How To Help Students Implement Effective Diabetes Management
- Check Blood Glucose Levels
- Plan for Disposal of Sharp Objects and Materials That Come in Contact with Blood
- Recognize and Treat Hypoglycemia (Low Blood Glucose)
- Recognize and Treat Hyperglycemia (High Blood Glucose)
- Administer Insulin and/or Other Diabetes Medication
- Plan for Disasters and Emergencies
- Follow an Individualized Meal Plan
- Promote Regular Physical Activity
- Help to Maintain a Healthy Weight
- Plan for Special Events, Field Trips, and Extracurricular Activities
- Deal with Emotional and Social Issues
- Understand Why Diabetes Self-Management Is Important
Diabetes management involves checking blood glucose levels throughout the day, following an individualized meal plan, getting regular physical activity, and administering insulin and/or blood glucose-lowering medications. These actions are taken to help maintain blood glucose levels in the target range and to prevent hypoglycemia or hyperglycemia. Students with diabetes must have access to supplies and equipment for immediate treatment of high and low blood glucose levels at all times.
Additional elements of effective diabetes management in school include: planning for appropriate disposal of sharp objects and materials that come in contact with blood; planning for disasters, emergencies, and lockdowns; planning for school-sponsored events outside the usual school day; and dealing with the emotional and social aspects of living with diabetes.
Check Blood Glucose Levels
One of the most important diabetes management tasks is to check (or monitor) blood glucose levels throughout the day using a blood glucose meter or a continuous glucose monitor (CGM). Students who use a CGM also use a blood glucose meter to verify CGM readings.
Blood Glucose Meter
A blood glucose meter is a small portable machine used to check blood glucose levels. Before using the blood glucose meter, wash and dry hands and the test site. Insert the test strip into the meter. Using a lancet (a small needle inserted in a spring-loaded device), perform a finger stick by pricking the side of the fingertip. Apply a drop of blood to the test strip. The meter then gives the blood glucose level as a number on its digital display.
Heat and humidity may affect blood glucose metes and test strips and may reduce the accuracy of blood glucose readings. This is especially important when blood glucose is checked outside (e.g., on the practice field). Consult the manufacturer’s instructions regarding the operation and storage environment for the student’s blood glucose meter.
Continuous Glucose Monitor
Some students use a continuous glucose monitor (CGM), a device that measures glucose levels and trends throughout the day. The CGM works through a sensor inserted under the skin that measures interstitial glucose levels (the glucose found in the fluid between cells) at regular intervals and sends the current equivalent blood glucose level wirelessly to a monitor. The monitor may be part of the insulin pump or a separate device, which may include a smartphone that is carried or worn by the student in a pocket, a backpack, or a purse.
The CGM sets off an alarm when blood glucose levels are too high or too low, or when they are increasing or decreasing at a rapid rate. Never ignore a CGM alarm. Appropriate action should be taken in accordance with the student’s Diabetes Medical Management Plan (DMMP).
Some CGMs can transmit data remotely to multiple devices at the same time via smartphone technology. The school nurse, trained diabetes personnel, the student’s health care providers, as well as the parents/guardians can have access to the CGM data and alarms in real time at locations remote from the student.
At this time, treatment decisions and diabetes care plan adjustments should not be based solely on CGM results. The sensor’s glucose levels should be confirmed with a blood glucose meter whenever the reading suggests insulin needs to be given or hypoglycemia needs to be treated. The CGM is a useful tool for identifying trends and can enhance the ability of the student’s personal diabetes health care team to make needed adjustments to the student’s diabetes care plan. Refer to the manufacturer’s instructions on how to use the student’s device.
Checking Blood Glucose During the School Day
The student’s personal diabetes health care team may order blood glucose checks with a meter several times during the school day. Some students may maintain a record of blood glucose results in their blood glucose meter or through other monitoring technology such as a smartphone or a logbook.
