The limited sample size of this survey means that the findings should be interpreted with caution. Despite our best intentions, the sample selection can not be regarded as truly random because of the possibility of selection bias creeping in during the patient recruitment and consenting process. The absence of researcher and study participant blinding is a limitation though participants were encouraged as much as possible to complete their own questionnaires where practical. It needs to be borne in mind that individuals with particularly negative experiences may have felt more inclined to participate in the study, viewing it as an opportunity to bring some of their experiences to light. Although this cannot be frowned upon, it could have introduced an element of recruitment bias into the results. Recall bias to some of the questions posed could have affected the results.

Whilst recognising the stated limitations, this survey still brings to the forefront some of the perceptions that patients with insulin-treated diabetes have. The study was not designed to appraise the reliability of the perceptions or to attempt to quantify them, but rather to describe certain perceptions held by this group of patients.

The interface between the workplace and workers with diabetes mellitus has rightfully begun to receive more attention in the medical literature. Some previous work has been done looking at the impact of the work environment on glycaemic control and adaptation to diabetes. It has been previously described that diabetes affects choice of work and that it often affects relationships at work, as well as raises important financial/job concerns.₁

We found from our survey that some individuals with insulin treated diabetes appear to hold certain perceptions with regards to the interface between their medical condition and its psycho-social ramifications, with a particular emphasis on the influence on gainful employment.

In general, men appeared to perceive more work related difficulties relating to 1) securing employment, 2) retaining employment and 3) gaining promotion.

The effects of shift work on specific medical disorders have also been reviewed by a previous author and the findings suggested that the strongest evidence exists for an association with peptic ulcer disease, coronary heart disease and compromised pregnancy outcome.₂ In another study (prospective controlled) the authors looked at the diabetes control in 32 diabetic subjects working either regular days or shifts in a large car assembly factory. The authors concluded that diabetic control of insulin treated subjects who worked shifts was not significantly different from individuals who worked days only. The diabetic control in both groups of the study was described as poor, and similar to that of subjects treated with oral hypoglycaemic agents. Slowly rotating shifts were however associated with better diabetic control than more rapidly rotating shifts.₃

From our survey of individuals with insulin-treated diabetes, we found that the work pattern appeared similar with 20% of the women, and 23.5% of the men surveyed being in a hybrid/shift pattern as opposed to a regular 0900 -1700 hour working day. Despite this similarity, men were more likely to express the view that they felt the shift pattern adversely affected the management of their diabetes, as compared to the women (75% versus 50%).

The commonest DM related management problems described whilst at work were hypoglycaemic episodes. However, most of these cases of hypoglycaemia were mild (71.4%) and self treated (no external help required).

This finding is consistent with a recent 12-month prospective study in Edinburgh, United Kingdom (UK) looking at the frequency, severity, and morbidity of hypoglycaemia occurring in the workplace in 243 people with insulin-treated diabetes.₄ The authors described the common occurrence of hypoglycaemic episodes in their cohort of regular workers. Mild hypoglycaemia occurred at work in a total of 580 reported episodes. However, severe hypoglycaemic episodes at work (requiring external help) were noted to be uncommon in the study cohort and seldom caused disruption or serious morbidity. A total of 35 episodes of severe hypoglycaemia were reported by 27 individuals (representing 11% of the entire 243 study population) and giving an over-all incidence of 0.14 episodes per person per annum. The point was presented that the restriction of employment opportunities for most people with insulin-treated diabetes may indeed be difficult to justify. The authors acknowledged that the inherent risk of severe hypoglycaemia in insulin-treated individuals could not be fully eliminated. They put forward the potential for improved employment opportunities of people with insulin-treated diabetes subject to: 1) a careful evaluation of the hazards in the workplace, 2) an assessment of the risks should an episode of severe hypoglycaemia be experienced, and 3) an evaluation of the risk of severe hypoglycaemia in the relevant individuals. ₄

Other problems relevant to diabetes management and experienced at work were 1) difficulties in insulin administration, 2) difficulties in glucose monitoring and 3) difficulties in securing time off for clinic attendances in the case of the men. Surprisingly, none of the 10 women in the survey indicated having ever experienced difficulties in securing time off to attend their scheduled clinics.

A previous questionnaire study of close to 2500 employer-businesses and industries in eight different areas of the UK reported on a finding that up to 16% of firms employing a diabetic person did not allow paid time off for clinic visits. It was also found that a total of 7% of those firms with a diabetic employee reported that diabetic workers were more often absent from work due to sickness. A duly noted finding however was that the majority of employers seemed to indicate that diabetes in itself does not limit employment prospects since most people with diabetes have few problems arising from their condition and can make good employees in a range of occupations.₅

The majority of our study group (20 out of 27, representing 74%) did not perceive that they had experienced discrimination at work on account of their having insulin-treated DM. Of the seven who felt they had been discriminated against, men were predominant (6 male, 1 female), and this represented 35% of the men and only 10% of the women surveyed.

A higher insurance premium was a common experience with 40% of the women and 53% of the men sharing this view. Transportation was considered to be important to both men and women, whether as a means of getting to work, or more so in the case of the men, as a necessity to carry out the requirements of their work. The nature of work performed at the workplace could to some extent explain the latter finding as many of the men where in occupations that required driving or job-related transfers e.g. postman, salesmen, small-vehicle company drivers, couriers etc.

Hypoglycaemia is a recognised and common side-effect of insulin therapy and the perception remains that this could present significant risks in certain occupations. The potential safety issues towards the individuals and that of others is often a recurring theme. Consequently, health and safety legislation may sometimes place restrictions on, and limitations to, the employment opportunities of individuals with insulin-treated diabetes in some industries.

Employment legislation in many developed countries now place some safeguards on the employee rights of individuals considered to have a disability as defined by Acts of legislation. The disability discrimination act (DDA) of 1995, as applicable in the UK is an example of such legislation, though its remit reaches beyond the area of employment.₆, ₇

In the UK, insulin-treated diabetes mellitus is one of the conditions covered by the DDA.₈ The DDA makes it unlawful to treat any person less favourably on the grounds of their disability. Service providers are under a duty to make reasonable adjustments to practices, policies or procedures that make it impossible or unreasonably difficult for disabled people to use a service. The Act requires that employers consider reasonable adjustments in, or to the workplace, to accommodate individuals with the said disability, in this instance the worker with insulin-treated diabetes. It readily becomes apparent that employers and employees may not agree as to the practicalities and ramifications of what either party would consider to be a reasonable adjustment to safeguard the effective discharge of duties. Adequate risk assessment on an individual basis by the employer would be essential before far reaching and long term decisions regarding employee suitability and safety for duties are made.

Striking the right balance on what can be accepted as a ‘reasonable adjustment' in the workplace may need to be judged by an external tribunal in certain cases. The DDA has evolved since it came into force in 1996 and judicial reviews have been required to reflect major changes to the Act.₆