# Maritime Health Research and Education-NET/DM2/Diabetes 2 Danish Group
#### Prevalence of Diabetes 2 study

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MAHRE-NET PROGRAM "EARLY DIAGNOSTIC OF DIABETES-2 THROUGH ROUTINE MEDICAL EXAMS" - DANISH GROUP
OBJECTIVE
Measure the prevalence of Diabetes 2 with an Hb1Ac blood test in A RANDOM SAMPLE among seafarers/fishermen who come for their medical examination -
-->Excel Data Registration Form
Time: Data collection for a pilot study from xxx to xxxx
TGn. IMC-GRP * Gluc in ayuna 11 Enero 2022
| 32=missing | IMC-GRP | | | Total |
| | 18-24 | 25-29 | 30+ | Total |
| | 43 | 50 | 31 | 124 |
| Normal | 95.6% | 69.4% | 58.5% | 73% |
| | 2 | 18 | 15 | 35 |
| pre-diabetes | 4.4% | 25.0% | 28.3% | 21% |
| | 0 | 4 | 7 | 11 |
| Diabetes | 0.0% | 5.6% | 13.2% | 6% |
| Total | 45 | 72 | 53 | 170 |
TGn. IMC-GRP * A1C
| | 24 | 25-29 | 30+ | Total |
| | 39 | 58 | 35 | 160 |
| Normal | 86.7% | 80.6% | 66.0% | 79.6% |
| | 5 | 10 | 13 | 30 |
| Pre-diab | 11.1% | 13.9% | 24.5% | 14.9% |
| | 1 | 4 | 5 | 11 |
| Diabetes | 2.2% | 5.6% | 9.4% | 5.5% |
| Total | 45 | 72 | 53 | 201 |
| | 100.0% | 100.0% | 100.0% | 100.0% |
PROTOCOL
The study is expected to be done in collaboration with DASAM Danish Society of Occupational and Environmental Medicine, DSMM Danish Society of Maritime Medicine, DASAMS Dansk Samfundsmedicinsk Selskab, SEMM Spanish Society of Maritime Medicine, and SFMM French Society of Maritime Medicine. The Danish part is directed to the train- and bus drivers, seafarers, and fishermen all with obligated biannual health examinations. The project is anchored in Bispebjerg's Occupational medical clinic in collaboration with all interested OM clinics in Denmark. According to "Dagens Medicin" will Southern Denmark create better collaboration on newly diagnosed diabetic patients Diabetes type 2 patients who have just been diagnosed are looking for help navigating their new life, shows a new report commissioned by Steno Diabetes Center Odense.

#### Background

The prevalence of diabetes 2 is globally increasing and especially increasing with social inequity in health in relation to work and living conditions among others in transport workers There is a significant underreporting of diabetes 2, and the true prevalence is not known. As part of DASAM's work with inequity in health in relation to occupational medicine, we will focus on some professional groups in the transport area with the greatest inequality in health that are at the same time covered by regular compulsory health examinations. These include among others the locomotive drivers at DSB, the bus drivers, the airline pilots, and the maritime staff, fishers, and seafarers. The intention is to utilize the one- or two-year mandatory health examinations in these groups to include tests for diabetes 2 with Hb1Ac strategically selected samples of the various professional groups in these occupations. The program starts in Spain with a descriptive study of the target group's prevalence of Diabetes2 from the 16th of June to 31th of December 2021 in one Maritime Health Clinics in Tarragona and two clinics in Barcelona. Later the intervention will be proposed inspired by what is already ongoing in different countries. Also, it is interesting that the Danish agreement 2021 for general practitioners focuses on inequality in health and professional development

#### Purpose

To measure the Hb1Ac prevalence in the target groups is the first step of the program Early diagnosis and prevention of diabetes2 among employees in jobs with mandatory health examinations. To use the mandatory health examinations to include valid tests for diabetes2, i.a. with a blood test to measure Hb1Ac. To use valid methods for diagnosis, prevention, and follow-up of the effect of interventions. The prevention includes i.a. arranging the organization of the work routines, and the workplaces so that employees with Diabetes2 can continue their employment with due consideration keeping their Diabetes2 in well-treated status. The aim is to provide a foundation safe and healthy preventive strategies within the UN Global Sustainable Goals, especially Goal 3: Good health and well-being for all workers and Goal 8: Decent Work and Economic Growth.