Blood glucose levels may need to be checked before and after eating snacks and meals, before and after physical activity, or when there are symptoms of hypoglycemia or hyperglycemia. In some students, symptoms may be subtle; blood glucose levels should be checked whenever symptoms are suspected.
Some students can check their own blood glucose levels. Other students need supervision. Still others need to have this task performed by a school nurse or trained diabetes personnel.
Students must be able to check their blood glucose levels and respond to levels that are too high or too low as quickly as possible. If recommended by the student’s personal diabetes health care team, it is medically preferable to permit students to check blood glucose levels and respond to the results in the classroom or wherever they happen to be. When in doubt, taking immediate action is important to prevent hypoglycemia and to prevent the student from missing class time.
Plan for Disposal of Sharp Objects and Materials That Come Into Contact With Blood
Checking blood glucose does not present a danger to other students or staff members when there is a plan for proper disposal of lancets and other materials that come into contact with blood. The school health team should agree on the plan, which should be consistent with standard precautions and local waste disposal laws.
Sharp objects (sharps) such as lancets and needles may be disposed of in a heavy-duty plastic or metal container with a tight-fitting lid that may be kept at school or in the student’s personal container. Some students may leave the lancet in their lancet device and bring it home for disposal. These arrangements should be agreed upon in advance by the school health team. Used blood glucose test strips and other materials may be discarded in the regular trash. Check with the local health department about health and safety requirements in your area.
Recognize and Treat Hypoglycemia (Low Blood Glucose)
Hypoglycemia, also called “low blood glucose” or “low blood sugar,” is a serious condition associated with diabetes that can happen very suddenly and requires immediate treatment. Hypoglycemia can impair a student’s cognitive abilities and adversely affect academic performance. Hypoglycemia can affect attention, mood, and ability to follow directions and therefore can be mistaken for misbehavior.
Hypoglycemia occurs when a student’s blood glucose level falls too low, usually as a result of too much insulin, missing or delaying meals or snacks, not eating enough food (carbohydrates), or participating in extra, intense, or unplanned physical activity. For most students, a blood glucose level of 70 mg/dL or less is considered hypoglycemia. Low blood glucose levels are more likely to occur before lunch, at the end of the school day, during or after physical education classes, or in the event of unanticipated physical activities. Hypoglycemia may occur due to illness, particularly gastrointestinal illness, or it may occur for no obvious reason.
Hypoglycemia usually can be treated easily and effectively. If it is not treated promptly, however, hypoglycemia can lead to loss of consciousness and seizures and can be life threatening.
Early recognition of hypoglycemia symptoms and prompt treatment in accordance with the student’s DMMP are necessary to prevent the onset of severe symptoms that may place the student in danger. This information, contained in the student’s Emergency Care Plans for Hypoglycemia and Hyperglycemia, should be provided to all school personnel who have responsibility for the student with diabetes during the school day. (See Tools for Effective Diabetes Management)
Usually, the first signs of hypoglycemia are due to the body releasing adrenaline and other hormones/compounds that cause sweating, shakiness, hunger, pallor, light-headedness, weakness, and headache. As hypoglycemia progresses and there is insufficient blood glucose for the brain to function normally, it can lead to changes in behavior, lethargy, progressive weakness, confusion, unconsciousness, seizures, and, if prolonged, even death.
Some children and adolescents may have "hypoglycemia unawareness." In other words, they do not experience early physical warning signs such as shaking, jitteriness, or sweating, and the only clue that their blood glucose levels are low is sudden behavior change. Even students who usually recognize when their blood glucose is low may sometimes have a sudden “low” without the initial symptoms. Although symptoms of hypoglycemia may vary from student to student, each student will tend to have the same symptoms each time hypoglycemia occurs. Therefore, all school personnel should know how to recognize hypoglycemia and know what to do if they observe its onset.
