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.

Hyperinsulinism


Related Terms

  • Endogenous Hyperinsulinism

Differential Diagnosis

  • Administration of total parenteral nutrition with an insulin additive
  • Adrenal insufficiency
  • Autoantibodies to insulin or insulin receptor
  • Nonislet cell tumor hypoglycemia
  • Nonpancreatic insulin-producing tumors
  • Self-induced factitious hypoglycemia (insulin injection, sulfonylurea ingestion)

Specialists

  • Endocrinologist
  • Gastroenterologist
  • General Surgeon
  • Internal Medicine Physician
  • Oncologist

Factors Influencing Duration

The individual's age may be a factor in the response to treatment: older individuals may not recover from surgery as quickly as younger ones. Complications from surgical interventions can occur in approximately 14% of patients (e.g., leakage from pancreas) and can hamper the recovery time. Additionally, development of other complications from treatment, such as abscesses, pancreatitis, fistula formation, hemorrhage, intestinal obstruction, pleural effusions, and side effects from chemotherapy can prolong the length of disability.

Medical Codes

ICD-9-CM:
251.0 - Hypoglycemic Coma; Iatrogenic Hyperinsulinism; Non-diabetic Insulin Coma
251.1 - Hypoglycemia, Other Specified; Hyperinsulinism NOS, Ectopic, Functional; Hyperplasia of Pancreatic Islet Beta Cells NOS
251.2 - Hypoglycemia, Unspecified; Hypoglycemia NOS; Reactive; Spontaneous

Overview

Hyperinsulinism (also called endogenous hyperinsulinism) refers to abnormally high levels of insulin in the bloodstream in association with documented low blood sugar (hypoglycemia).

Insulin, a hormone produced by beta or islet cells located within the pancreas, helps regulate sugar (glucose) levels in the blood by promoting sugar uptake from the blood into tissue. Therefore, insulin's effect is to lower blood sugar concentrations. In hyperinsulinism, insulin levels in the blood are very high, causing abnormally low blood sugar.

The primary cause of hyperinsulinism is an insulinoma, a tumor of the islet cells in the pancreas that secretes high amounts of insulin. Self-induced (factitious) hyperinsulinism may be caused by ingestion of sulfonylureas (medications used to stimulate insulin secretion in the treatment of diabetes). Very rare causes of hyperinsulinism include antibodies to insulin; antibodies to the insulin receptor; and an increase in the number of islet cells in the pancreas (islet cell hyperplasia or nesidioblastosis).

Most individuals with hyperinsulinism (85% to 90%) have a non-cancerous (benign) pancreatic insulinoma; in about 10% of cases, however, the insulinoma is cancerous (malignant) (Radebold).

Incidence and Prevalence: The prevalence of insulinomas in the US is 4 per 1,000,000 persons per year (Siperstein). Internationally, the estimated incidence is 1 per 1,000,000 persons per year (Radebold).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Insulinomas occur in all age groups, although they occur most commonly between the ages of 40 and 60 (Tran 199). The median age at diagnosis is usually 47 years (Siperstein). Hyperinsulinism occurs more frequently in women than men, with a 3 to 2 female-to-male ratio (Radebold).

Obesity and consumption of a diet rich in carbohydrates are risk factors for this disease.

Source: Medical Disability Advisor



Diagnosis

History: Individuals may complain of symptoms due to low blood sugar, such as sweating, weakness, increased heart rate, palpitations, and hunger. They may also report double vision (diplopia), blurred vision, confusion, anxiety, stupor, seizures, or coma.

Physical exam: The exam may reveal confusion or abnormal behavior, lethargy, or unconsciousness; tremors or trembling may be present. If the hyperinsulinism is caused by an insulinoma that has spread (metastasized) to the liver, the individual may show yellowing of the skin (jaundice). Examination (palpation) of the abdomen may reveal an enlarged liver (hepatomegaly).

Tests: Hyperinsulinism is characterized by high blood concentrations of insulin and low concentrations of blood sugar even after a period of time without food (fast). Blood levels of insulin, glucose proinsulin (insulin precursor), and C-peptide (a byproduct from insulin production) are measured after an overnight fast. If the overnight fasting test does not prove diagnostic, a 72-hour in-hospital fasting study with serial measurements of insulin and glucose levels can be done.

Insulin radioimmunoassay is a very sensitive laboratory method for measuring the fasting insulin concentration in the blood. Another type of radioimmunoassay measures the insulin precursor (proinsulin radioimmunoassay).

Levels of proinsulin (the precursor molecule of insulin), C-peptide, and urinary sulfonylureas may be measured to rule out self-administration of insulin or hypoglycemic drugs. Specialized tests for antibodies to insulin or insulin receptors may also be performed.

Imaging studies should be done only after the diagnosis of insulinoma has been confirmed by laboratory testing. Abdominal CT scan (dual phase contrast spiral CT) is the best noninvasive imaging test to identify a pancreatic tumor (insulinoma). Intraoperative ultrasound is currently the best method for localization of insulinomas. Other successful methods include endoscopic ultrasonography, MRI, angiography, and octreotide scan. Abdominal ultrasound is ineffective and should not be used.

