# Protocol for accurate screening diabetes type 2 and hypertension in the ILO guidelines in seafarers’ routine medical examinations
#### Background

Seafarers, have a great inequity in health at work with a higher risk of overweight, metabolic syndrome, diabetes type 2 and hypertension and a need for accurate early diagnosis and prevention
While the objective one hundred years ago for the fit-for-duty medical examinations was purely related to the safety of the seafarers and the ships, now the ILO guidelines inspire to include protocols related to the general health of seafarers beyond the fit-for-duty protocol. The focus on early diagnosis of Type 2 diabetes and hypertension seems to be a good choice for intervention based on the evidence that pre-hypertension and pre-diabetes mellitus Type 2 can be reversed by non-pharmacological and pharmacological measures
Screening in medical practice for hypertension can cause validity issues, and more research is needed. The actual background dates back to February 2021 when the President of IMHA Rob Verbist with the support of Europeche and European Transport Workers Union (ETF) calls for MAHRE-Net to establish a research group on a valid, early diagnosis of diabetes and hypertension in the fit-for-duty studies, to launch a preventive program and to carry out revision of the ILO's guide for seafarers' health surveys.The problem with the use of urine sticks for e.g. Diagnosis of diabetes has been reported in previous publications. The purpose of this pilot is to describe and test how an accurate diagnosis of diabetes and hypertension at different stages and relevant risk factors can be integrated into the fit-for-duty studies for seafarers.

#### Objectives

* To try out how the proposed accurate measures of Diabetes Type 2 (DMT2) and Hypertension (HTN) function in the routine health examinations.
* To use the mandatory health examinations to include valid tests for diabetes Type 2, i.a. with a blood test to measure Hb1Ac and Hypertension.
* To establish and integrate together with the ship owners a "Green-ship" health promotion program with work routines, that support employees with Diabetes Type 2 and Hypertension can continue their employment with due consideration keeping their Diabetes2 and Hypertension in well-treated status.
* To include work exposure data to point out the specific workloads e.g. skippers more sedentary work and higher risk for HTN and T2D.

#### Education and training in health promotion and safety for medical doctors and seafarers

We intend to develop education and training online programs for seafarers, maritime medical doctors and other relevant groups mainly based on available materials like the "Marihealth-project",The MARIWEL coursesand the 7 ways to make healthy habits a priority when at seaand the E-Healthy Ship Hamburg Project, supported by proposals on what should be donethe MariHealth EU project and one article from a Danish Ph.D project just to mention few of all contributions to the subject. An online seminar on the subject will be planned for Sept 2022

#### Goals

Systematization and national/international centralization of the results of the routine medical examinations for different job groups to be used for eduation/training and the planning of the healthy "Green-ship"

#### Study design

Cross-sectional clinical study using data collected in the maritime health clinics, mainly in the General Practice clinics.

#### Time frame for data collection

Pilot data collection period in the clinics after agreement in 2022

#### Inclusion criteria

* All seafarers, and fishermen, attending to routine health examinations are included in the pilot study in 2022
* All are included irrespective of age and risk status, for example, not only those with visible higher risk status for example with obesity and older
* Those with normal A1C results (normal blood pressure) in the test are included as positive diabetes/hipertension if they have answered using diabetes /antihypertensive medicine in the interview scheme.

#### Demographics

Gender, age, nationality,

#### Work exposure data

Coastal Fish bridge=11; Costal Fish not bridge=1; Deep sea fish Bridge= 12; DeepSee fish Not bridge=2; SeafarerBridge =3; Sea-Deck = 4; Sea-Engine= 5;Diver=6; Off-shore =7

#### Personal health promotion

Smoking (no/former/smoker) intake of fruit and vegetables (high/little/none) and physical activity (high/little/none)

#### Which test for T2DM diagnostics can we recommend for the fit-for-duty examinations in the ILO Guidelines?

ADA recommend either A1C, fasting blood glucose, or glucose load for T2DM diagnosis[1] However, there are significant price differences and the maritime clinics may be unable to pay and access to clinical laboratories is also needed. Question: Should we recommend the use of a Glycometer (< 1 usd/test) [2]and the DIABSCORE [3][4]in the fit-for-duty studies where HbA1c is not possible or not wanted? .
->Excel data sheet ready for data entry - download to your PC/Laptop(Google Drive)

#### Laboratory data

Height, weight -->BMI, Glycated Hemoglobin (HbA1c), fasting glucose, waist circumference, blood pressure, If fasting plasma glucose (FPG) is taken in the clinic per routine then the result is included in the Excel Data Form,

#### Data collection

* Laboratory data as above
* Personal information from the interview scheme on use of medicine for diabetes and/or hypertension
* Excel Data Sheet for use in the pilot project
* The medical doctor reduce the administrative work time with the help from assistant personnel
* The data collection can be divided in time periods e.g. every second month and still keep a random sample

#### Accurate measurement of blood pressure

Accurate measurement of blood pressure is essential to classify individuals, to ascertain blood pressure–related risk, and to guide management. The auscultatory technique with a trained observer and mercury sphygmomanometer continues to be the method of choice for measurement in the office, using the first and fifth phases of the Korotkoff sounds. The use of mercury is declining, and alternatives are needed. Aneroid devices are suitable, but they require frequent calibration. Hybrid devices that use electronic transducers instead of mercury have promise. Guidelines on diagnosing HTN recommend certain aspects that we must take into account and certain things that we must avoid:
* In the 30 minutes before your blood pressure is taken, no smoking, no caffeine and no exercise. In the 5 minutes before your blood pressure is taken sit still.
* During blood pressure is taken make sure the cuff is the right size and in the right place, keep your cuffed arm on a flat surface, like a table and at heart level, sit upright, feet flat on floor and don`t talk.
Avoid this things:
* Putting the cuff over clothing, rather than a bare arm, can add 10-40 mm Hg to a measurement.
* Having a full bladder can tack on 10-15 mm Hg.
* Talking or having a conversation: an additional 10-15 mm Hg.
* Failing to support the arm at heart level can add 10 mm Hg.
* An unsupported back can increase a measurement by 5-10 mm Hg. That same range applies to feet left dangling from an exam table or high chair.
* Crossing legs means an extra 2-8 mm Hg
* Do not sit with your back bent
* No alcohol> 5 the day before

#### 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 trialsIf the cluster and the individual practices in the cluster can access data that is aggregated for the individual extension number in a way that does not make it possible to identify individual patients, it is "statistical information" as far as the patients and personal data are concerned. in relation to the doctor identified via his outpatient number

#### Diagnostics

Amendments are needed, in the training curriculum for maritime medical doctors and the international and national guidelines as well.
* One Hb1Ac test (or Fasting Glucose ≥ 126mg/dl) of (5,7-6,4 = pre-diabetes) Diabetes ≥ 6.5% is sufficient to confirm the (pre-)diabetes diagnosis (not be repeated the same day) (see Figure 4)
* 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 and Hypertension well controlled and to stay fit for work
American Diabetes Association Danish Endocrinological Society and the International Society of Hypertension Global Hypertension Practice Guidelines Supplemental ADA risk test for T2D

#### 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 and the International Society of Hypertension Global Hypertension Practice Guidelines

#### 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 Type 2 and Hypertension 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.