Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Diabetes Mellitus Type 2


Related Terms

  • Adult Onset Diabetes Mellitus
  • NIDDM
  • Non-insulin Dependent Diabetes Mellitus
  • Nonketotic Diabetes Mellitus
  • T2DM
  • Type 2 Diabetes
  • Type 2 Diabetes Mellitus

Differential Diagnosis

Specialists

  • Cardiologist, Cardiovascular Physician
  • Clinical Psychologist
  • Endocrinologist
  • Nephrologist
  • Neurologist
  • Ophthalmologist
  • Orthopedic (Orthopaedic) Surgeon
  • Urologist

Comorbid Conditions

Factors Influencing Duration

Factors influencing the length of disability include the presence and progression of complications, infections, loss of vision, amputation of foot or leg, dialysis, individual compliance with self-care regimen, and response to treatment.

Medical Codes

ICD-9-CM:
250.00 - Diabetes Mellitus Type II
250.02 - Diabetes Mellitus without Mention of Complication; Type II or Unspecified Type, Uncontrolled
250.12 - Diabetes with Ketoacidosis; Diabetic: Acidosis without Mention of Coma, Ketosis without Mention of Coma; Type II or Unspecified Type, Uncontrolled
250.22 - Diabetes with Hyperosmolarity; Hyperosmolar (Nonketotic) Coma; Type II or Unspecified Type, Uncontrolled
250.40 - Diabetes with Renal Manifestations; Type II or Unspecified Type, not Stated as Uncontrolled
250.42 - Diabetes with Renal Manifestations; Type II or Unspecified Type, Uncontrolled
250.52 - Diabetes with Ophthalmic Manifestations; Type II or Unspecified Type, Uncontrolled
250.60 - Diabetes with Neurological Manifestations; Type II or Unspecified Type, not Stated as Uncontrolled
250.62 - Diabetes with Neurological Manifestations; Type II or Unspecified Type, Uncontrolled
250.70 - Diabetes with Peripheral Circulatory Disorders; Type II or Unspecified Type, Not Stated as Uncontrolled
250.72 - Diabetes with Peripheral Circulatory Disorders; Type II or Unspecified Type, Uncontrolled
250.80 - Type II (Non-insulin Dependent Type) or Unspecified Type Diabetes Mellitus with Other Specified Manifestations, Not Stated as Uncontrolled
250.82 - Type II (Non-insulin Dependent Type) or Unspecified Type Diabetes Mellitus with Other Specified Manifestations, Uncontrolled
250.90 - Diabetes with Unspecified Complications; Type II or Unspecified Type, not Stated as Uncontrolled
250.92 - Diabetes with Unspecified Complications; Type II or Unspecified Type, Uncontrolled

Overview

Diabetes mellitus (diabetes) is a metabolic disorder characterized by abnormally high levels of a simple sugar (glucose) in the blood (hyperglycemia) as a result of defects in insulin secretion or defective action of insulin or both. The two most common types of diabetes are type 1 and type 2. Type 1 diabetes is a deficiency in insulin secretion resulting from autoimmune destruction of insulin-producing cells in the pancreas (pancreatic islet ß cells); individuals with type 1 diabetes must receive exogenous insulin to prevent ketoacidosis, a life-threatening complication of type 1 diabetes (thus its former name of insulin-dependent diabetes mellitus or IDDM). Type 2 diabetes (non-insulin dependent diabetes mellitus or NIDDM) is an endocrine abnormality ranging from insulin resistance with relative insulin deficiency, to a defect in the secretion of insulin, with or without insulin resistance. Type 2 diabetes usually begins in mid-life (adult onset diabetes) but an increase in the frequency of the diagnosis during childhood is being observed. It is the predominant type of diabetes internationally.

