# Maritime Health Research and Education-NET/The International Type 2 Diabetes Mellitus and Hypertension Research Group/Revision of the ILO Guidelines for medical examinations of seafarers Part I
## Revision of the ILO Guidelines for medical examinations of seafarers Part I

The revision is done on request to MAHRE-Net in Feb 2021 from the International Maritime Health Association (IMHA), Europeche and European Transport Workers
Authors: The International Diabetes Mellitus and Hypertension Research Group A subgroup of MAHRE-Net
Part I:
Part II

## Guidance to persons authorized by competent authorities to conduct medical examinations and to issue medical certificates p 21ff->

Citations from the “Guidelines”: in Italics Health-promotion data supplemental to the ‘fit-for-duty’ data This revision covers the Seafarers and the Fishers Guidelines for medical examinations. The revision is based on the evidence for the low validity of the urine-stick test for the early diagnosis of type 2 diabetes . The guidelines for seafarers’ medical examinations include health promotion beyond the fit-for-duty protocol, page: p.18 (iv), which is the core issue here: “The medical examination can be used to provide an opportunity to identify early disease or risk factors for subsequent illness. The seafarer can be advised on preventive measures or referred for further investigation or treatment in order to maximize their opportunities for continuing their career at sea” Our focus is on the early diagnosis and early implementation of T2DM health prevention to preserve good health in general and good eyesight, specifically, for the seafarers who are dependent on good vision to remain in their jobs for many years. The proposed health-promotion program focusing on T2DM and hypertension has an impact on all types of metabolic syndrome diseases and can help keep workers active for more years. The aim is to provide a foundation for the evidence base to foster safe and healthy preventive strategies and policies 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. Effective health promotion, however, is dependent on research, which, in turn, depends on access to valid data. The centralization of data is needed for the research for health promotion regarding T2DM, hypertension and related metabolic syndrome diseases. In conclusion, Appendix F should be completed as before but supplemented by the Appendix F-1 Scientific Data Form for research purposes.

## XII. Conducting medical examinations, pg18

Unfortunately, the model for how to report laboratory data, especially in regard to urine-stick tests in Appendix F in the “Guidelines” has been misunderstood by maritime authorities as well as maritime doctors for many years. In the fit-for-duty guidelines, the national authorities have chosen to follow the example on page 51 (Appendix F) in the ‘Guidelines’ by asking for the results (glucose, protein, blood) based on urine dipstick analysis without mentioning the need for a supplemental HbA1C or similar high-validity test for the unbiased early diagnosis of T2D(1). Although urine dipsticks can be used to determine pathological changes in urine, they cannot serve as a valid diagnostic tool for T2D. Indeed, a review of studies on using urine dipsticks to test for T2D concluded that they should not be used due to their low sensitivity to detect T2D accurately, with the consequence of a high number of false negative tests. In one such study, the sensitivity of the urine dipstick to detect T2D correctly was 20.8% (95% CI: 8.1–52.8%), and a similar study from Sweden revealed a sensitivity of 18.1% versus the far higher sensitivities of fasting glucose and HbA1C.. Neglecting to use valid tests for the early diagnosis of T2D internationally in the fit-for-duty tests over decennia may have increased the prevalence of major microvascular complications and quality-adjusted life-years (QALYs) as well as financial losses for workers, employers and states.
Text to be corrected pg.20 (x)
“The validity of any test used for the identification of a relevant medical condition will depend on the frequency with which the condition occurs. Use is a matter for national or local judgement, based on disease incidence and test validity. The meaning of this text is unclear, and should be replaced by the following: “Sensitivity and specificity describe the accuracy of a test that reports the presence or absence of a condition. In a diagnostic test, sensitivity is a measure of how well a test can identify true positives”

## Attention to the seafarers´ specific working conditions

The medical specialist in maritime medicine should pay particular attention to the fact that seafarers are vulnerable patients compared to most shore workers and may need to be referred to specialists in suspected cases of (pre-)hypertension and or (pre-)T2DM to be noted in the scientific data sheet (APPENDIX F-1) While the ‘Guidelines’ should be openly promoted, the data collection for research should be included as part of the medical health examinations, and the medical health examinations report should be divided into two parts:

## Diabetes and hypertension prevention programs

Simple lifestyle measures have been shown to be effective in preventing or delaying the onset of type 2 diabetes, hypertension and its complications:
* 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
* Avoid tobacco use – smoking increases the risk of diabetes and cardiovascular disease