Source: Medical Disability Advisor



Treatment

The majority of individuals with hyperinsulinism have benign insulin-secreting insulinomas, which respond well to surgical removal. This procedure is curative in 93% to 100% of all benign cases. A portion of the pancreas may have to be removed (partial pancreatectomy) if there are multiple insulinomas. Individuals who are unable to undergo surgery or have malignant insulinomas may be treated with medications. Medications that inhibit insulin secretion (diazoxide combined with thiazide diuretics), suppress insulin secretion (somatostatin analogs like octreotide) or raise blood glucose levels (e.g., glucocorticoids, certain drugs used to control blood pressure) may be prescribed. Chemotherapy or radiofrequency thermal ablation may be helpful in patients with hepatic metastasis from a malignant insulinoma.

Source: Medical Disability Advisor



Prognosis

Approximately 93% to 100% of individuals with hyperinsulinism caused by an insulinoma have complete, long-term cure after surgical removal of the tumor. Individuals treated with drug therapy may expect less severe hypoglycemia 62% of the time. In about 26% of individuals treated with drug therapy, blood concentrations of insulin and glucose return to normal. Patients with malignant insulinomas usually remain disease-free for a median of 5 years after curative resection; about 65% of these individuals will have a recurrence, with a median survival of about 19 months (Siperstein).

Source: Medical Disability Advisor



Rehabilitation

Initially, education is necessary for the individual to understand the role of insulin in the body and the effects of food and exercise on insulin levels. Even if the cause of hyperinsulinism is assessed as insulinoma (tumor of the islets of Langerhans in the pancreas), proper diet and exercise are crucial for maintaining insulin levels within the body. Central obesity, or storage of excess fat in the abdominal area—a condition which currently affects more men than women—is an independent risk factor for insulin resistance, diabetes, and coronary heart disease. Individuals should be made aware that their current lifestyle, if it includes things such as overeating, inactivity, or smoking, might be contributing to their problems with insulin.

The individual will typically undergo a nutritional assessment by a licensed nutritionist. A strict diet regimen is usually established. A typical diet plan may include caloric levels of 1,200, 1,500, and 1,800. Saturated fats should be limited to 5% to 10% of their daily intake, while percentages of complex carbohydrate intake should range form 30% to 45%, depending on the nutritionist's evaluation. Excess calories that are not utilized through everyday activity should be expired through regular exercise. Aerobic exercise is one of the most effective methods of controlling high insulin levels.

Before engaging in an exercise program, the individual is usually screened for any condition, such as hypertension or arthritis, which may require a specialized protocol. Exercise should be a regular part of daily life. Moderate-to-intense aerobic exercises, such as brisk walking or stationary cycling, should be performed at least 4 times a week for at least 30 minutes per session. The individual should work up to at least an hour of exercise 4 to 5 times a week. Insulin lowering effects are seen up to 48 hours after aerobic exercise; however, if not performed continuously, exercise benefits cease. Targeted heart rate for exertion control is set based on age, and should be followed to prevent over- or under-exertion. An aqua therapy routine may be prescribed for those individuals whose weight makes it difficult to perform aerobic exercises such as walking for prolonged periods of time. The aqua environment also helps to alleviate stress on joints and creates a protective environment for individuals who fear injury. In some instances, a reduction in body weight by as little as 10% shows marked improvement in insulin stabilization.

A diagnosis of hyperinsulinism should not require medical leave unless tumor removal or organ damage necessitates hospitalization or surgery. Behavior modification such as smoking cessation and weight management should not be influenced by workplace stressors. If job stress is an issue, the individual may participate in stress management or relaxation therapy. In any case, if hyperinsulinism is not controlled, exercise and diet management is ongoing.

Source: Medical Disability Advisor



Complications

A possible complication of insulinoma is metastasis of a malignant tumor.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

If treatment includes surgery, individuals may need to perform sedentary work for 2 to 4 weeks until recovery is complete. Otherwise, no work restrictions or accommodations are usually 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:

  • Has diagnosis of hyperinsulinism been confirmed?
  • Was the cause of hyperinsulinism identified?
  • Has individual experienced any complications related to the hyperinsulinism?

Regarding treatment:

  • Do symptoms persist despite surgical removal of the insulinoma?
  • What additional treatment options are available to this individual?
  • If drug treatment is not adequate, is surgical intervention now an option?
  • Does the patient have untreatable metastases from a malignant tumor?
  • Would individual benefit from diet modification and enrollment in a weight loss program?
  • Were any underlying conditions (e.g., islet cell tumor, nonpancreatic tumor, factitious hypoglycemia, malnutrition) that might have been related to the hyperinsulinism in this patient treated appropriately?

Regarding prognosis:

  • If symptoms persist despite treatment, would individual benefit from further evaluation by a specialist?
  • Would individual benefit from consultation with a nutritionist/dietitian?
  • Is individual currently enrolled in a weight loss program?

Source: Medical Disability Advisor



References

Cited

Radebold, Klaus. "Insulinoma." eMedicine. Eds. Pradyumma D. Phatak, et al. 1 Nov. 2001. Medscape. 14 Oct. 2004 <http://emedicine.com/med/topic2677.htm>.

Siperstein, Alan, Orlo Clark, and Robert J. Rushakoff. "Insulinoma and other Hypoglycemias." Diabetes and Carbohydrate Metabolism. Eds. Ira D. Goldfine and Robert J. Rushakoff. 1st ed. Endotext, Endotext. MDText. 14 Oct. 2004 <http://www.endotext.org/diabetes/diabetes39/diabetes39.htm>.

Tran, Tuan-Huy, Pathak D. Ram, and L. P. Amelita. "Metastatic Insulinoma: Case Report and Review of the Literature." South Medical Journal 97 2 (2004): 199-201.

Source: Medical Disability Advisor






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