Insulin is a hormone produced in the pancreas. Located behind the liver in the right upper abdomen, the pancreas is a gland with both an exocrine function (secretion of substances to the exterior of the body, in this case the lumen of the duodenum) and an endocrine function (secretion of substances into the bloodstream). The exocrine pancreatic function is associated with digestion (production and secretion of pancreatic juice and enzymes); the endocrine pancreatic function is associated with control of the metabolism of glucose (production and secretion of the hormones insulin and glucagon). Insulin helps metabolize food, converting it into energy. In type 2 diabetes, reduced production of insulin by the pancreas may coexist with resistance of the body to the action of insulin. The inability to secrete sufficient amounts of insulin varies considerably from person to person. Without sufficient insulin, glucose cannot be transported from the blood into the body's cells; it accumulates in the blood, resulting in hyperglycemia.

Genetic predisposition for diabetes is believed to be an important risk factor for type 1 and type 2 diabetes. Classic symptoms of diabetes such as frequent urination, excessive thirst and hunger, mood swings, and light-headedness may not develop in all individuals, and diabetes type 2 can go unrecognized for years before it is diagnosed. Diabetes is associated with complications such as persistent infection, loss of nerve function (peripheral neuropathy), vision loss (retinopathy), kidney disease (diabetic nephropathy), gout, poor peripheral circulation sometimes leading to amputation, and an increased risk of heart disease (coronary artery disease) and stroke (cerebral vascular accident). Risk for developing diabetes can be significantly reduced in susceptible individuals through weight control and regular exercise.

Incidence and Prevalence: About 1.9 million people in the US aged 20 and older were diagnosed with diabetes in 2010 and another 79 million or 35% of the adult population is estimated to have prediabetes ("2011 National Diabetes Fact Sheet"). Pre-diabetes is a condition in which blood glucose levels are higher than normal but not high enough to diagnose diabetes. Diabetes affects 25.8 million people of all ages or 8.3% of the US population ("2011 National Diabetes Fact Sheet"). Ninety to ninety-five percent of these individuals have type 2 diabetes (American Diabetes Association).

Incidence of type 2 diabetes mellitus is rising and is expected to increase worldwide in the coming decade. From 1970 to 2000, the incidence of diabetes doubled (Fox). In 2008, diabetes was the 7th leading cause of death in the US but among American Indians/Alaskan Natives diabetes ranked 4th and it ranked 5th among black Americans and Hispanics (Heron). Incidence is also rapidly increasing in US children and adolescents due to the rise of childhood obesity; 2 million American adolescents have pre-diabetes ("2011 National Diabetes Fact Sheet"). The incidence of type 2 diabetes now exceeds type 1 diabetes among black American, Asian Pacific Islander and American Indian children 10 – 19 years old and among Hispanic children aged 15 - 19 (Dabelea). Increases among Hispanic and black American children appear to be greater than among other ethnic populations (Liese).

Source: Medical Disability Advisor



Causation and Known Risk Factors

The key to understanding the causes of diabetes is in the recognition of the many different types of diabetes. Risk factors also vary from population to population suggesting genetic and / or unknown non-genetic risk factors. In general, commonly acknowledged risk factors include age, obesity, family history of diabetes, diet, sedentary lifestyle and ethnic background. Individuals with a family history of type 2 diabetes in a parent or sibling, who are over the age of 45, or who are obese (body mass index [BMI] greater than 30) have a greater likelihood of developing the disease. Obesity and fat distribution have been identified as major causes of diabetes. Diabetes morbidity and mortality decline precipitously with reduced caloric intake (Rewers). Poor diet as is commonly found in the west is associated with increased risk of diabetes in both men and women (van Dam; Fung). A sedentary lifestyle increases the risk of diabetes and regular aerobic exercise can improve glycemic control (Colberg). A previously identified abnormal fasting plasma glucose, high blood pressure, and high cholesterol (generally total cholesterol >200 mg/dL) are considered to be major risk factors for type 2 diabetes. This disorder is more common among Hispanics, Native Americans, blacks, Asians and Pacific Islanders than non-Hispanic whites ("2011 National Diabetes Facts Sheet").