## Intervention in collaboration with the shareholders

The success of the personal struggles depends however, on supportive environments, established by the shareholders with the needed conditions for good health practices for persons with diabetes, hypertension and all others with risk for chronic metabolic diseases. The shareholders are prompted to establish the specific conditions at work that are needed for seafarers to maintain good health practices, especially for employees with type 2 diabetes and hypertension in different types of jobs. The necessary conditions are different in various job groups, and an analysis of these conditions and suggestions for how they can be made optimal is needed. Implementations for adequate structural changes in workplaces, sufficient time for meal breaks and restroom visits, cooks who prepare healthful lunches, a fitness room and other relevant installations should be considered imperative. Among the important shareholders are also the authorities to give permission to run specific research projects with access to the needed data as example about the knowledge on the risk on Diabetes type-2 if the good advises are not followed.

## Shareholders responsibilities
### National Maritime Authorities (NMA)

The NMA have the responsibilities to control and to secure through the MLC 2006 visits on board that facilities to keep good health for those with Diabetes and or Hypertension, overweight and obesity are in place. Inspectors talk during the MLC inspections with the ships captain and representatives of the crew and report to the make an impression on how it’s going and plan how to amend failures deadline. The NMA elaborate instructions and guidelines for how the diabetics and hypertensive crew keep the relevant standards to keep good health. The NMA is responsible to inform and educate the maritime medical doctors to extend the fit-for duty medical examinations with the health promotions issues and provide the clinical data for the competent national research institutes. The NMA aims to persue safe and healthy preventive strategies and policies 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, but also Goal 4: Quality Education, Goal 5: Gender Equity, Goal 8: Decent Work and Economic Growth, Goal 10: Reduced Inequity (Compliance with MLC2006 and the C188), Goal 12: Responsible Consumption and Production (Ships’ SOx and NOx emissions), Goal 14: Life underwater observations on compliance with good waste management, Goal 17: Partnerships to achieve the Goals.

### The National board of health

Keep the responsibility to look after the maritime doctors comply with the regulations to take care of good promotion especially related to the Chronicle non-infectious diseases and direction nation advices. Also to see that the data from the Maritime doctors are transferred to the national research unit and analysed.

### The maritime doctors

Keep the responsibility to comply with the regulations to take care of health promotion for infectious diseases and chronic non-infectious diseases and direction nation advices. Also to see that the clinical data from the Maritime doctors are transferred to the national research unit as described in APPENDIX F-1

### The seafarers

They are responsible to be know updated on how to prevent in practice diabetes type 2 and hypertension other chronic non-infectious diseases

### The ship owners

The ship owners are challenged to maintain a stable and supportive health environment for fishers and seafarers who work up to 12 hours per day over several months away from shore. A supportive environment includes opportunities during workdays for time and allowance for relevant work breaks, restroom visits, access to nutritious meals in good social company, time off and possibilities for adequate physical activity. During the MLC2006 inspections these issues are inspected and ordered to be updated where needed.

## APPENDIX F

The maritime doctors complete the ‘fit-for-duty’ examinations according to the guidelines and send their reports with the information in the APPENDIX F to the maritime authorities.
Go to Part I

## How to make accurate Blood pressure measurements in the clinic?

For the accurate diagnosis and management of Blood pressure, proper methods are recommended for the accurate measurement and documentation of BP.
A recognized automatic blood pressure measurement apparatus should be used. Three measurements should be carried out by the examining physician. Measurements should be carried out on the subject in a seated position.
HTN is the most attributable modifiable cardiovascular disease (CVD) events risk factor. In recent years the incidence and prevalence of HTN have increased while rates of HTN control have declined. Measuring blood pressure is one of the most common procedures performed at a medical office. Yet, studies have shown that nurses, medical assistants and even doctors make numerous mistakes when taking readings. 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

## Self-hypertensive control on board and at home

Self-monitoring of patients hypertension is necessary. Instructions and the relevant equipment in the Ships medical Chest on board is required). In addition, courses are needed as well as revisions to the International Medical Guide for Ships (and ships’ medical Chest) During sailing it shall be possible to measure blood pressure in individuals having treatment for high blood pressure. At least two automatic apparatus should be available on all ships in case one of the devices breaks Ships Medical Chest

