Category: 2017 Winter – Diabetes Focus eMag

diabetes invisible disability

Is diabetes an invisible disability?

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Dr Louise Johnson explains why diabetes can be classified as an invisible disability, but stresses that the term disability should not be used to describe a person as weaker or lesser than anyone else as everyone has a purpose, special uniqueness and value.

Diabetes distress

Living with diabetes is complex and involves various self-care activities, e.g. taking medication, healthy eating, carbohydrate counting, physical activity, checking blood glucose and problem solving5. These self-care behaviours are required to keep HbA1c (the three-month predictive glucose value) in target range – usually between 6,5% and 7,5%, according to the individualised value your doctor has decided on, after discussion with you. The HbA1c should be on target to prevent or delay onset of devastating complications.

The burden of self-management, living with diabetes-related complications (or the risk of their development) and managing difficult social situations has the potential to cause considerable emotional distress. The concept of diabetes distress was recognised in the early 1990s. Data shows that about one quarter of UK adults with diabetes experience elevated or severe diabetes distress at any given time. Similar rates are reported in Europe, Australia, and the USA6. It is also documented that diabetes distress is present among partners of those with diabetes.

Diabetes distress is the emotional response of specific aspects of living with and managing diabetes. The data shows that the higher the diabetes distress, the poorer the HbA1c. Your doctor can use different diabetes distress scales to determine your amount of distress and help with the management of it. Remember that diabetes distress is not depression.

Why would diabetes be an invisible disability?

To answer the question, let’s first look at the definition. The Oxford dictionary defines disability as: “the condition of being unable to perform because of physical or mental unfitness.”

Invisible or hidden disability is defined as disabilities that are not immediately apparent. This is an umbrella term that captures a whole spectrum of hidden disabilities or challenges.

It is estimated that 10% of the population in the USA have a medical condition that could be considered a type of invisible disability. Nearly one in two people, in the USA, have a chronic medical condition of one kind or another, but most of these people are not considered to be disabled, as their conditions do not impair their normal everyday activities.

According to the American Disabilities Act (ADA) of 1990, an individual with a disability is a person who:

  • Has a physical or mental impairment that substantially limits one or more major life activities.
  • Has a record of such impairment.

Invisible disabilities can include chronic illnesses, such as kidney failure, diabetes and sleep disorders; if these diseases significantly impair normal activities of daily living. Epilepsy, ulcerative colitis, and Attention Deficit Hyperactivity Disorder (ADHD) can also be classified as invisible disabilities.

A growing number of organisations, governments and institutions are implementing policies and regulations to accommodate persons with invisible disabilities. Governments and school boards have implemented screening tests to identify students with learning disabilities, as well as other invisible disabilities.

Statistics of invisible disabilities

About 10% of Americans have a medical condition that could be considered an invisible disability. It is shown that 96% of people with chronic medical conditions live with a condition that is invisible. These people do not use a cane or any assistive device nor show that they have a medical condition. About 25% of them have some type of activity limitation, ranging from mid to severe; the remaining 75% are not disabled by their chronic conditions.

Although the disability creates a challenge for the person who has it, the reality of the disability can be difficult for others to recognise or acknowledge. Others may not understand the cause of the problem, if they cannot see evidence of it in a visible way.

South African data shows that people with disabilities generally experienced career advancement challenges and reach career plateau. This study indicated that there is prejudice against invisible disabilities, and as a result, employees are reluctant to declare their disability7.

Why define invisible disability?

In general, the term disability is often used to describe an ongoing physical challenge. This could be a bump in life that can be well-managed or a mountain that creates serious changes and loss. Either way, this should not be used to describe a person as weaker or lesser than anyone else. Everyone has a purpose, special uniqueness and value, no matter what hurdles they may face.

If we take this into consideration, then the answer to the question, “Is diabetes an invisible disability?” should be yes, but only occasionally. It is important to keep into consideration the fact that there will be times when you’re not able to perform certain tasks due to a hypoglycaemic event. It is important to let your colleague or supervisor know and to take time out and correct this event.

In the case of a light hypoglycaemic event, it would take 15 to 30 minutes before the person is able to continue their work. This is an average, and dependent on the fact whether there are other co-morbid conditions also present in this patient, such as kidney failure or a previous heart attack or stroke.

Other complications

Diabetic patients that are not aware of their hypoglycaemic event are in a high-risk group. It is suggested that they wear monitors that can alert them of the lowering of blood glucose to enable them to act timely. There are a few continuous glucose monitors (CGM) available in South Africa.

