(1) Diabetes usually does not impact an individual's ability to perform a job, but employers sometimes question the safety and effectiveness of employees with diabetes. (2) Any employment evaluation of a person with diabetes should involve an individualized assessment by a healthcare professional with diabetes expertise, including input from the treating physician. (3) Blanket restrictions on employment for those with diabetes are inappropriate; the ability to perform job duties safely varies between individuals and depends on their specific treatment and medical history.

1. P O S I T I O N S T A T E M E N T
Diabetes and Employment
AMERICAN DIABETES ASSOCIATION
A
s of 2007, approximately 23.6 mil- cations used to the tools used to vidualized assessment of the candidate or
lion Americans have diabetes (1), administer them and to monitor blood employee with diabetes.
most of whom are or wish to be par- glucose levels.
ticipating members of the workforce. Di- Employment decisions should not be Role of diabetes health care
abetes usually has no impact on an based on generalizations or stereotypes professionals
individual’s ability to do a particular job, regarding the effects of diabetes. The im- When questions arise about the medical
and indeed an employer may not even pact of diabetes and its management var- fitness of a person with diabetes for a par-
know that a given employee has diabetes. ies widely among individuals. Therefore, ticular job, a health care professional with
In 1984, the American Diabetes Associa- a proper assessment of individual candi- expertise in treating diabetes should per-
tion adopted the following position on dates for employment or current employ- form an individualized assessment. The
employment: ees must take this variability into account. involvement of the diabetes health care
Any person with diabetes, whether insulin
In addition, federal and state laws re- professional should occur before any ad-
[treated] or non–insulin [treated], should quire employers to make decisions that verse employment decision, such as fail-
be eligible for any employment for which are based on assessment of the circum- ure to hire or promote or termination. A
he/she is otherwise qualified. stances and capabilities of the individual health professional who is familiar with
with diabetes for the particular job in the person with diabetes and who has ex-
Questions are sometimes raised by em- question (2,3). Application of blanket pertise in treating diabetes is best able to
ployers about the safety and effectiveness policies to individuals with diabetes re- perform such an assessment. In some sit-
of individuals with diabetes in a given job. sults in people with diabetes being denied uations and in complex cases, an endocri-
When such questions are legitimately employment for which they are well qual- nologist or a physician who specializes in
raised, a person with diabetes should be ified and fully capable of performing ef- treating diabetes or its complications is
individually assessed to determine fectively and safely. It should be noted the best qualified health professional to
whether or not that person can safely and that, as a result of amendments to the assume this responsibility (4). The indi-
effectively perform the particular duties of Americans with Disabilities Act, which vidual’s treating physician is generally the
the job in question. This document pro- became effective on 1 January 2009, all health care professional with the best
vides a general set of guidelines for eval- persons with diabetes are considered to knowledge of an individual’s diabetes.
uating individuals with diabetes for have a “disability” within the meaning of Thus, even when the employer utilizes its
employment, including how an assess- that law. This is because, among other own physician to perform the evaluation,
ment should be performed and what the opinions of the treating physician and
reasons, diabetes constitutes a substantial
changes (accommodations) in the work- other health care professionals with clin-
limitation on endocrine system function-
place may be needed for an individual ical expertise in diabetes should be sought
ing—the Act was amended to extend its
with diabetes. out and carefully considered. In situations
coverage to persons with a substantial where there is disagreement between the
I. EVALUATING limitation in, among other things, a major opinion of the employee’s treating physi-
INDIVIDUALS WITH bodily function, such as the endocrine cian and that of the employer’s physician,
DIABETES FOR system. Therefore, persons with diabetes the evaluation should be handed over to
EMPLOYMENT — It was once com- are protected from discrimination in em- an independent health care professional
mon practice to restrict individuals with ployment and other areas. The amend- with significant clinical expertise in
diabetes from certain jobs or classes of ments overturned a series of Supreme diabetes.