## Measure Your Blood Pressure on a Regular Basis

Measuring your blood pressure is an important step toward keeping a healthy blood pressure. Because high blood pressure and elevated blood pressure often have no symptoms, checking your blood pressure is the only way to know for sure whether it is too high. You can measure your blood pressure at home and at sea with a home blood pressure monitor Learn steps you can take to lower your risk for health problems from high blood pressure such as heart disease and stroke. Request equipments should be in the Ships Medical Chest

## When should hypertensive seafarers be referred to hypertension clinics?

Compared to shore workers, seafarers are socially vulnerable hypertension patients with a need for special attention and may need to be referred to a hypertension clinic. A referral can also be relevant for providing instructions for self-hypertensive control on board and at home. The findings from randomised controlled trial, followed up for 6- and 12-months in primary care settings in Hong Kong. Patients newly diagnosed with grade 1 hypertension (aged 40-70 years) were consecutively recruited. Automatic referral of newly diagnosed grade 1 hypertensive patients for further one-to-one dietitian counseling on top of primary care physician's usual care. The findings did not support automatic referral of newly diagnosed grade 1 hypertensive patients. Patients with those risk factors identified should receive more clinical attention to reduce their CV risk(possibly add more studies)

## How to make accurate diagnosis of T2DM in the clinic (and the diagnostic costs)

Urinary glucose has been widely used as a screening tool for diabetes being non-invasive and easy to perform. The renal threshold for glucose (approximately 10 mmol/l) corresponds well to a relevant screening level for postprandial hyperglycemia. However, the method is unable to pick up elevated fasting- and preprandial hyperglycemia below this threshold, and while it reflects an average level of blood glucose since last voiding, it cannot reflect chronic hyperglycemia. Furthermore, under- or overestimation is seen in conditions with high- (long diabetes duration or kidney failure) or low- (pregnancy, children, MODY diabetes) renal glucose thresholds. Finally, fluid intake may influence urine concentration and thus glycosuria test results.
Since 2011, Glycolated Hemoglobin (HbA1c) has been used to diagnose diabetes in most countries and replaced blood glucose performed in the fasting state or 2 hours after and oral glucose tolerance test. A confirmed HbA1c concentration ≥ 48 mmol/mol defines diabetes. The use of HbA1c was made possible after establishment of a reference measurement procedure for international standardization of routine HbA1c assays. There were several reasons for this recommendation. HbA1c was already used in clinical practice for decision making on antidiabetic treatment. Compared to glucose measures, HbA1c is stronger associated with most long-term micro- and macrovascular diabetes complications. Measurement variability is negligible (~1%) compared to blood glucose (12-15%). HbA1c does not require fasting and is obviously less time consuming than the cumbersome oral glucose tolerance test. In some cases, a blood glucose measure may be a relevant alternative to the HbA1c, primarily in conditions where HbA1c does not fully reflect glucose levels, such as severe anemia, kidney failure, or in persons with hemoglobinopathies. Importantly, for low income countries, HbA1c is a rather expensive measure, and not possible to apply to the general diabetes population .

## When should a T2DM seafarer be referred to a specialist department

Transport workers like seafarers and truck, bus, train, and taxi drivers as well as fishers are known to have significant inequities regarding their health at work, including a high risk of developing type 2 diabetes. Compared to shore workers, seafarers are socially vulnerable type 2 diabetes patients with a need for special attention, as described by Rogvi et al.If a diabetes patient has any kind of diabetic complication he or she should be referred to a specialized diabetes clinic if possible (FG)

## Self-management of diabetes and hypertension on board and at home

Self-monitoring of blood glucose for non-insulin-treated adults with Type 2 diabetes is necessary. Instructions and relevant equipment in the medical chest on board are needed and have been added to the actual revision of the International Medical Guide for Ships and the Medical Inventory lists. A few crew embers on board shall know how to measure blood glucose and to treat severe hypoglycemia using glucagon, which must be present on all ship chests.FG
Request that equipment for self-control of diabetes type 2 should be in the Ships Medical Chest.The Norwegian Gard association is one of the advisors for healthy diet and exercises while on board.
* The PEME allows for early recognition of seafarers at risk followed by careful monitoring and treatment. Treatment is aimed at correcting lifestyle issues:
* Changes in diet to reduce the intake of high sugar foods and beverages and other carbohydrates and increase servings of fruit and vegetables.
* Guidelines for Healthy Food Onboard Merchant Ships provides tips for healthy food plans.
* Exercising at least three times a week for 30 minutes each time, aiming to achieve an exercise heart rate of 75% of maximum. This can be easily calculated as follows: (220 – age) x 0.75 = recommended heart rate during exercise to derive cardiovascular benefit. For an average 45-year-old, this would mean an exercise heart rate of 131 beats per minute.
* Monitoring the blood sugar levels with tests such as urine glucose tests, blood sugar tests and a diabetes control measuring test, an HBA1C, which provides a measure of diabetes control over the last six weeks.
* The seafarer must also keep a logbook of their diabetes control to enable them to understand their health condition, and to take responsibility for its management.
* Using prescribed medication regularly and notifying their doctor of any change in their diabetes control, so that appropriate adjustments to their treatment regime can be made.

