CHAPTER 6 LIVING WITH DIABETES
An individual with a chronic disease is more vulnerable to a range of psychological and psychiatric disorders. Depression and anxiety are commoner in diabetics than in the general population. The presence of complications further lowers the quality of life and increases the likelihood of depression. The interaction between mental health and diabetes can lead to a vicious cycle of worsening diabetic management and mental illness.
This increased prevalence of depression among diabetics underpins the new QOF indicators added in 2006: all patients with diabetes and/or heart disease should be screened “on one occasion during the previous 15 months” for depression using the two standard screening questions:
Interestingly, the evidence underpinning the new indicators has been challenged. A Cochrane review concluded “that routine feedback of the results of screening to clinicians results in a marginal increase in the rate of diagnosis of depression. However, patients’ outcomes are not improved at 6–12 months as a consequence of screening”. The review also concluded that the sceening test fails to meet the National Screening Committee’s criteria for the test, the treatment and the screening programme (see Chapter 1) (Gilbody et al 2006).
The current guidelines are regularly updated and found on the Driver and Vehicle Licensing Agency’s (DVLA) website: www.dvla.gov.uk/at_a_glance/ch3_diabetes.htm). This also provides contact details for the DVLA.
The Road Traffic Acts require that diabetics (irrespective of treatment) who are either applicants or driving licence holders must notify the DVLA of their condition and of any problems or diabetes complications that develop that may affect the safety of driving. Failure to inform the DVLA is now a criminal offence. For medico-legal reasons, health-care professionals should document in the medical records that they have advised the patient to notify the DVLA. GPs may be contacted by a medical officer from the DVLA with a request for further information (usually a DIAB3 form), such as details about glycaemic control (particularly the risk of hypoglycaemia), visual problems and any limb problems.
Group I (ordinary) licence holders and applicants on insulin are granted a licence up to 3 years. On renewal they are required to make a self-declaration that may lead to medical enquiries. Those treated with diet and tablets or diet alone are permitted to hold a licence valid to 70 years of age, subject to the conditions and the need to report any change to insulin treatment. For Group 1 (ordinary) licence holders and applicants, a questionnaire (Diabetic 1) needs to be completed (downloadable: www.dvla.gov.uk/drivers/dmed1_files/pdf/diab1.pdf).
Since 1991, diabetics on insulin have been banned from applying for and renewing thereafter a Group 2 (bus, coach and large goods vehicle driver) licence. Diabetics on diet alone or diet and tablet treatment are permitted to hold a Group 2 licence, subject to the absence of any relevant disability and to not being on insulin. Also, drivers with insulin-treated diabetes should not drive emergency vehicles, due to “… the difficulties for an individual, regardless of whether they may appear to have exemplary glycaemic control, in adhering to the monitoring processes required when responding to an emergency situation” (DVLA 2006).
Insulin is a drug within the meaning of the Road Traffic Act 1988, and a driver “in control of a motor vehicle” with symptoms of hypoglycaemia runs the risk of being charged with driving under the influence of drugs. To avoid this and to correctly manage a hypoglycaemic episode:
If an insurance company asks about diabetes, then the applicant must inform the company if he is diabetic. Failure to do so and also to notify the DVLA can invalidate cover in the event of a claim.
Since the Disability Discrimination Act (1995) came into effect at the end of 1996, insurers can refuse or charge more for cover only with evidence of an increased risk of making a claim. However, because most evidence available about diabetic drivers indicates that they pose no higher risk than nondiabetic drivers, many insurance companies no longer ask about diabetes when cover is applied for.
Some companies, who base their risk assessment on their experience of drivers with diabetes, may still refuse cover or impose special terms or charge an increased premium if their statistics “show” a higher risk. When this happens, it is worth challenging the insurer, especially if the applicant’s diabetes is stable and well controlled. It is always worth shopping around for quotes from a number of insurers, as premiums can vary considerably.
Influenza and pneumonia are common, preventable infectious diseases associated with high mortality and morbidity in people with chronic diseases, such as diabetes. There are limited data on the morbidity and mortality of influenza and pneumococcal pneumonia specifically in diabetics. Safe and effective vaccines are available that can greatly reduce the risk of serious complications from these diseases. Unless contraindicated, the DoH recommends immunisation against influenza and pneumococcal pneumonia in all individuals with diabetes.
Diabetes UK has produced a useful booklet, Employment and diabetes.
Since October 2004, blanket bans have been lifted for diabetics joining the police, fire and ambulance services, but applicants need to demonstrate that their diabetes is well controlled (with hypo-awareness), regularly monitored, and free of complications. The minimum levels of physical and mental fitness are still necessary for all applicants.
Any diabetic is entitled to be considered for any employment for which he is otherwise qualified. UK (via the Disability Discrimination Act) and European legislation offer protection against discrimination in employment against individuals with a medical condition such as diabetes. Due to a lack of up-to-date knowledge about diabetes, employers may fear that a diabetic poses a potential safety risk to the employer and/or the public. Most diabetics can manage their condition so that there is minimal risk of incapacitation from problems such as hypoglycaemia (ADA 2007). Employers need to consider whether the individual’s qualifications and medical circumstances (the condition, its treatment and any specific risks or problems) can be matched to the job specification. The Disability Rights Commission provides useful information for both employers and workers with long-term conditions such as diabetes.
Working shifts can increase the risk of developing either metabolic syndrome or type 2 diabetes (Knutsson 2003). Altering working hours, such as changing shifts or working overtime, can disrupt eating and sleeping patterns in people with pre-existing diabetes, and may lead to a worsening of glycaemic control, particularly if the rotation pattern is rapid. Increased physical activity can affect blood glucose levels, and may require adjustments in calorific intake and treatment to maintain reasonable glycaemic control. Physically demanding work at unexpected times increases the risk of hypoglycaemia.
If on insulin, then it is sensible to use a newer prolonged-acting insulin (insulins glargine or detemir) as the basal insulin. These have the advantages of only being administered once daily and at the same time of day irrespective of the work pattern. Rapid-acting analogues (insulins lispro, aspart or glulisine) can then be administered to cover unpredictable and variable mealtimes. Where possible, patients should aim to time meals at 4 to 5 hour intervals, with snacks if required, and to keep to consistent quantities and types of food.
Adjustments to dosages, type and/or timing of insulin are usually necessary when working shifts, although administering insulin can usually be delayed 1 to 2 hours without significantly affecting diabetic control. This may be sufficient to cover an afternoon shift. If extra food is consumed later in the day, an appropriate increase in the later insulin dose may be needed. Major changes, such as moving to and from night shifts, require careful planning of food intake (more during the shift) and insulin administration, and patients may seek professional advice.
The stress of illness can produce transient insulin resistance and worsen glycaemic control; even if there is little or no calorific intake. Patients treated with diet only or on oral medication may temporarily require insulin.
Diabetics do and should be able to travel. They need to observe the same precautions as the rest of the population, but also to make their own arrangements to reduce the risk of diabetes complications and emergencies. Constant perfect glycaemic control is not an absolute necessity, but the extremes of hypoglycaemia and hyperglycaemia should be avoided.
Pre-travel planning is essential and involves obtaining essential information, ensuring current optimal diabetic management and having in place all the necessary arrangements. Health-care professionals and organisations, such as Diabetes UK and the NHS Scotland (on its website, www.fitfortravel.scot.nhs.uk), can provide useful information.