Metabolic syndrome, a condition characterized by obesity, glucose intolerance, hypertension, high triglycerides, and low HDL cholesterol ("good" cholesterol), increases the risk of developing type 2 diabetes. It is thought that patients with type 2 diabetes have only a 20% to 40% reduction of the beta cell mass, so the reduction of more than 80% of insulin release that is observed must be contingent on other defects in the function of such cells.

Source: Medical Disability Advisor



Diagnosis

History: Individuals often are asymptomatic and only occasionally report the classic symptoms of diabetes mellitus, including increased urination (polyuria), excessive thirst (polydipsia), and excessive hunger (polyphagia). The individual may complain of frequent skin infections that are slow to heal, itching, blurred vision, tingling, numbness, and pain in the arms and legs. There may be a feeling of general fatigue and drowsiness. Women may experience chronic vaginal infections (vaginitis).

Physical exam: High blood pressure is present in at least half the individuals with type 2 diabetes, and obesity is a very common finding. The feet and lower legs are examined carefully for signs of ulceration, persistent infection, or gout. Blood pressure in the leg may be lower than in the arm (ankle-brachial index) indicating poor circulation to the extremities. A decreased sensation of pain may be detected in the legs and feet consistent with peripheral nerve dysfunction (diabetic neuropathy). An eye exam may reveal changes in the blood vessels, bleeding, and yellow or white patches in the retina (diabetic retinopathy).

Tests: A random blood glucose level and fasting blood glucose level are typically elevated. A 2-hour-after-eating (postprandial) blood glucose level is also usually elevated. In addition, an elevated glycosylated hemoglobin (HbA1c) (glucose bound to a protein [hemoglobin] in red blood cells) is often used to confirm the diagnosis, which depends primarily on plasma glucose levels, especially an elevated level of fasting plasma glucose (FPG). Glucose tolerance testing measures and compares fasting and non-fasting blood glucose levels to evaluate glucose metabolism. The oral glucose tolerance test measures blood glucose at half-hour intervals within 2 hours after drinking a set amount of a glucose solution. Individuals with diabetes show abnormal rises in blood glucose (hyperglycemia) within the 2-hour period.

Urinalysis is performed to measure the amount of glucose excreted in the urine; elevated urine glucose (glycosuria) is a typical abnormal finding in diabetes. The absence of ketosis (abnormally elevated concentration of ketones in the blood) is a primary feature that distinguishes type 2 from type 1 diabetes (ketones are usually seen in early untreated type 1 diabetes). A blood chemistry profile is performed to evaluate lipid levels, fluid and electrolyte balance, and to measure serum creatinine, an indicator of kidney function. Periodic testing of the amount of HbA1c may be used to estimate plasma glucose levels over the preceding 1 to 3 months, and may help the physician recommend changes in diet, exercise, and oral glucose-lowering drugs or insulin therapy.

Source: Medical Disability Advisor



Treatment

According to the American Diabetes Association, eating well-balanced, healthy meals, and engaging in regular aerobic exercise are the best preventive and therapeutic measures for those with a family history of type 2 diabetes or with type 2 diabetes. Both can significantly improve glucose tolerance and decrease medication requirements. Individual education in weight control through diet and exercise can be an effective combination to control type 2 diabetes. Stress reduction techniques also assist in controlling type 2 diabetes. Self-care education aimed at providing early intervention for any injuries to the lower legs and feet, including small scratches, should include daily inspection of feet and lower extremities, daily foot cleansing, moisturizing, and nail trimming. Wearing protective footwear can additionally guard against injury. If diet, exercise, and stress reduction are not effective in controlling blood glucose levels, the physician may need to prescribe medication (oral hypoglycemics) to lower blood glucose. Diabetes mellitus type 2 is a progressive, chronic disease, so over time individuals with this disease are likely to need oral hypoglycemics and eventually insulin to control it.