As soon as the student exhibits symptoms of low blood glucose, treat the situation as a hypoglycemic emergency as outlined in the student’s Emergency Care Plan for Hypoglycemia. Immediately contact the school nurse or trained diabetes personnel who will check the student’s blood glucose level and treat the student for hypoglycemia. If the school nurse or trained diabetes personnel are not available, or if the blood glucose level cannot be checked, school personnel should treat the student for hypoglycemia as outlined in the Emergency Care Plan for Hypoglycemia. Symptoms will progress if not treated immediately. When in doubt, always treat for hypoglycemia.
Treatment for Mild to Moderate Hypoglycemia
The following checklist provides a generally accepted approach for the treatment of mild to moderate hypoglycemia. Each student’s specific hypoglycemia treatment plan is provided in the student’s DMMP.
Treatment for Severe Hypoglycemia
Severe hypoglycemia is rare at school and generally can be prevented with prompt treatment of mild to moderate symptoms of low blood glucose. When hypoglycemia symptoms are severe, the school nurse or trained diabetes personnel must be notified and must respond immediately.
Symptoms of severe hypoglycemia may include: inability to eat food or drink fluids, unconsciousness, unresponsiveness, and seizure activity or convulsions (jerking movements). At this point, school personnel should never attempt to give the student food or a drink or to put anything in the mouth, because it could cause choking.
Severe hypoglycemia is treated by administering glucagon by injection. Glucagon is a hormone that raises blood glucose levels by causing the release of glycogen (a form of stored carbohydrate) from the liver. Glucagon is given by the school nurse or trained diabetes personnel. Although it may cause nausea and vomiting when the student regains consciousness, glucagon is a potentially life-saving treatment that cannot harm a student.
The school nurse and/or trained diabetes personnel must know where the student’s glucagon emergency kit is stored, have access to it at all times, and be familiar with the glucagon instructions before an emergency arises.
Glucagon Emergency Kit
The parents/guardians should supply the school with a glucagon emergency kit if prescribed. The kit usually contains a bottle (vial) of glucagon in powder form and a pre-filled syringe with special liquid; the two ingredients should only be mixed just before a glucagon injection is given. The glucagon emergency kit may be stored at room temperature. The school nurse and/or trained diabetes personnel should also be aware of the expiration date on the kit and notify the student’s parents/guardians when a new kit is needed.
Recognize and Treat Hyperglycemia (High Blood Glucose)
Hyperglycemia means blood glucose levels are above the target range, as specified in the student’s DMMP. Almost all students with diabetes will experience blood glucose levels above their target range at times throughout the day. For many students, these elevations in blood glucose will be only minimally above the target range (less than 250 mg/dL) and are short in duration. Other students may experience daily spikes of blood glucose levels that are high (in excess of 250 mg/dL) and of longer duration.
Hyperglycemia does not usually result in a medical emergency. Hyperglycemia may be caused by too little insulin or other blood glucose-lowering medications, a malfunction in the insulin pump or infusion set, food intake that has not been covered adequately by insulin or other blood glucose-lowering medications, or decreased physical activity. Other causes include: illness, infection, injury, or severe physical or emotional stress. Onset of hyperglycemia may occur over several hours or days.
Symptoms of hyperglycemia include: increased thirst, dry mouth, frequent or increased urination, change in appetite, blurry vision, and fatigue. In the short term, hyperglycemia can impair cognitive abilities and adversely affect academic performance. In the long term, moderately high blood glucose levels can increase risk for serious complications such as heart disease, stroke, blindness, kidney failure, nerve disease, gum disease, and amputations.
Hyperglycemia needs to be recognized and treated in accordance with the student’s DMMP. Information in the DMMP should be used to develop the student’s Emergency Care Plan for Hyperglycemia. All school personnel who have responsibility for the student with diabetes should receive a copy of the Emergency Care Plan for Hyperglycemia and be prepared to recognize and respond to the signs and symptoms of hyperglycemia. (See Tools for Effective Diabetes Management)
As soon as symptoms of hyperglycemia are suspected, notify the school nurse or trained diabetes personnel. Treatment of hyperglycemia begins with checking the student’s blood glucose level to determine if it is above the target range. When checking blood glucose at a time not specified in the DMMP, treatment decisions should take into account the time and amount of the student’s last carbohydrate intake or insulin dose.