employment solely because of the diagno- Court decisions that had severely nar-
sis of diabetes or the use of insulin, with- rowed who was covered by the law and
resulted in many people with diabetes Individual assessment
out regard to an individual’s abilities or
and other chronic illnesses being denied A medical evaluation of an individual
circumstances. Such “blanket bans” are
protection from discrimination. This sec- with diabetes may occur only in limited
medically inappropriate and ignore the
circumstances (3). Employers may not in-
many advancements in diabetes manage- tion provides an overview of the factors
quire about an individual’s health sta-
ment that range from the types of medi- relevant to a medically appropriate indi-
tus— directly or indirectly and regardless
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
of the type of job— before making a job
Revised Fall 2009. offer, but may require a medical examina-
DOI: 10.2337/dc11-S082
© 2011 by the American Diabetes Association. Readers may use this article as long as the work is properly tion or make a medical inquiry once an
cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons. offer of employment has been extended
org/licenses/by-nc-nd/3.0/ for details. and before the individual begins the job.
S82 DIABETES CARE, VOLUME 34, SUPPLEMENT 1, JANUARY 2011 care.diabetesjournals.org

2. Position Statement
The job offer may be conditioned on the considered. Only health care profession- based on sufficient and appropriate
results of the medical inquiry or examina- als tasked with such evaluations should medical data and should never be made
tion. An employer may withdraw an offer have access to employee medical informa- based solely on one piece of data. (E)
from an applicant with diabetes only if it tion, and this information must be kept ● Screening guidelines and protocols can
becomes clear that he or she cannot do the separate from personnel records (3). be useful tools in making decisions
essential functions of the job or would about employment if they are used in
pose a direct threat (i.e., a significant risk Screening guidelines an objective way and based on the latest
of substantial harm) to health or safety A number of screening guidelines for scientific knowledge about diabetes
and such threat could not be eliminated evaluating individuals with diabetes in and its management. (E)
with an accommodation (a workplace various types of high risk jobs have been
change that enables a worker with a dis- developed in recent years. Examples in- II. EVALUATING THE
ability to safely and effectively perform clude the American College of Occupa- SAFETY RISK OF
job duties). Another situation in which a tional and Environmental Medicine’s EMPLOYEES WITH
medical evaluation is permissible is when National Consensus Guideline for the DIABETES — Employers who deny
a problem potentially related to the em- Medical Evaluation of Law Enforcement job opportunities because they perceive
ployee’s diabetes arises on the job and Officers, the National Fire Protection As- all people with diabetes to be a safety risk
such problem could affect job perfor- sociation’s Standard on Comprehensive do so based on misconceptions, misinfor-
mance and/or safety. In this situation, a Occupational Medical Program for Fire mation, or a lack of current information
physician may be asked to evaluate the Departments, the U.S. Department of about diabetes. The following guidelines
employee’s fitness to remain on the job Transportation’s Federal Motor Carrier provide information for evaluating an in-
and/or his or her ability to safely perform Safety Administration’s Diabetes Exemp- dividual with diabetes who works or
the job. tion Program, and the U.S. Marshall Ser- seeks to work in what may be considered
Employers also may obtain medical vice and Federal Occupational Health a safety-sensitive position.
information about an employee when Law Enforcement Program Diabetes
the employee has requested an accomo- Protocol. Safety concerns
dation and his or her disability or need Such guidelines and protocols can be The first step in evaluating safety con-
for accommodation is not obvious. An useful tools in making decisions about in- cerns is to determine whether the con-
employer should not rely on a medical dividual candidates or employees if they cerns are reasonable in light of the job
evaluation to deny an employment op- are used in an objective way and based on duties the individual must perform. For
portunity to an individual with diabetes the latest scientific knowledge about dia- most types of employment (such as jobs
unless it is conducted by a health care betes and its management. These proto- in an office, retail, or food service environ-
professional with expertise in diabetes cols should be regularly reevaluated and ment) there is no reason to believe that the
and based on sufficient and appropriate updated to reflect changes in diabetes individual’s diabetes will put employees
medical data. The information sought and knowledge and evidence and should be or the public at risk. In other types of em-
assessed must be properly limited to data developed and reviewed by health care ployment (such as jobs where the individ-
relevant to the individual’s diabetes and professionals with significant experience ual must carry a firearm or operate
job performance (3). The data needed will in diabetes and its treatment. Individuals dangerous machinery) the safety concern
vary depending on the type of job and the who do not meet the standards set forth in is whether the employee will become sud-
reason for the evaluation, but an evalua- such protocols should be given the op- denly disoriented or incapacitated. Such
tion should never be made based only on portunity to demonstrate exceptional cir- episodes, which are usually due to se-
one piece of data, such as a single blood cumstances that would justify deviating verely low blood glucose (hypoglycemia),
glucose result or A1C result. Since diabe- from the guidelines. Such guidelines or occur only in people receiving certain
tes is a chronic disease in which health protocols are not absolute criteria but treatments such as insulin or secreta-
status and management requirements rather the framework for a thorough indi- gogues such as sulfonylureas and even
naturally change over time, it is inappro- vidualized assessment. then occur infrequently. Workplace ac-
priate—and medically unnecessary—for commodations can be made that are min-
examiners to collect all past laboratory Recommendations imal yet effective in helping the individual
values or information regarding office vis- ● People with diabetes should be individ- to manage his or her diabetes on the job
its whether or not related to diabetes. ually considered for employment based and avoid severe hypoglycemia.
