Diabetes is a disease in which the body does not produce or properly use insulin. Insulin is a hormone that is needed to convert sugar, starches and other food into energy needed for daily life. Nearly 24 million people in the United States have diabetes, which means that 7.8% of the United States population has the disease.

There are two major types of diabetes:

Type 1 (formerly known as “juvenile diabetes” or “insulin-dependent diabetes”) – a disease in which the body produces very little or no insulin, often first diagnosed in children and young adults. People with type 1 diabetes must receive insulin from an outside source (typically through injections or use of an insulin pump) to stay alive. Type 1 diabetes accounts for 5 to 10 percent of all cases of diabetes diagnosed in the United States.

In type 2 diabetes (formerly known as “adult onset” diabetes) the body retains the ability to make insulin, but cannot make enough to meet its needs because cells cannot recognize insulin or use it as effectively as in people without diabetes. Type 2 accounts for 90 to 95 percent of diabetes cases in the United States. Some people with type 2 (particularly in the early stages of the disease) can control their diabetes through diet and exercise. Others must take various types of oral medications, while still others use insulin, much as those with type 1 do.

Diabetes causes blood glucose (sugar) levels to be too high. This is known as hyperglycemia. In the short term, high blood glucose levels can cause hunger, thirst, headache, blurry vision, frequent urination, itchy and dry skin, and, if it is not treated for a period of time, diabetic ketoacidosis, which can cause breathing difficulties, coma, and even death. Hyperglycemia is treated by taking insulin, which lowers blood glucose levels.

In the long term, high blood glucose levels can cause a number of serious complications such as eye disease (which can lead to blindness), kidney disease , nerve damage (neuropathy), heart attack, stroke, hypertension and foot problems that can lead to leg/foot amputations.

Insulin and oral medications do not cure diabetes. Moreover, insulin and some oral medications can cause blood glucose levels to go too low. This is known as hypoglycemia and can result in tremors, palpitations and sweating, confusion, drowsiness, mood changes, unresponsiveness, unconsciousness, convulsions, and death. Mild hypoglycemia is treated with a source of quick-acting sugar, such as hard candy or a glucose tablet. Severe hypoglycemia is treated with injections of a hormone called glucagon.

This does not mean that most people with diabetes, or even diabetes treated with insulin, will experience the most extreme symptoms of high and low blood glucose levels. It does mean that people with diabetes must use vigilance in order to keep their blood glucose levels as close to normal as possible in order to avoid a broad range of immediate and long-term medical problems.

Diabetes cannot be cured, but through diabetes self-management, people with diabetes adjust food, insulin and/or oral medication, and exercise in order to keep blood glucose levels within a prescribed range. The person with diabetes needs to take responsibility for maintaining a good diet, exercising, and seeking appropriate medical care. Those who take good care of themselves can be as productive or even more productive than other employees simply because they are knowledgeable about and participate in a healthy life-style.

The ADA defines a person with a disability in three ways:

• An individual who has a physical or mental impairment that substantially limits one or more major life activities;
• Someone who has a record of such an impairment; or
• Someone who is regarded as having such an impairment.

Under regulations issued by the Equal Employment Opportunity Commission (implementing amendments to the ADA), diabetes is listed as a condition that will consistently be found to be a disability covered under the ADA. This is because, as the agency’s regulations conclude, diabetes substantially limits major life activities such as functions of the endocrine system.

Diabetes is not well known or understood by many employers. The vast majority of people with diabetes live and work successfully without negative impact on their work. Because their condition does not impact their ability to do their job, they may choose to not make their employer aware of their condition. Fear of discrimination keeps many employees with diabetes quiet.

In what areas might employers discriminate?

As with any disability, the potential to discriminate exists at any point in the employment process.

Examples:

• A nurse sent her resume to 16 institutions that advertised job openings for which she was well-qualified and in her cover letter mentioned her diabetes. She had only two responses, and no job offer.
• A man with diabetes initially hired to run a shipboard boutique was rejected by the company doctor; the doctor assumed, without reviewing the man’s medical records or examining him, that he posed an unacceptable safety risk.
• An airline employee was forced to take one 20-minute break rather than the two 10-minute breaks she needed to test her blood glucose, take insulin, and/or eat.
• A cashier with diabetic neuropathy was unable to do his job because the employer would not allow him to sit down between customers, even though standing was not an essential job function.
• A person with diabetes was rejected for the position of police officer because the municipal police department had a blanket policy that disqualified anyone who uses insulin – even though the applicant had informed the department that he had successfully held a law enforcement position in another county for a number of years and had maintained excellent control of his blood glucose levels throughout this period to the present.

These situations reflect the fear and misunderstanding surrounding this condition. As with any other disability, the ADA requires employers to focus upon actual, and not perceived, limitations of the disease.

Despite good monitoring of diet, medication, and exercise, some people with diabetes may experience hypoglycemia or hyperglycemia. However, most people with diabetes recognize the warning signals of these conditions and immediately take appropriate action to bring their blood glucose level back to a safe range.

It is important that employers make the reasonable accommodations that allow people with diabetes to check their blood glucose level by self-administering a finger stick test (which takes less than a minute) and then administering medication (for high glucose levels) or a source of sugar (for low glucose levels). It only takes a few minutes for the person’s blood glucose to return to normal.

