Drivers with Diabetes - What to do

Diabetes and the Motor Carrier industry

Diabetes seems to be a growing issue with many of my clients, as it continues to be a growing concern with our entire country.  Knowing this to potentially cause some drivers and their employer to be in violation with the safety regulations I have sought out articles on the matter, and have found one specific to both the illness and what the regulations say about it.

The article below was taken from the website of North American Transportation Management Institute (NATMI).  If you or one of your drivers has been diagnosed with Diabetes, please read this very informative article on the illness.  But also read through to see what the DOT/FMCSA states in the safety regulations regarding a driver with diabetes.  Reading this article may help your driver, but also keep your company from being in violation with the regulations and posing a threat to roadway safety.

Diabetes is a serious illness which is increasing in the United States. There may be some misunderstandings about the disease and the regulations surrounding it pertaining to the trucking industry. The following article attempts to clarify and simplify some of the issues.

Diabetes defined
There are several kinds of diabetes mellitus, including primary diabetes mellitus (where no other associated disease is present) and secondary diabetes mellitus (where some identifiable condition causes or allows a diabetic syndrome to develop).

Within the primary category, there is autoimmune (type 1 - insulin dependent) diabetes mellitus and non-autoimmune (type 2 - noninsulin dependent) diabetes mellitus. Within the non-autoimmune diabetes, there is adult onset which is the most common type associated with obesity and maturity-onset diabetes of the young (MODY).  MODY is type 2 diabetes non-insulin dependent previously only seen in adults but now being seen in the young morbidly obese child.

Individuals with type 1 diabetes do not make enough insulin, and therefore must inject themselves with insulin multiple times a day. They are prone to a condition called diabetic ketoacidosis where sugar levels rise dramatically and there is an overproduction of ketones leading to marked change in the acid-base balance in the body producing coma and in some cases if not treated appropriately, death.

Non-autoimmune noninsulin dependent diabetes (NIDDM) (type2) does not produce diabetic ketoacidosis.  Non-immune noninsulin dependent diabetics (NIDDM) can eventually become insulin dependent (IDDM) and need insulin to manage the elevated blood sugars when oral medications are no longer working. 

Types of Diabetes Mellitus Affecting Trucking
In regards to the trucking industry, there are 2 types of Diabetes Mellitus (IDDM and NIDDM) to be most knowledgeable about.

Type One: aka juvenile diabetes. Type one diabetes (IDDM)is a condition where the body either does not produce any insulin or enough insulin. The insulin producing organs (pancreas, beta cells, islets of Langerhans) become damaged, resulting in the lack/loss of insulin production. The cause can be genetic, meaning people are born with it and have to deal with it their entire lives. Or, it can be caused/triggered by certain viral infections in adults.
Those with type one diabetes (IDDM) inject insulin multiple times daily into the bloodstream.

Type Two: aka adult onset diabetes. Type two diabetes (NIDDM) results when the body resists or improperly uses the insulin that is produced by the pancreas. This insulin resistance is related to improper/unhealthy diet (high sugar and carbohydrate content), lack of exercise/activity and excessive weight gain. Fat cell build-up around internal organs such as the pancreas is one of the keys to triggering type two diabetes (NIDDM). There can be a genetic predisposition towards type two diabetes. Those with type two diabetes (NIDDM) can usually control the disease through a combination of proper diet, increased activity level, weight loss and prescription medications; however, in some cases where control can’t be maintained, the use of insulin injections may also be required.

Historically, drivers diagnosed with Type One diabetes mellitus have been disqualified from driving commercial vehicles in interstate commerce. However, the FMCSA has opened up the waiver/exemption process to allow some of these drivers to be qualified. (See the end of this article for more information on this process).
 
Those diagnosed with Type Two diabetes mellitus who demonstrate good control of the disease historically have been qualified to drive by medical examiners.

Medical Problems Associated with Diabetes Mellitus
The medical problems surrounding diabetes are both short term and long term.

Long term medical problems include:

• Higher risk of stroke and gradual deterioration of brain functions.

• High risk of hypertension and heart disease, also blood clotting and slow healing of injuries.

• Chronic organ problems especially with the kidneys. Renal disease is the leading cause of death and disability in diabetics.

• Circulatory problems often occur in the extremities. Foot problems can become disabling and ultimately require amputation due to infection or poor circulation. There is poor healing due to a suppressed immune system.

• Deteriorating eyesight, possible blindness from either simple or proliferative diabetic retinopathy. Diabetic retinopathy is the leading cause of blindness in this country.

• Diabetic Neuropathy - nerve damage affecting all nerves i.e., loss of sensation in extremities and reduced bodily control of bowels.

• Arteriosclerosis - blockage of blood vessels throughout the body but especially around the heart tissue.

Short term medical problems associated with diabetes include:

• Diabetic shock: Also known as insulin shock. It only occurs in IDDM. Hypoglycemia (very low blood sugar) can result in loss of consciousness. This can happen if too much insulin is injected for the amount of calories consumed. A person can go into coma if glucose is not given soon enough.  A person must consume sugar/carbohydrates to get blood sugar level back to normal.
• Diabetic Ketoacidosis: A condition that develops in IDDM when insulin is needed, but not administered. Very high levels of blood sugar develop very quickly along with the development of ketones and an acid-based imbalance develops. This will lead to dehydration and eventually coma and death if not properly treated.
• Hyperosmolar Coma: A condition of severe dehydration, very high blood sugar levels without the development of ketones or acid-base imbalance which requires high levels of  intravenous fluids and minerals to recover.  Extended very high levels of glucose in the blood can result in coma or death. This can happen if non-insulin dependent diabetics do not monitor glucose levels or follow physician instructions for proper insulin dosage.