Only medical information relevant to on the requirements of the specific job
evaluating an individual’s current capac- and the individual’s medical condition, Hypoglycemia
ity for safe performance of the particular treatment regimen, and medical his- Hypoglycemia is defined as a blood glu-
job at issue should be collected. For ex- tory. (E) cose level 70 mg/dl (4,6). It is a poten-
ample, in some circumstances a review of ● When questions arise about the medi- tial side effect of some diabetes
an individual’s hypoglycemia history may cal fitness of a person with diabetes for treatments, including insulin and sulfo-
be relevant to the evaluation and should a particular job, a health care profes- nlyureas. It can usually be effectively self-
be collected. sional with expertise in treating diabe- treated by ingestion of glucose
Information about the individual’s di- tes should perform an individualized (carbohydrate) and is not often associated
abetes management (such as the current assessment; input from the treating with loss of consciousness or a seizure.
treatment regimen, medications, and physician should always be included. Severe hypoglycemia, requiring the assis-
blood glucose logs), job duties, and work (E) tance of another person, is a medical
environment are all relevant factors to be ● Employment evaluations should be emergency. Symptoms of severe hypogly-
care.diabetesjournals.org DIABETES CARE, VOLUME 34, SUPPLEMENT 1, JANUARY 2011 S83

3. Diabetes and Employment
cemia may include confusion or, rarely, thy), eyes (retinopathy), kidneys (ne- careful changes to their diabetes manage-
seizure or loss of consciousness (6). Most phropathy), or heart, not all individuals ment regimen (for example, more fre-
individuals with diabetes never experi- with diabetes develop these long-term quent blood glucose testing or frequent
ence an episode of severe hypoglycemia complications. Such complications be- meals).
because either they are not on medication come relevant in employment decisions Presence of diabetes-related complica-
that causes it or they recognize the early only when they are established and inter- tions. Chronic complications that may
warning signs and can quickly self-treat fere with the performance of the actual result from long-term diabetes involve the
the problem by drinking or eating. Also, job being considered. Evaluations should blood vessels and nerves. These compli-
with self-monitoring of blood glucose lev- not be based on speculation as to what cations may involve nerve (neuropathy),
els, most people with diabetes can man- might occur in the future. Job evaluations eye (retinopathy), kidney (nephropathy),
age their condition in such a manner that should take high blood glucose levels into and heart disease. In turn, these problems
there is minimal risk of incapacitation account only if they have already caused can lead to amputation, blindness or
from hypoglycemia because mildly low long-term complications such as visual other vision problems, including vision
glucose levels can be easily detected and impairment that interfere with perfor- loss, kidney failure, stroke, or heart at-
treated (4,7). mance of the specific job. tack. As these complications could poten-
A single episode of severe hypoglyce- tially affect job performance and safety,
mia should not per se disqualify an indi- Aspects of a safety assessment such complications should be evaluated
vidual from employment. Rather, an When an individual with diabetes is as- by a specialist in the specific area related
appropriate evaluation should be under- sessed for safety risk there are several as- to the complication. If complications are
taken by a health care professional with pects that must be considered. not present, their possible future develop-
expertise in diabetes to determine the Blood glucose test results. A single ment should not be addressed, both be-
cause of the low blood glucose, the cir- blood glucose test result only gives infor- cause of laws prohibiting such
cumstances of the episode, whether it was mation about an individual’s blood glu- consideration and because with medical
an isolated incident, whether adjustment cose level at one particular point in time. monitoring and therapies, long-term
to the insulin regimen may mitigate this Because blood glucose levels fluctuate complications can now often be avoided
risk, and the likelihood of such an episode throughout the day (this is also true for or delayed. Thus, many people with dia-
happening again. Some episodes of severe people without diabetes), one test result is betes never develop any of these compli-
hypoglycemia can be explained and cor- of no use in assessing the overall health of cations, and those that do generally
rected with the assistance of a diabetes a person with diabetes. The results of a develop them over a period of years.
