Managing diabetes requires diligence and discipline. It often requires lifestyle changes—-healthy eating at every meal and daily physical activity—which aren’t the dominant behaviors in the U.S.

Diligence and discipline for managing diabetes can also push up against another reality: most U.S. adults spend half their waking hours at work. For the 20 million with diabetes, their jobs can be a hurdle to effectively manage the disease.

How well do healthcare providers consider their patients’ work as factor in managing diabetes? A new paper scheduled to be published in the Journal of Occupational and Environmental Medicine explores the experiences and perspectives of occupational medicine doctors. The study specifically examines shift-work and diabetes management.

Why focus on shift work? That is, work schedules that involve afternoon or evening shifts, rotating shifts, or other irregular non-daytime schedules. Shift work is associated with poor sleep quality and duration. Relevant to diabetes, the evidence is mounting on the relationship between circadian disruption, metabolic syndrome, hypoglycemic episodes, and other adverse physiological effects (e.g., here, here, here, here.)

Medical students, Isaac VanDam and Jessica Dai, and their mentor Kenneth Rosenman at Michigan State University College of Human Medicine conducted a survey of the clinical members of the Michigan Occupational & Environmental Medicine Association (MOEMA). Forty-seven of 94 responded, with more than 80 percent reporting they had some patients who have “shift work” schedules. The authors compared the physicians’ responses about the care of patients with diabetes to identify differences depending on the patients’ work schedule. Their findings include:

• The respondents considered the most important factors in the management of diabetes to be BMI, diet, and insulin use.
• Shift work was ranked significantly lower as an important factor in the management of diabetes.
• For day-shift workers, the most common strategy used by respondents was coordinating with the patient’s primary care physician.
• For those who are shift-workers, the most common strategy was educating the patient on self-management of diabetes.
• In addition, the least common strategy used by respondents for the shift-workers was sleep hygiene referrals and restriction to a different shift.

That final bullet is particularly noteworthy.  A day shift schedule can facilitate sleep quality and duration, thus improving a worker’s ability to manage their diabetes. The authors note:

“Less than 40 percent of providers surveyed commonly recommended worker accommodations, activity restriction for safety concerns, or changing from shift work for workers with diabetes. These may be important aspects of properly managing diabetes in the workplace. The Association of Occupational and Environmental Clinics recommends that patients with poorly controlled diabetes be questioned about aspects of their work which may worsen diabetes management (e.g. break schedule, temperature extremes, activities, etc.). Workers that have at risk work profiles would then be educated on the effect of their job on their diabetes as well as given ways to reduce their risk of poor outcomes.”

They also note that the American Diabetes Association’s (ADA) most recent Standards of Medical Care recommend that physicians assess their patients’ sleep patterns and duration, noting the association between poor sleep quality, short sleep, and long sleep with higher A1C in people with type 2 diabetes.

Lead author Isaac VanDam made an interesting observation about those ADA standards. He told me:

“Out of curiosity, I went back to review the ADA’s 2016 edition. It did not include include an assessment of sleep quality. It is topic added in the ADA’s 2017 edition.” It was carried forward into the 2018 edition.

Diabetes experts recognize the role of sleep in diabetes management. Shift work can certainly contribute to poor sleep quality (e.g., here, here).

The survey by VanDam and colleagues tells us that occupational medicine physicians are eager for guidelines to assist in the management of diabetes among shift workers. They want tools to help assess the work environment as a factor in the disease. With more than 100 million Americans having diabetes or prediabetes, the role of work to improve or impede management of the disease is a vitally important line of research.