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Faculty/Steering Committee

Faculty/Steering Committee. Steering Committee: Pamela Allweiss , MD, MPH Medical Officer Centers for Disease Control and Prevention Division of Diabetes Translation Atlanta, GA

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Faculty/Steering Committee

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  1. Faculty/Steering Committee Steering Committee: • Pamela Allweiss, MD, MPHMedical 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, FACOEMChief Medical OfficerMed MatRx, LLCConsulting Medical DirectorE & P Business Strategy SolutionsLithonia, GA

  2. Pre-Symposium Survey • Located in the front inside pocket of your syllabus • A member of our staff will be collecting these shortly

  3. Faculty/Steering Committee Disclosures The 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.

  4. Non-faculty/Reviewer Disclosures Non-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.

  5. Educational Objectives At 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

  6. 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.

  7. 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.

  8. 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

  9. 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

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

  11. 1994 2000 1994 2000 No Data <14.0% 14.0-17.9% 18.0-21.9% 22.0-25.9% ≥26.0% Age-adjusted Percentage of US Adults Who Were Obese or Who Had Diagnosed Diabetes 2009 Obesity (BMI ≥30 kg/m2) Diabetes 2009 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.

  12. 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.

  13. 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

  14. 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 Occupational Medicine Terms Diabetes Education Terms

  15. Diabetes in the Workplace Employer Perspectives Employee Perspectives • Knowledge of numbers of diabetic workers • Specific employment policies • Employer attitudes toward diabetic workers • Confidentiality • Problems in obtaining employment • Problems in maintaining employment • Discrimination??

  16. 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

  17. 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

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

  19. Job Restrictions • Job placement • Temporary or permanent restrictions • Health status: temporary or permanent

  20. 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

  21. 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

  22. 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

  23. 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.

  24. 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

  25. Practical Considerations in Current Diabetes Drug Therapy

  26. Natural History of Type 2 Diabetes Adapted from: International Diabetes Center (Minneapolis, MN).

  27. Sulfonylurea Meglitinide Hyperglycemia Therapy for Type 2 Diabetes: Sites of Action Gut Pancreas Insulin Deficiency Impaired Insulin Secretion = Carbohydrate Metabolism Exogenous Insulin Rx Acarbose Muscle Liver Glucose Uptake Insulin Resistance = HGP Pioglitazone Metformin

  28. Insulin SecretagoguesSulfonylureas (SFUs) and Meglitinides First-generation SFUs (introduced in the 1950s): Chlorpropamide(Diabinese) Tolbutamide(Orinase) Tolazamide(Tolinase) Seldom used; cause prolonged hypoglycemia

  29. Insulin SecretagoguesSulfonylureas Second Generation SFUs: Introduced in the 1960s Glyburide(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

  30. 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

  31. 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)

  32. 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

  33. 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

  34. 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) Exenatidelong-acting (Bydureon)

  35. GLP-1 Agonists Occupational Medicine Terms Diabetes Education 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)

  36. 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

  37. 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)

  38. Type 2 DiabetesA Failure of Mealtime Insulin Secretion (as Hyperglycemia Worsens, Insulin Secretion Is further Impaired) Adapted from Caotes PA et al. Diabetes Res ClinPract. 1994;26:177-187.

  39. 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

  40. 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 Blood Glucose Testing (SMBG)

  41. Landscape of Employer Health and Business Case for Diabetes Initiatives

  42. Population Changes • Aging • Changing Ethnic Mix • Obesity • Unhealthy Lifestyles • Caregiving Demands

  43. 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

  44. It’s More Than Health Care Costs…The Economic Toll of Poor Health Includes Direct and Indirect Costs Source: National Business Group on Health.

  45. 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.

  46. ~ $30,000 ~ $31,000 ~ $32,000 ~ $32,000 $38k Gilmer TP et al. Diabetes Care.1997;20:1847-1853.

  47. Access to Diabetes Management • Time, cost, distance • Adult learning theories • Workplace culture • Employee empowerment • Impact of low health literacy

  48. 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

  49. 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!!

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