health care professional. series of self-monitored blood glucose
However, recurrent episodes of se- measurements over a period of time, how- Inappropriate assessments
vere hypoglycemia may indicate that an ever, can give valuable information about The following tools and terms do not ac-
individual may in fact not be able to safely an individual’s diabetes health. Blood glu- curately reflect the current state of diabe-
perform a job, particularly jobs or tasks cose records should be assessed by a tes treatment and should be avoided in an
involving significant risk of harm to em- health care professional with expertise in assessment of whether an individual with
ployees or the public, especially when diabetes (7). diabetes is able to safely and effectively
these episodes cannot be explained. The History of severe hypoglycemia. Of- perform a particular job.
person’s medical history and details of ten, a key factor in assessing employment Urine glucose tests. Urine glucose re-
any history of severe hypoglycemia safety and risk is documentation of inci- sults are no longer considered to be an
should be examined closely to determine dents of severe hypoglycemia. An individ- appropriate and accurate methodology
whether it is likely that such episodes will ual who has managed his or her diabetes for assessing diabetes control (8). Before
recur on the job. In all cases, job duties over an extended period of time without the mid-1970s, urine glucose tests were
should be carefully examined to deter- experiencing severe hypoglycemia is un- the best available method of monitoring
mine whether there are ways to minimize likely to experience this condition in the blood glucose levels. However, the urine
the risk of severe hypoglycemia (such as future. Conversely, multiple incidents of test is not a reliable or accurate indicator
adjustment of the insulin regimen or pro- severe hypoglycemia may in some situa- of blood glucose levels and is a poor mea-
viding additional breaks to check blood tions be disqualifying for high-risk occu- sure of the individual’s current health sta-
glucose levels). pations. However, the circumstances of tus. Blood glucose monitoring is a more
each incident should be examined, as accurate and timely means to measure
Hyperglycemia some incidents can be explained due to glycemic control. Urine glucose tests
In contrast to hypoglycemia, high blood changes in insulin dosage, illness, or other should never be used to evaluate the em-
glucose levels (hyperglycemia) can cause factors and thus will be unlikely to recur ployability of a person with diabetes.
long-term complications over years or de- or have already been addressed by the in- A1C and estimated average glucose
cades but does not normally lead to any dividual through changes to his or her di- (eAG). Hemoglobin A1C (A1C) test re-
adverse effect on job performance. The abetes treatment regimen or education. sults reflect average glycemia over several
symptoms of hyperglycemia generally de- Hypoglycemia unawareness. Some in- months and correlate with mean plasma
velop over hours or days and do not occur dividuals over time lose the ability to rec- glucose levels (4). An eAG is directly re-
suddenly. Therefore, hyperglycemia does ognize the early warning signs of lated to A1C and also provides an individ-
not pose an immediate risk of sudden in- hypoglycemia. These individuals are at ual with an estimate of average blood
capacitation. While over years or decades, increased risk for a sudden episode of se- glucose over a period of time, but it uses
high blood glucose may cause long-term vere hypoglycemia. Some of these indi- the same values and units that are ob-
complications to the nerves (neuropa- viduals may be able to lessen this risk with served when using a glucose meter or re-
S84 DIABETES CARE, VOLUME 34, SUPPLEMENT 1, JANUARY 2011 care.diabetesjournals.org

4. Position Statement
cording a fasting glucose value on a lab are relevant in employment decisions care tasks that should be provided when-
report (5). A1C/eAG values provide only when they are established and in- ever feasible.