Is there a cure?
Although there is no cure for diabetes, research is on-going and there are medical advances in the field. Some are more promising than others and include: insulin pumps to replace manual injection of insulin; new drugs and advanced drug therapies; stem cell research into a possible cure; and transplantation of pancreas and beta cells into the human body.

What do drivers need to do to stay healthy?

1. See a doctor regularly for check-ups. If diagnosed with diabetes, follow the doctor’s prescription and health regimen.
2. Lose weight. It is estimated that even losing 20 lbs. initially can be of immense help in controlling type 2 diabetes.
3. Stay active, try to get regular physical activity.
4. Eat healthy and nutritious foods. Avoid high fat/high calorie foods, monitor carbohydrate and sugars closely. Good foods include proteins, fruits, vegetables and most nuts. Consult a trained dietician.
5. Monitor the body daily for signs of trouble.

Leo Hughes, CDS, ARM
Great West Casualty Company
L.HUGHES@gwccnet.com

Federal Safety Regulations

Federal Motor Carrier Safety Regulations have explicit regulations pertaining to diabetes mellitus as diagnosed in commercial motor vehicle drivers.
The rules and guidelines specify a driver is qualified as follows;

391.41 (b)(3) Has no established medical history or clinical diagnosis of diabetes mellitus currently requiring insulin for control.

In addition, there is further medical criteria and information in the FMCSR’s:
FMCSA Medical Advisory Criteria

A person is physically qualified to drive a commercial motor vehicle if that person:

Has no established medical history or clinical diagnosis of diabetes mellitus currently requiring insulin for control.

Diabetes mellitus is a disease which, on occasion, can result in a loss of consciousness or disorientation in time and space. Individuals who require insulin for control have conditions which can get out of control by the use of too much or too little insulin, or food intake not consistent with the insulin dosage. Incapacitation may occur from symptoms of hyperglycemic or hypoglycemic reactions (drowsiness, semiconsciousness, diabetic coma, or insulin shock).

The administration of insulin is within itself a complicated process requiring insulin, syringe, needle, alcohol sponge and a sterile technique. Factors related to long-haul commercial motor vehicle operations such as fatigue, lack of sleep, poor diet, emotional conditions, stress, and concomitant illness, compound the diabetic problem. Because of these inherent dangers, the FMCSA has consistently held that a diabetic who uses insulin for control does not meet the minimum physical requirements of the FMCSRs.

Hypoglycemic drugs, taken orally, are sometimes prescribed for diabetic individuals to help stimulate natural body production of insulin. If the condition can be controlled by the use of oral medication and diet, then an individual may be qualified under the present rule.

See Conference Report on Diabetic Disorders and Commercial Drivers and Insulin-Using Commercial Motor Vehicle Drivers at: http://www.fmcsa.dot.gov/facts-research/research-technology/publications/medreports.htm

American Diabetes Association resources
The Federal Motor Carrier Administration has approved waivers/exemptions for diabetes under some circumstances, as listed in Part 391.49 of the FMCSR’s. The following are example questions on this topic from the FAQ section of the American Diabetes Association website (www.diabetes.org):

I heard there’s a new law for CDLs. Does this mean I can now drive a truck if I use insulin?  

Yes, as part of the transportation bill passed by Congress in July 2005, and signed into law by President Bush in August 2005, people who use insulin to treat their diabetes will have an easier time getting an exemption that will allow them to drive trucks and other commercial vehicles in interstate commerce.

I didn’t know people who use insulin to treat their diabetes weren’t allowed to drive commercial vehicles. What’s the big deal?  

For many years there was a blanket ban that prohibited anyone with diabetes who used insulin from driving commercial vehicles in interstate commerce. In 2003, the Federal Motor Carrier Safety Administration (FMCSA) at the U.S. Department of Transportation replaced this blanket ban and announced a Diabetes Exemption Program to allow for case-by-case assessment of commercial drivers. Under this Program, individuals with insulin-treated diabetes would be allowed to operate commercial vehicles in interstate commerce if they met certain conditions.

Can I just start driving or do I need to do anything first?  

Until FMCSA amends the physical qualification standard in the regulations, individuals with insulin-treated diabetes who wish to drive in interstate commerce will still need to apply for an exemption with FMCSA. Drivers who wish to continue driving intrastate only, and who are licensed by their state to do so, may continue driving as normal and do not need to apply for a diabetes exemption unless they wish to drive interstate.

I have a waiver from my state, do I need to do anything?  

You do not need to do anything if you hold a valid state waiver and do not wish to drive a commercial vehicle in interstate commerce. If you want to begin driving across state lines, or otherwise driving in interstate commerce (defined below), and you use insulin to treat your diabetes, you will need to apply for an exemption with the Federal Motor Carrier Safety Administration.

How do I apply for an exemption?  

Individuals wishing to apply for a diabetes exemption should download a copy of the application (PDF) available on the FMCSA web site at. The application requires that you be evaluated by an endocrinologist and an ophthalmologist or optometrist, and that these doctors provide certain information about your diabetes. You or your doctor may also need to provide other information as requested by the agency.

………..Go to this address to read the rest of the questions and answers:

http://www.diabetes.org/advocacy-and-legalresources/discrimination/CDLFAQ.jsp

Sources for this article:
Dr. Leonel Herrera, Great West Casualty Company
Federal Motor Carrier Safety Regulations
American Diabetes Association
Humphreys Diabetes Center, Boise ID
Harrison’s Principles of Internal Medicine, 14th edition