## The International Diabetes Federation recommended dietary guidelines for the general population (hypertension)

* Choosing water, coffee or tea instead of fruit juice, soda, or other sugar sweetened beverages
* Eating at least three servings of vegetable every day, including leafy green vegetables
* Eating up to three servings of fresh fruit every day
* Choosing nuts, a piece of fresh fruit, or unsweetened yoghurt for a snack
* Limiting alcohol intake to a maximum of two standard drinks per day
* Choosing lean cuts of white meat, poultry or seafood instead of red or processed meat
* Choosing peanut butter instead of chocolate spread or jam
* Choosing wholegrain bread, rice, or pasta instead of white bread, rice, or pasta
* Choosing unsaturated fats (olive oil, canola oil, corn oil, or sunflower oil) instead of saturated fats (butter, ghee, animal fat, coconut oil or palm oil).

## APPENDIX F-1 Clinical Scientific Data Form

The national maritime authorities are urged to include APPENDIX F-1 supplemental to APPENDIX F and make arrangements to transfer the digital data collected in Excel format to the competent national research institute for further analysis, reporting and publication. The reported data in APPENDIX F-1 should be without personal name, ID number or company identification, considered as “non-personal” under the General Data Protection Regulation (GDPR) without need to be acknowledged by the European Ethical Committees
Analysis of the epidemiological Prevalence data will allow for the identification of trends and comparisons between the countries etc. To estimate the real prevalence and prevalence rates we include all, regardless of their risk, such as obesity and their age. In Appendix F-1 is underscored that the authorities must give access to the needed data as example to learn from intervention studies in risk on Diabetes type-2.
Excel Lab. data registration scheme
| Inform Cons (1) | Age | Gend | Natio (2) | Fisher | Seaf | Waist cm | Dia BLOOD PRESSURE | Sys BLOOD PRESSURE | A1C (3) | FSG | Hight cm | Weight Kg | Do you have Diabetes? y/n (4) | Do you have Hypertension? (4) y/n | Take any Medi-cine?(4) | ref to DM spec | ref to Hyp spec |
| y | 33 | m | 1 | x | | 95 | 80 | 130 | 5,5 | | 175 | 77 | n | n | n | n | |
* Ask the seafarer/fisherman if we can use anonymised data for research
* Own country= 1, Other = 2
* Variable with decimals in Excel in "Standard" use commas"," not in "."
* Copy the answer from interview scheme
* Metformin = 1 other medicine = 2
| DIABETES TYPE 2 | | HbA1c | Fasting Glucose |
| | Value Measurement today: -> | | |
| | Mark Preliminary Diagnosis | | |
| Normal | | ≤ 5,6% | ≤ 100 mg/dl |
| Prediabetes | | 5.7-6.4% | 100 -125 mg/dl |
| Diabetes | | ≥ 6,5% | ≥126 mg/dl |
| Diabetes (=taking anti-DM) | | | |
| HYPERTENSION (HTN) | | Diastolic | Systolic |
| | Value Measurement today: -> | | |
| | Mark preliminary diagnosis | | |
| Normal | | 80 | 130 |
| Prehypertension | | 80-89 | 130-139 |
| Hypertension Stage 1 | | 90-99 | 140-159 |
| Hypertension Stage 2 | | 100+ | 160+ |
| HTN=anti-hypertensive med. | | | |
Inform seafarer whether (s)he is Non-diabetic, Pre-diabetec or Diabetic give advice and refer to specialist, if needed
Inform seafarer whether: non-hypertensive/pre-hypertensive/ hypertensive (see definitions), give advice and refer to hypertensive specialist if needed.
Use standardized reporting for research purposes, send data to designated international researcher contact (MAHRE-Net)