health care providers with important in- terfere with the performance of the ac- Administering insulin. Employees may
formation about the effectiveness of an in- tual job being considered. (E) need short breaks during the workday to
dividual’s treatment regimen (4) but are ● Proper safety assessments should in- administer insulin when it is needed. In-
often misused in assessing whether an in- clude review of blood glucose test re- sulin can be safely administered wherever
dividual can safely perform a job. Because sults, history of severe hypoglycemia, the employee happens to be. The em-
they identify only averages and not presence of hypoglycemia unaware- ployee may also need a place to store in-
whether the person had severe extreme ness, and presence of diabetes-related sulin and other supplies if work
blood glucose readings, A1C/eAG results complications and should not include conditions (such as extreme tempera-
are of no value in predicting short-term urine glucose or AIC/eAG tests or be tures) prevent the supplies from being
complications of diabetes and thus have based on a general assessment of level carried on the person (10).
no use in evaluating individuals in em- of control. (E) Food and drink. Employees may need
ployment situations. access to food and/or beverages during
The American Diabetes Association III. ACCOMMODATING the workday. This is particularly impor-
recommends that in most patients A1C EMPLOYEES WITH tant in the event that the employee needs
levels be kept below 7% (4), or eAG below DIABETES — Individuals with diabe- to quickly respond to low blood glucose
154 mg/dl. This recommendation sets a tes may need certain changes or accom- levels or maintain hydration if glucose
target in order to lessen the chances of modations on the job in order to perform levels are high. Employees should be per-
long-term complications of high blood their work responsibilities effectively and mitted to consume food or beverages as
glucose levels but does not provide useful safely. Federal and state laws require the needed at their desk or work station (ex-
information on whether the individual is provision of “reasonable accommoda- cept in an extremely rare situation in
at significant risk for hypoglycemia or tions” to help an employee with diabetes which this would pose a hazard and cre-
suboptimal job performance and is not a to perform the essential functions of the ate a safety issue, and if this is the case, an
measure of “compliance” with therapy. job (3). Additional laws provide for leave alternative site should be provided).
An A1C or eAG cut off score is not med- for an employee to deal with his or her Leave. Employees may need leave or a
ically justified in employment evaluations medical needs or those of a family mem- flexible work schedule to accommodate
and should never be a determinative fac- ber (9). Although there are some typical medical appointments or other diabetes
tor in employment. accommodations that many people with care needs. Occasionally, employees may
“Uncontrolled” or “brittle” diabetes. diabetes use, the need for accommoda- need to miss work due to unanticipated
Sometimes an individual’s diabetes is de- tions must be assessed on an individual- events (severe hypoglycemic episode) or
scribed as “uncontrolled,” “poorly con- ized basis (2). illness.
trolled,” or “brittle.” These terms are not Work schedules. Certain types of work
well defined and are not relevant to job Accommodating daily diabetes schedules, such as rotating or split shifts,
evaluations. As such, giving an opinion management needs can make it especially difficult for some
on the level of “control” an individual has Many of the accommodations that em- individuals to manage diabetes
over diabetes is not the same as assessing ployees with diabetes need on a day-to- effectively.
whether that individual is qualified to day basis are those that allow them to
perform a particular job and can do so manage their diabetes in the workplace as Accommodating complications of
safely. Such an individual assessment is they would elsewhere. They are usually diabetes
the only relevant evaluation. simple accommodations, can be provided In addition to accommodating the day-to-
without any cost to the employer, and day management of diabetes in the work-
Recommendations should cause little or no disruption in the place, for some individuals it is also
● Evaluating the safety risk of employees workplace. Most employers are required necessary to seek modifications for long-
with diabetes includes determining to provide accommodations unless those term diabetes-related complications.
whether the concerns are reasonable in accommodations would create an undue Such people can remain productive em-
light of the job duties the individual burden (3). Some accommodations that ployees if appropriate accommodations
must perform. (E) may be needed include the following. are implemented.