#### Goals

Systematisation and national centralisation of the results of the mandatory medical examinations for different job groups,

#### Study design

Cross-sectional clinical study using data collected in the maritime health clinics, GP-clinics, and the OM-clinics

#### Time frame for data collection

Data are collected from xxx to xxxx in GP1 and GP2. The data collection stops when 400 participants in each country is included.

#### Inclusion criteria

* All the selected groups of transport workers, seafarers, and fishermen, coming to routine health examinations are included in a given time period.
* Participants are invited randomly irrespective of risk status, for example, not only those with visible higher risk status for example with obesity.
* Retrospective random samples of medical records for 1/2 year for all, with inclusion of all coming to medical examination without any selection due to higher risk
* Those with normal A1C results in the test are included as positive diabetes if they have answered "yes" having diabetes in the interview scheme.
* To get unbiased samples of prevalence data, then all seafarers/fishers/transport workers coming for routine medical examination must be included in the study irrespective of their (visible) risk (while daily practice is something else) The study example below shows that if only those at higher risk (obesity and overweight) are included, then pre- and diabetes prevalence results will be biased to higher prevalences like 20.0% and 33.4% in these IMC groups respectively. Demographics
Place: GP1, GP 2, age, gender, seafarer, fisherman, nationality.

#### Laboratory data

HbA1c, height in cm and weight in kg. If fasting plasma glucose (FPG) is taken in the clinic per routine then the result is included in the Excel Data Forms.

#### Data collection

* Laboratory data as above
* Personal information from the interview scheme on known diabetes and use of Metformin
-->Excel Data Registration Form

#### Diagnostics

Most of the European Maritime authorities’ national fit-for duty guidelines, have chosen to follow the International “Guidelines” example as stated on page 51 (Appendix F) in the “Guidelines” by offering urine dipsticks analysis without mentioning the need for a supplemental HbA1C or other valid test for an unbiased early diagnosis of T2D . Due to the low sensitivity to detect T2D without false negatives, urine dipsticks should be used to determine pathological changes in urine but not for the early diagnosis of T2D. The urine dipstick test should be supplemented with the fasting glucose or Hb1Ac test for the early diagnosis of T2D. The valid clinical monitoring of T2D among fishers, seafarers and other transport workers is the basis for an effective, evidence-based intervention plan. Amendments are needed, in the training curriculum for maritime medical doctors and in the international and national guidelines
* One Hb1Ac test of ≥ 6.5% is sufficient to confirm the diabetes diagnosis and should not be repeated the same day.
* A positive test should be repeated within 14 days to verify the first lab test
* Preventive advice is given according to the clinic advices to keep diabetes well controlled and to stay fit for work
American Diabetes Association Danish Endocrinological Society

#### Prevention

Simple lifestyle measures have been shown to be effective in preventing or delaying the onset of type 2 diabetes. To help prevent type 2 diabetes and its complications, people should:
* Achieve and maintain healthy body weight
* Physically active – doing at least 30 minutes of regular, moderate-intensity activity on most days. More activity is required for weight control
* Eat a healthy diet, avoiding sugar and saturated fats; and
* Avoid tobacco use – smoking increases the risk of diabetes and cardiovascular disease One test, HbA1c is sufficient to diagnose diabetes. A positive diagnosis can be made if the HbA1c level is ≥6.5% A case of positive diagnosis should be confirmed with a repeat HbA1c test and/or plasma glucose A case of positive diagnosis should be confirmed with a repeat HbA1c test and/or plasma glucose American Diabetes Association Danish Endocrinological Society

#### Intervention in collaboration with the shareholders

The shareholders in the respective job groups are included to help to establish the needed specific conditions available for keeping good health practices for employees with Diabetes 2 in the different job types. This in order to have good opportunities during the working day to have time and allowance for relevant work breaks, restroom visits, access to healthy meals in a good social company, and possibilities for adequate physical activities. These conditions are different for each job group and the analysis of these conditions and suggestions on how it can be made optimal is part of the project. Installations for the adequate structural change in the workplaces, time for meal breaks and restroom visits, cooks are hired to make healthy lunches, fitness room, and other relevant installations.

