DOT Medical Guidelines: Diabetes

The Department of Transportation (DOT) Medical Examination is very highly regulated as illness complications can have serious consequences for the driver, the examiner, and the general public. DOT medical guidelines outline the health criteria that commercial vehicle drivers must meet to qualify for certification. One health condition that is closely reviewed by the DOT is diabetes. Individuals with known or suspected diabetes are required to provide specific medical information to the DOT-certifying physician regarding diabetic control. The DOT definition of diabetic control often causes confusion for individuals seeking certification, as well as their employers. The following information provides answers to common questions and clears up misconceptions about diabetes and DOT certification.

The maximum certification for a person with diabetes is one year. According to DOT guidelines, a person with diabetes, whether controlled with diet alone or diet plus medication, must meet the following criteria:

• Maintain a glycosylated hemoglobin (Hemoglobin A1C or “HBA1C”) of 8% or less.

The HBA1C is a measure of the average amount of sugar in the blood over the last 3 months. A normal HBA1C is less than 5.7%. Values between 5.7 and 6.4% are classified as being in the pre-diabetic range. These individuals should be closely monitored. If the level is above 6.4%, then the person is diabetic. The HBA1C correlates very well with end organ (blood vessels, nerves, kidneys, heart, or eyes) damage and therefore is a popular marker for disease control. Red blood cells have a lifespan of about 90 days before they are removed by the spleen. Glucose sticks to the hemoglobin in red blood cells. Therefore, the glycosylated hemoglobin can be a good estimate of the average blood sugar and is much more accurate in assessing diabetic control than a fasting blood sugar that varies from day to day. Obviously, it takes about 3 months for the HBA1C to drop, generally by 1 percentage point. Therefore,

• 3 Consecutive Fasting Glucose Levels of 180 mg/dl or less is also acceptable when a person is showing strong efforts towards glucose control.

An HBA1C level of 5% correlates with a blood sugar level of 90 mg/dl and the value increases by 30 mg/dl for each point above 5%. Hence, a blood sugar of 180 suggests an HBA1C of 8.

• The driver must not have a history of the following:

(a) One or more hypoglycemic episodes in the past 12 months, 
         or 2 or more occurrences in the past 5 years resulting in:
          1. Seizure
          2. Loss of Consciousness
          3. Need for Assistance from another person
          4. Period of Confusion

(b) Signs of End Organ Damage:
          1. Retinopathy
          2. Macular Degeneration
          3. Peripheral Neuropathy
          4. Congestive Heart Disease
          5. Stroke
          6. Peripheral Vascular Disease
          7. Kidney Failure

Prior to 2004, diabetic control for DOT certification was assumed adequate if glucose was absent from the routine urine testing done at the time of examination. Likewise, individuals with sugar in their urine were assumed to be diabetic. Both assumptions are fraught with error, as some diabetics only “spill sugar” when the blood glucose value is very high, and non-diabetics can spill sugar after eating, say, a candy bar. This type of testing is only a spot check, giving “at the moment” information. It is, however, an inexpensive way to screen individuals who have no idea of their health risks. “On many occasions, BarnesCare providers are the first to tell a patient that they are diabetic. In a country where 25.8 million people are diabetic, 7.0 million of them are undiagnosed, and 79 million people are pre-diabetic*, we have to do everything we can to abate this crisis. Diabetes screening also provides an exciting opportunity to promote diet and exercise programs to our workforce,” says Leslie Arroyo Robins, DO, FAAFP, BarnesCare physician.

Diabetic individuals seeking DOT certification must provide current (within six months) diabetic control information to the examining physician. This information should be available as part of routine diabetes care through the individual’s primary care physician. To avoid delays in certification, BarnesCare recommends that individuals meet with their primary care physician in advance of the examination to obtain copies of the required laboratory information, then bring that information to the DOT appointment.

Diabetics who require insulin for control cannot be approved for DOT certification unless they have a waiver. The diabetic waiver application and program details can be found on the Federal Motor Carrier Safety Administration website. The process for obtaining a waiver is cumbersome and only a small number of drivers have received this exemption since the waiver program was instituted in 1996. “These medical guidelines can be quite complex,” says Scott C. Jones, DO, MPH, FAOCOPM, BarnesCare medical director. “The medical team at BarnesCare understands the DOT regulations and their importance in promoting driver health, wellness and public safety. We are always available to answer any questions or concerns you may have.”

*The 2011 National Diabetes Fact Sheet

The Facts About Tetanus, Diphtheria and Pertussis Vaccines

Many people are confused by the vaccines for tetanus, diphtheria and pertussis. Here are the facts to help you determine which vaccine you need.