● Most people with diabetes can manage Testing blood glucose. Breaks may be For example, an employee with dia-
their condition in such a manner that needed to allow an individual to test betic retinopathy or other vision impair-
there is no or minimal risk of incapaci- blood glucose levels when needed. Such ments may benefit from using a big screen
tation from hypoglycemia at work. A checks only take minutes to complete. computer or other visual aids, while an
single episode of severe hypoglycemia Some individuals use continuous glucose employee with nerve pain may benefit
should not per se disqualify an individ- monitors but will still need an opportu- from reduced walking distances or having
ual from employment, but an individ- nity to check blood glucose with a meter. the ability to sit down on the job. Individ-
ual with recurrent episodes of severe Blood glucose can be checked wherever uals with kidney problems may need to
hypoglycemia may be unable to safely the employee is without putting other have flexibility to take time off work for
perform certain jobs, especially when employees at risk, and employers should dialysis treatment.
those episodes cannot be explained. (E) not limit where employees with diabetes It is impossible to provide an exhaus-
● Hyperglycemia does not pose an imme- are permitted to manage their diabetes. tive list of potential accommodations. The
diate risk of sudden incapacitation on Some employees may prefer to have a pri- key message in accommodating an em-
the job, and long-term complications vate location for testing or other diabetes ployee with diabetes is to ensure that ac-
care.diabetesjournals.org DIABETES CARE, VOLUME 34, SUPPLEMENT 1, JANUARY 2011 S85

5. Diabetes and Employment
commodations are tailored to the jobs. The therapies for, and effects of, di- 2. Equal Employment Opportunity Com-
individual and effective in helping the in- abetes vary greatly from person to person, mission, “Questions and Answers About
dividual perform his or her job. Input so employers must consider each person’s Diabetes in the Workplace and the Amer-
from health care professionals who spe- capacities and needs on an individual ba- icans with Disabilities Act (ADA)” Oct.
cialize in the particular complication, or sis. People with diabetes should always be 29, 2003. Available from http://www
from vocational rehabilitation specialists evaluated individually with the assistance .eeoc.gov/facts/diabetes.html. Accessed
26 May 2008
or organizations, may help identify ap- of experienced diabetes health care pro-
3. Americans with Disabilities Act of 1990,
propriate accommodations. fessionals. The requirements of the spe- 42 U.S.C. §12101 et seq.
cific job and the individual’s ability to 4. American Diabetes Association: Stan-
perform that job, with or without reason- dards of medical care in diabetes—2011
Recommendations able accommodations, always need to be
● Individuals with diabetes may need ac- (Position Statement). Diabetes Care 34
considered. (Suppl. 1):S11–S61, 2011
commodations on the job in order to
5. Nathan DM, Kuenen J, Borg R, Zheng H,
perform their work responsibilities ef- Schoenfeld D, Heine R: Translating the A1C
fectively and safely; these include ac- Acknowledgments — The American Diabe- assay into estimated average glucose values.
commodating daily diabetes needs and, tes Assocation thanks the members of the Diabetes Care 31:1473–1478, 2008
when present, the complications of di- volunteer writing group for this updated state- 6. American Diabetes Association: Defining
abetes. All such accommodations must ment: John E. Anderson, MD; Michael A.
and reporting hypoglycemia in diabetes, a
be tailored to the individual and effec- Greene, JD; John W. Griffin, Jr., JD; Daniel B.
report from the American Diabetes Asso-
Kohrman, JD; Daniel Lorber, MD, FACP,
tive in helping the individual perform ciation Workgroup on Hypoglycemia. Di-
CDE; Christopher D. Saudek, MD; Desmond
his or her job. (E) Schatz, MD; and Linda Siminerio, RN, PhD, abetes Care 28:1245–1249, 2005
CDE. 7. American Diabetes Association: Self-moni-
toring of blood glucose (Consensus State-
CONCLUSION — Individuals with
ment). Diabetes Care 17:81– 86, 1994
diabetes can and do serve as highly pro- 8. American Diabetes Association: Tests of gly-
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S86 DIABETES CARE, VOLUME 34, SUPPLEMENT 1, JANUARY 2011 care.diabetesjournals.org