In some cases oral medications may not be enough to effectively control glucose levels and insulin therapy is needed. In these individuals pancreatic beta cell failure occurs and they lose all insulin secretory ability, requiring insulin therapy since oral medication will have little or no effect. Insulin may be administered alone or in combination with an oral medication. Insulin can be self-injected; a health care provider will train the individual in the proper method of injection. Insulin therapy also might be required if exercise and diet are particularly difficult for an individual with physical disabilities, obesity, or comorbid conditions that reduce the ability to exercise.

Treatment also includes monitoring blood glucose levels at regular intervals by the physician and daily by the individual with a home-monitoring glucometer. Periodic testing of glycosylated hemoglobin (HbA1c) provides an indication of glucose levels over the preceding 30 to 90 days. The individual should be educated about the symptoms of, and early response to, hyperglycemia and abnormally low glucose levels (hypoglycemia). The individual should also have regular physical and eye exams.

Source: Medical Disability Advisor



Prognosis

Exercise and weight loss make the body more sensitive to the action of insulin and thereby help to control blood glucose levels. Outcomes are favorable with good regulation of blood glucose levels and compliance with the recommended self-care regimen. The development of complications will adversely affect outcome. Diabetes-related blindness, kidney disease, and amputation can result in permanent disability.

Although type 2 diabetes is a chronic, progressive condition with no known cure, the condition usually can be effectively managed with patient education and regular, appropriate medical care.

Source: Medical Disability Advisor



Complications

Complications of type 2 diabetes mellitus, some of which can be fatal, include hypoglycemia, infection, poor wound healing, gout, poor blood circulation in the extremities, gangrene, amputation of a lower extremity, skin ulceration, eye disease (diabetic retinopathy, glaucoma, cataracts), erectile dysfunction, joint disease (Charcot joints), nerve damage (diabetic neuropathy), heart disease (cardiovascular disease, atherosclerosis), heart attack (myocardial infarction), stroke (cerebral vascular accident), and kidney failure (end stage renal disease).

The presence of retinopathy is predictive of the relationship between elevated glucose levels and development of diabetic complications.

Hyperosmolar hyperglycaemic state (HHS) formerly called hyperosmolar non-ketotic hyperglycaemic coma (HONK) and diabetic ketoacidosis (DKA) seen in type 1 diabetes are rare in type 2 diabetes. HHS, however, is seen in newly diagnosed individuals and the elderly and is associated with high mortality.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Frequent breaks and a private place with facilities for hand washing and disposal of glucose testing strips may be needed to allow for monitoring glucose levels. Limitations may be placed on continuous physical exertion, working in extreme temperature or moist areas, working at unprotected heights, and working in isolated areas alone. If the disease progresses and is associated with visual or sensory impairment, work requiring visual acuity, fine dexterity, prolonged walking, or heavy labor may need to be limited.

Risk: Most onset of type 2 diabetes can be managed with any occupation. For a discussion of psychosocial risk factors, including an "association among job stress, psychosocial factors, and worsened diabetic control," refer to "Disease and Injury Causation," page 242.

Capacity: Individuals with very irregular diabetes control may be precluded from driving, flying, working at unprotected heights or in safety sensitive positions. For information concerning the problematic aspect of regulating activities for those using insulin, refer to "Work Ability and Return to Work," page 137.

Tolerance: A conducive work environment where time is available to an employee to measure blood glucose and administer medication may be able to remove any perceived barriers to return to work.

Source: Medical Disability Advisor



Maximum Medical Improvement

In the absence of severe secondary complications (such as MI, stroke, renal failure), MMI can be determined within 84 days, depending on the complexity of the treatment regimen required.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Does individual have a family history of diabetes?
  • Is individual over 45?
  • Is individual obese?
  • Is individual sedentary rather than physically active?
  • Does individual have polydipsia, polyuria, and polyphagia?
  • Does individual complain of frequent skin infections that are slow to heal, itching, blurred vision, tingling, numbness, pain in the arms and legs, general fatigue and drowsiness? If female, does individual have chronic vaginitis?
  • On exam, did individual have hypertension, obesity, leg ulcers, or changes in the eye?
  • Were a urinalysis, fasting plasma glucose, glucose tolerance test, and blood chemistry profile done? Were HDL cholesterol and / or total cholesterol elevated?
  • Were conditions with similar symptoms ruled out?