The hypoglycaemic unaware diabetes patient usually has long-standing diabetes (more than 20 years) and has a degree of kidney failure. It should be noted that this could occur in a diabetic patient with a shorter duration of disease, if they have frequent hypoglycaemic events. The consequence of this is the body becomes use to the lower blood glucose, and its warning system only switches on very late.

The diabetic patient with complications, such as progressive retinopathy (bleeding eye disease), chronic end-stage kidney failure on haemodialysis, and amputations need some special arrangement with their work. The person with progressive diabetic retinopathy may need special measures to help with reading while patients on dialysis need time off work two to three times a week to get dialysis. There are dialysis units that operate at night to accommodate working people. This prevents absence from work.

This invisible disability is transient in the beginning due to the low and high blood sugars but can become a permanent disability. The disability only becomes evident when there is eyesight impairment, amputations, and chronic kidney failure on dialysis.

All patients should realise they can be proactive by gaining knowledge and prevent the invisible disability from becoming an overt disability. Knowledge is power; use this power to manage your diabetes as well as you can with the help of your diabetes doctor. Remember that you are unique and have a special purpose in life. You can rise to the occasion with the help of your diabetes team.

References:

  1. Peeples M, Tomky D, Mulcahy K et. al. (2007) ‘Evolution of the American Association of diabetes Educators’ diabetes education outcomes project.’ Diabetes Educ. 33 p794-817
  2. Dennick K, Sturt J, Hessler D et. al. (2016) ‘High rates of elevated diabetes distress in research populations: a systematic review and meta-analysis.’ Int Diabetes Nurs. http://dx.doi.org/10.1080/20573316205720161202497.
  3. Potgieter IL, Coetzee M, Ximba T (2017) ‘Exploring career advancement challenges people with disabilities are facing in the South African work context’ SA Journal of Human Resource Management ,15(0) p815 http://doi.org/10.4102/sajhrm.v1510.815

MEET OUR EXPERT - Dr Louise Johnson

Dr Louise Johnson
Dr Louise Johnson is a specialist physician passionate about diabetes and endocrinology. She enjoys helping people with diabetes live a full life with optimal quality. She is based in Pretoria in private practice.
jobs diabetes patients

What jobs can’t diabetes patients do?

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There are certain types of jobs that diabetes patients are not allowed to do, especially if they are on insulin. Dr Louise Johnson explains the jobs that fall in this category and further discusses other concerns that diabetes patients could have while in the workplace.

Pilot

A Type 1 diabetes patient can’t be a pilot, however, a Type 2 diabetes patient, only treated with metformin tablets, can. The reasoning behind this is other oral medications and especially insulin could cause a sudden drop in blood glucose. This is dangerous for not only the pilot but passengers and public on the ground.

Mining industry

As soon as diabetes patients who work in the mining industry go on insulin, it becomes dangerous to go underground due to the risk of hypoglycaemia.

Public transport drivers

Since the driver controls the vehicle (taxi, bus, train) that carries passengers from point A to point B, it can be risky if the driver experiences hypoglycaemia. It can also be dangerous, if the driver has high blood sugar as it may lead to drowsiness and possible accidents.

Other concerns

Safety shoes

Diabetes patients working in industries where safety shoes are a requirement, need to ask their doctor to write a motivation to wear special safety shoes, suitable for diabetic patients. This is of importance to prevent their feet from injuries, such as scratches, pressure points and ulcers. Since injuries on the foot of a diabetes patient can lead to deeper ulcers and infection.

If it is not treated correctly and the patient has impaired sensation (peripheral neuropathy), it can contribute to the development of an amputation should the wounds not heal. Diabetes patients with impaired sensation often complain of burning feet, especially at night. They are the high-risk group for feet problems.

Writing exams

Diabetes patients that are on the go with studies should discuss their condition with the lecturers or invigilators. They need to inform them that their blood glucose can go incredibly high due to stress, and can cause severe drowsiness and a diabetic ketoacidosis (high sugar coma).

Diabetic ketoacidosis is a condition where the sugar rises exceptionally high due to insufficient insulin in the body. The body’s metabolism changes from using glucose as substrate for energy to using muscle breakdown products, called free fatty acids. The result is difficulty breathing, abdominal pain, nausea, vomiting, and confusion. This is a medical emergency, and can lead to death if not treated urgently.