#### Ethics for protection of personal data

Confidentiality in the handling of personal data is in accordance with the rules of the national data protection agencies and the General Data Protection Regulation (GDPR) and is prepared with. No personally sensitive information is included in the data set given to the researchers, so approval from the Ethics Committee is not necessary. All questionnaires ask for informed consent as the first question.Types of experiments not to be notified: Questionnaire and interview surveys; Registry research surveys; Quality assurance projects; Non-interventional drug trials

#### The goal of the Diabetes-2 Research group in transport workers

The goal of the Diabetes-2 Research is to foster and support both basic and clinical research in diabetes-2 and related metabolic disorders with the ultimate purpose of translating findings into opportunities to prevent these diseases and to improve clinical care and outcomes for transport workers. The aim is to provide a foundation safe and healthy preventive strategies within the UN Global Sustainable Goals, especially Goal 3: Good health and well-being for all workers and Goal 8: Decent Work and Economic Growth.

#### References

* ↑ https://www.dropbox.com/s/8g9kjdlz3jx0br1/Syddanmark%20vil%20skabe%20bedre%20samarbejde%20om%20nydiagnosticerede%20diabetespatienter%20-%20Dagens%20Medicin.pdf?dl=0
* ↑ Herttua, Kimmo, Linda Juel Ahrenfeldt, and Tapio Paljarvi. “Risk of Major Chronic Diseases in Transport, Rescue and Security Industries: A Longitudinal Register-Based Study.” Occupational and Environmental Medicine, August 29, 2021. https://doi.org/10.1136/oemed-2021-107764
* ↑ Mata-Cases, Manel; Mauricio, Dídac; Real, Jordi; Bolíbar, Bonaventura; Franch-Nadal, Josep (2016-11-01). "Is diabetes mellitus correctly registered and classified in primary care? A population-based study in Catalonia, Spain". Endocrinología y Nutrición (English Edition) 63 (9): 440–448. doi:10.1016/j.endoen.2016.10.005. ISSN 2173-5093. https://www.Elsevier.es/en-Revista-endocrinologia-nutricion-english-edition--412-articulo-is-diabetes-mellitus-correctly-registered-S2173509316300952.
* ↑ https://ugeskriftet.dk/nyhed/ny-overenskomst-de-praktiserende-laeger-har-fokus-pa-ulighed-i-sundhed-og-faglig-udvikling
* ↑ Yap, C.W., Ang, Y.G., Quek, T.P.L., Heng, B.H., Chew, D.E.K., 2018. Re-examining the sensitivity of HbA1c to screen for diabetes mellitus. Journal of Diabetes 10, 380–385. https://doi.org/10.1111/1753-0407.12615
* ↑ Guidelines on the medical examinations of seafarers [Internet]. 2011 [cited 2021 Dec 22] Available from: http://www.ilo.org/sector/Resources/codes-of-practice-and guidelines/WCMS_174794/lang--en/index.htm
* ↑ Jensen, O. C. Et al. & MAHRE-Net, Rethinking the use of urine dipstick for early diagnosis of Type 2 Diabetes 29 Dec 2021 (Submitted): International Maritime Health
* ↑ Jensen, O. C. et al. Early diagnosis of T2DM using highly sensitive diagnostics tests in the mandatory medical examinations for fishers, seafarers and other transport-workers (Accepted 28 Dec 2021): Primary Care Diabetes
* ↑ Wei, Ooi Yau, og Stewart Teece. “Urine dipsticks in screening for diabetes mellitus”. Emergency Medicine Journal : EMJ 23, nr. 2 (februar 2006): 138. https://doi.org/10.1136/emj.2005.033456
* ↑ Friderichsen, Bolette, og Margareta Maunsbach. “Glycosuric tests should not be employed in population screenings for NIDDM”. Journal of Public Health 19, nr. 1 (1. marts 1997): 55–60. https://doi.org/10.1093/oxfordjournals.pubmed.a024588
* ↑ https://komite.regionsyddanmark.dk/i-tvivl-om-anmeldelse