of diabetes is not

apportionable if industrial injury impacted on diabetes; this may present a large future bill to the industrial carrier.

• Rating diabetes follows standard Table in the AMA Guides, 5th edition, with maximum WPI of 10% allotted for type 2 diabetes. Microvascular complications of diabetes may need to be rated under separate organ system tables.

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