The risk of hypoglycemia generally does not create a danger in the workplace. Thus, for example, there is no reason to disqualify a person from a desk job simply because he or she experiences even extreme hypoglycemia.

Even in those jobs where severe hypoglycemia could create a danger (for example, law enforcement positions) there is no reason to disqualify a person simply because he or she has diabetes or uses insulin. Rather, both the current state of diabetes management and judicial interpretations of the ADA have stressed that each person should be evaluated individually. The American Diabetes Association has stated, "Employment decisions should not be based on generalizations or stereotypes regarding the effects of diabetes. The impact of diabetes and its management varies widely among individuals. Therefore, a proper assessment of individual candidates for employment or current employees must take this variability into account.”

There are very few restrictions for people with diabetes. Employers should not assume that diabetes will increase safety concerns. An employer may not deny an employment opportunity to a worker with diabetes based on safety concerns, unless it can demonstrate that the specific applicant or employee would pose a "direct threat" or significant risk of substantial harm to himself or herself or others that cannot be reduced or eliminated through reasonable accommodation. This assessment must be based on objective, factual evidence, including the best recent medical evidence and advances to treat and control diabetes. In addition, individuals should be assessed for their present ability to safely perform the essential functions of the job, not based upon the possibility of future complications.

Problems may occur with those who cannot avoid severe hypoglycemia, and consequently they may not be able to work in safety-sensitive jobs. However, since this is quite uncommon, the employee, based on his or her experiences, should generally make this decision, not the employer, unless the employer can show that the specific employee presents a direct threat to workplace health or safety. Diabetes is a highly individualized condition. Ideally the employee, his or her doctor, and the employer will work together to ensure success.

For the most part, people with diabetes should need no special treatment from their supervisors. An understanding of the condition and the possible need for regular work schedules and meal breaks is usually helpful and appreciated. Living successfully with diabetes means that a person must be self-disciplined, self-aware, and self-responsible, all valued characteristics in many jobs.

The Americans with Disabilities Act requires employers to "reasonably accommodate" the limitations imposed by a person’s physical or mental disability. Reasonable accommodation is defined as modification or adjustment of a job, employment practice, or the work environment that makes it possible for a qualified person with a disability to be employed. The law states that the employer needs to accommodate during the first contact with the person with the disability, during the application process, on the job, in training, on the work site, and when considering promotions and layoffs. If job duties change, new accommodations may need to be made.

The ADA requires an employer to accommodate unless doing so would cause the employer an undue hardship. If an employer finds that the cost of an accommodation would impose an undue hardship, and no funding is available from another source, an applicant or employee with a disability should be offered the option of paying for the portion of the cost that constitutes an undue hardship, or of providing the accommodation.

If we think of accommodations as "productivity enhancements" similar to others made in the workplace, they become part of the cost of doing business.

The ADA requires that employers only accommodate known disabilities. The most common accommodation that a person with diabetes needs is easy and virtually cost-free: the time and space to check blood glucose levels and to self-administer medication or food. Schedules should be arranged to accommodate this. A private place to test and a place to store diabetes care supplies should be available if the employee desires it, as well. The employee may also need to test on an as-needed basis, when he or she can tell blood glucose levels are starting to rise or fall.

Individuals with diabetes may need access to food and/or beverages during the workday. For example, the employee may need to eat a snack to treat low blood glucose or drink water in order to keep hydrated. Employees should be permitted to eat or drink at their desk or work station where possible.

Employees may need leave or a flexible work schedule due to medical appointments or other diabetes care needs. Occasionally, employees may need to miss work due to the effects of hypoglycemia, hyperglycemia or illness. Also, certain work schedules, such as rotating or split shifts, can make it especially difficult for some individuals to manage their diabetes, and may need to be modified.

Some people with diabetes do experience complications such as vision loss, nerve damage, or amputation that may require additional accommodations.

If the diabetes has resulted in visual loss, accommodations can be made. Low vision aids may prove useful. The employee’s eye care professional may suggest magnification, appropriate lighting, or large print materials. The employee may want to contact a local resource center for people who are blind or visually impaired for a low vision assessment on the job to find useful aids.

Other people may develop complications such as neuropathy or amputation that make walking difficult. These conditions can often be accommodated by such easy actions as allowing an employee to sit while working or to limit walking by having a close parking spot or permitting shortcuts through the facility.

For most people with diabetes, the employer should have no concerns about training and promotion. If the employee’s diabetes has caused significant functional limitations, and if training activities are planned, consult the employee about possible accommodations needed in the training environment.

These may include:

• regular testing of blood glucose levels and meal breaks, just as during the normal work day
• training materials put into alternative formats such as large print
• having another trainee copy his or her notes if training is conducted in a darkened room

Employers should assume that people with diabetes have the same career goals and aspirations as any other employee. A person’s diabetes should play no part in decisions about transfers and promotions. Rather, employers should concentrate only on the appropriateness of the person’s skills for a new position and determine if reasonable accommodations are needed. By capitalizing on a person's strengths and accommodating limitations, employers can maximize the productivity of their employees.