The Td vaccine has been used for many years. It protects against tetanus and diphtheria. The Tdap vaccine was developed in 2005 for adolescents and adults which protects against tetanus, diphtheria and pertussis (Whooping Cough).

Tetanus, diphtheria and pertussis are all caused by bacteria. Diphtheria and pertussis are spread from person to person. Tetanus enters the body through cuts, scratches, or wounds.

The United States averaged more than 1,300 cases of tetanus and 175,000 cases of diphtheria each year before vaccines. Since vaccines have been available, tetanus cases have fallen by over 96% and diphtheria cases by over 99.9%.

Before 2005, only children younger than 7 years of age could get pertussis vaccine. In 2004 there were more than 8,000 cases of pertussis in the U.S among adolescents and more than 7,000 cases among adults.

The Tdap can be used in three ways:

     1) as catch-up for people who did not get all their doses
          of DTap or DTP when they were children
     2) as a booster every 10 years 
     3) for protection against tetanus infection after a wound

The Centers for Disease Control and Prevention (CDC) recommends:

• Infants and children should receive 5 doses of the DTaP vaccine at 2, 4, and 6 months, at 15 through 18 months, and at 4 through 6 years. All 5 doses are needed for maximum protection. Children 7-10 years of age who are not fully vaccinated with DTaP should receive a dose of Tdap instead of waiting for the 11-12 year old check up.
• Adolescents should receive the Tdap vaccine at their regular check-up at age 11 or 12. If teenagers (13 through 18 years) missed getting the Tdap vaccine, parents should ask the doctor about getting it for them now.
• Adults who are 19 through 64 years old should get a 1-time dose of Tdap in place of the Td booster they’re recommended to receive every 10 years. No need to wait until you are due for your Td booste -- the dose of Tdap can be given earlier than the 10-year mark since the last Td booster. It's a good idea for adults to talk to a healthcare provider about what's best for their specific situation.
• Pregnant women should ideally receive Tdap before pregnancy. Otherwise, it is recommended that Tdap be given after delivery, before leaving the hospital or birthing center. If a pregnant woman is at increased risk for getting whooping cough, such as during a community outbreak, her doctor may consider giving Tdap during pregnancy. Although pregnancy is not a contraindication for receiving Tdap, a pregnant woman and her doctor should discuss the risks and benefits before choosing to receive Tdap during pregnancy.
• Adults 65 years and older who have not previously received a dose of Tdap and have close contact with infants should receive one dose of Tdap. Other adults in this age group who have not previously received a dose of Tdap and will not have close contact with infants may receive a dose of Tdap. Receiving Tdap may be especially important during a community outbreak and/or if caring for an infant.

Call your doctor to see what is best for you and your family. For more information, visit the Centers for Disease Control and Prevention website.

Cool Shades of Summer

Now that summer has officially begun, many of us make the annual trek to the mall to find a stylish pair of shades. Mary Migneco, OD, a Washington University School of Medicine optometrist at Barnes-Jewish Hospital, offers the following tips when purchasing prescription or non-prescription shades.

“The first thing you need to look at is the UV protection,” Dr. Migneco says. “In order to be labeled as UV protected by the government, there’s an American National Standards Institute (ANSI) standard. The sunglasses need to have at least 95 percent of the UVA rays blocked out and 97 percent of the UVB rays. Always remember UVB are the bad ones. You really want the higher protection from the UVB rays.

“Even the off-the-rack cheap sunglasses from the grocery store must have those ANSI standards and be tested in order to say UV protected,” she says.

The UV protection is an actual clear coating on the lenses. All prescription sunglasses are manufactured with this clear coating. However, it’s an option on regular prescription eyeglasses and it can be added after the eyeglasses have been purchased. Dr. Migneco points out that non-prescription shades may or may not be coated. “That’s why, as a consumer, you need to make sure the sunglasses have the UV-protected label,” Dr. Migneco says.

The bottom line is that quality sunglasses are just as important as quality eyeglasses.

“It can actually be worse if you don’t have UV protection,” Dr. Migneco says. “The dark tint allows your pupils to dilate, then more light actually goes in. If UV light is going in, that can cause damage to the back of the eye. It will give you less protection than no sunglasses at all.

“Brown is the more natural tint, so if you’re looking through brown lenses you won’t get blue- or yellow-tinted hues. It looks more natural. Blue tints are good for highway driving to cut down on the reflections off the highway. Blue is also good for water sports.”

Dr. Migneco says that damage over a long period of time can lead to eye disease such as cataracts and macular degeneration. She recommends UV-protected lenses for younger people as a deterrent to help lessen the chances of eye disease later in life.

“Long-term exposure to sunlight’s UV radiation is linked to eye disease,” Dr. Migneco says.