Hence, why the lecturer/invigilator should also allow the diabetic student to take a sugar snack, glucose test machine, and insulin into the examination room. This is necessary to correct low or high blood sugar immediately to prevent any acute complications. Additional time should also be allocated to the student during exams, should the student have a low blood sugar event as it takes up to 30 minutes for the brain function to return to normal.

Driving

For many South Africans, driving forms part of their work – either by driving long distances to get to work or driving being one of their duties. Diabetes can affect driving due to hypoglycaemia. The low blood sugar may result in transient cognitive dysfunction or even loss of consciousness.

In a simulator, it was shown that cognitive functions critical to driving, such as reaction times and hand-eye coordination are impaired during hypoglycaemia. People experiencing hypoglycaemia ignored road signs and did not keep to lanes3.

Diabetes can also affect driving due to chronic complications associated with diabetes. The bleeding diabetic eye with decreased vision and the patient with an amputated limb has more difficulty to drive. The same can be said of the diabetic patient that had a stroke.

Type 2 diabetes is often associated with sleep apnea (stop breathing intermittently). This is a condition where a person has excessive daytime sleepiness due to snoring and a severe interrupted sleep pattern at night, which can be dangerous if the person is driving. Sleep apnea can be associated with obesity. It is effectively managed with a continuous positive airway pressure (CPAP) machine that increases the pressures in the airways at night and prevents the sleep apnea.

Any diabetic that had a severe hypoglycaemic event should not drive for at least six weeks thereafter. A severe low blood sugar event is where a person needs the help of a third party or is hospitalised due to hypoglycaemia. They can start driving again after six weeks or only after their awareness of hypoglycaemia has returned4.

Type 2 diabetes

People with Type 2 diabetes can do most occupations, if they follow a rigorous healthy lifestyle and diet to prevent going onto insulin.

Insulin is currently still needed after about 10 years of Type 2 diabetes but there are a variety of new drugs on the horizon that may help stretch this period even longer. Always take your HbA1c (average blood glucose value) into consideration to prevent complications and stay on target.

Managing your diabetes and workday

In the normal course of a workday, diabetes should be taken into consideration. Midday meals should not be skipped. If a person works at a company with a canteen, it would be reasonable to expect the company to cater for people with diabetes. Scholars and students attending academic institutions have the same requirements for special low-glycaemic index (GI) meals. Ideally, these institutions should cater for these scholars and students and their special needs.

The 2015 International Diabetes Federation (IDF) stats show that one in eleven people have diabetes, while the number of people suffering from diabetes in Africa was 14,2 million. This means that there are many diabetes patients at any company or academic institution.

One should take into consideration that obesity has epidemic proportions and healthy food consumption can help curb the diabetes epidemic. The South African National Health and Nutrition Examination Survey (SAHANES) data show that one third of men and two thirds of women are currently obese in South Africa1.

The data shows accordingly in Type 2 diabetes – an unhealthy lifestyle plays a major role in developing Type 2 diabetes and 80-90% of Type 2 diabetes patients are overweight. Data also showed that if obese people loose 5% to 10% of their weight, diabetes could be prevented2.

Any company should screen employees for diabetes at least once a year, since early detection of Type 2 diabetes can be excellently managed with lifestyle management such as moderate exercise and weight loss.

References:

  1. Shisana O, Labadarios D, Rehle T et. al. (2014) ‘The South African National Health and Nutrition Examination Survey. ( SANHANES-1)
  2. Wing RR, Lang W, Wadden TA et. al. (2011) ‘ Benefits of modest weight loss in improving cardiovascular risk factors in overweight and obese individuals with type 2 diabetes.’ Diabetes Care, 34(7) p1481-1486
  3. Cox DJ, Gonder-Frederick L, Kovatchev B et. al. (1993) ‘Driving decrements in type 1 diabetes during moderate hypoglycaemia.’ Diabetes, 42 p239-43
  4. SEMDSA Type 2 diabetes guideline expert committee. (2017) ‘The 2017 SEMDSA Guideline for the management of type 2 Diabetes.’ JEMDSA,22 (1)Supplement 1 (S1-S196)

MEET OUR EXPERT - Dr Louise Johnson

Dr Louise Johnson
Dr Louise Johnson is a specialist physician passionate about diabetes and endocrinology. She enjoys helping people with diabetes live a full life with optimal quality. She is based in Pretoria in private practice.