Regarding treatment:

  • Does individual eat well-balanced, healthy meals and participate in regular aerobic exercise?
  • Was individual trained in daily inspection and early intervention of injuries to the lower legs? Daily foot care?
  • Were oral hypoglycemics given?
  • Does individual monitor blood sugar regularly?
  • Are plasma glucose levels stable?
  • Has it become necessary for individual to take insulin?
  • Has individual been compliant with self-care recommendations and treatment regimen?

Regarding prognosis:

  • Can individual's employer accommodate any necessary restrictions?
  • Are blood pressure and cholesterol being controlled?
  • Was smoking cessation advised?
  • Does individual have any conditions that may affect ability to recover?
  • Have any complications developed that would slow or prevent recovery such as hypoglycemia, infection, gangrene, amputation of a lower extremity, skin ulceration, diabetic retinopathy, glaucoma, cataracts, erectile dysfunction, joint disease, diabetic neuropathy, cardiovascular disease, atherosclerosis, heart attack, stroke, or kidney failure?

Source: Medical Disability Advisor



References

Cited

"2011 National Diabetes Fact Sheet." CDC. 2011. Centers for Disease Control and Prevention. 15 May 2013 <http://www.cdc.gov/diabetes/pubs/factsheet11.htm>.

American Diabetes Association. "Diagnosis and Classification of Diabetes Mellitus." Diabetes Care 34 Suppl 1 (2011): S62-S69.

Colberg, Sheri R. , et al. "Exercise and Type 2 Diabetes." Diabetes Care 33 (12) (2010): e147-e167.

Dabelea, D. , et al. "Incidence of diabetes in youth in the United States: the SEARCH for Diabetes in Youth Study." JAMA 297 (24) (2007): 2716-2724.

Fox, C. S. , et al. "Trends in the incidence of type 2 diabetes mellitus from the 1970s to the 1990s: the Framingham Heart Study." Circulation 113 (25) (2006): 2914-2918.

Fung, T. T. , et al. "Dietary patterns, meat intake, and the risk of type 2 diabetes in women." Archives of Internal Medicine 164 (20) (2004): 2235-2240.

Heron, M. "Deaths: Leading causes for 2008." National Vital Statistics Reports 60 (6) (2008): 1-94.

Liese, A. D. , et al. "The burden of diabetes mellitus among US youth: prevalence estimates from the SEARCH for Diabetes in Youth Study." Pediatrics 118 (4) (2006): 1510-1518.

Melhorn, J. Mark, and William Ackerman, eds. Disease and Injury Causation, Guides to the Evaluation of. AMA Press, 2008.

Rewers, M. , and R. Hamman. "Chapter 9. National Diabetes Data Group, National Institutes of Health." Diabetes in America. 2nd ed. National Institutes of Health, 1995. 179-220. National Diabetes Information Clearinghouse (NDIC). 95-1468 National Institutes of Health (NIH). 16 May 2013 <http://diabetes.niddk.nih.gov/dm/pubs/america/contents.aspx>.

Talmage, J. B. , J. M. Melhorn, and M. H. Hyman, eds. Work Ability and Return to Work, AMA Guides to the Evaluation of. Second ed. Chicago: AMA Press, 2011.

van Dam, R. M. , et al. "Dietary patterns and risk for type 2 diabetes mellitus in U.S. men." Annals of Internal Medicine 136 (3) (2002): 201-209.

Williams, R. H., and Reed P. Larsen, eds. Williams Textbook of Endocrinology. 10th ed. Philadelphia: Elsevier, Inc., 2003.

Source: Medical Disability Advisor






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