In accordance with the Emergency Care Plan for Hyperglycemia, the student’s urine or blood should be checked for ketones, the chemicals the body makes when there is not enough insulin in the blood and the body must break down fat for energy. The urine ketone test involves dipping a special strip into the urine, waiting a specified amount of time, and then comparing the resulting color to a color chart. The blood ketone test is done with a finger stick using a special meter and a test strip, similar to checking blood glucose. If the test indicates ketones are present, notify the parents/guardians. Students with type 2 diabetes usually still make a reasonable amount of insulin, and therefore, ketone checks may not be prescribed.
Ketones and Diabetic Ketoacidosis
While hyperglycemia does not usually result in a medical emergency, the following situations may lead to a breakdown of fat, causing ketones to form along with the hyperglycemia:
- Significant or prolonged insulin deficiency from failure to take any insulin or the correct amount of insulin
- An insulin pump or infusion set malfunction causing an interruption in insulin delivery
- Physical or emotional stress that increases the release of hormones, that work against the action of insulin
- Infection or illness, particularly with diarrhea and/or vomiting
Ketones are usually associated with high blood glucose levels but also may occur when a student is ill and blood glucose levels fall below the student’s target range. At first, ketones will be cleared by the kidneys into the urine, but as their production increases, they build up in the bloodstream causing diabetic ketoacidosis (DKA), a medical emergency.
Diabetic ketoacidosis develops over hours to days and is associated with hyperglycemia, a buildup of ketones (ketosis) in the blood, and dehydration. As a result of these conditions, the classic signs of diabetic ketoacidosis include: severe abdominal pain; nausea and vomiting; fruity breath, heavy breathing, or shortness of breath; chest pain; increasing sleepiness or lethargy; and depressed level of consciousness. As soon as these symptoms are observed, the school nurse or trained diabetes personnel should call 911, the parents/guardians, and the student’s health care provider. Stay with the student until Emergency Medical Services arrive.
Students with type 1 diabetes—and many students with type 2 diabetes—need to administer or be given insulin at regular times during the school day. Students may need to take insulin to cover meals and/or snacks and may need additional or corrective dosages of insulin to treat hyperglycemia as specified in the DMMP. It is medically preferable that the student be allowed to self-administer insulin in the classroom or wherever they happen to be.
The DMMP, which will be different for each student, specifies the dosage, delivery system, and schedule for insulin administration. The Individualized Health Care Plan (IHP) and the student’s education plan, based on the DMMP, should specify who will administer prescribed insulin and under what circumstances.
Some students who need insulin during the school day are able to administer it on their own; others will need supervision; and yet others will need someone to administer the insulin for them. The school nurse and/or trained diabetes personnel should assist with insulin administration in accordance with the student’s health care plans and education plans.
A diabetes-trained health care professional such as the school nurse or a certified diabetes educator should teach, monitor, and supervise trained diabetes personnel to administer insulin.
Types of Insulin
Today, new types of insulin and new delivery systems help keep blood glucose levels within the target range. These options, however, require more frequent blood glucose monitoring and more assistance for the student with diabetes.
Insulin has three characteristics:
- Onset is the length of time before insulin reaches the bloodstream and begins lowering blood glucose levels.
- Peak is the time at which insulin is at its maximum strength in terms of lowering blood glucose levels.
- Duration is the number of hours during which insulin continues to lower blood glucose levels.
Insulin is classified in four types by how it works:
- Rapid-acting begins to work about 15 minutes after injection, peaks in about 1 hour, and continues to work for 2 to 4 hours.
- Short-acting usually reaches the bloodstream within 30 minutes after injection, peaks anywhere from 2 to 3 hours after injection, and is effective for approximately 3 to 6 hours.
- Intermediate-acting generally reaches the bloodstream about 2 to 4 hours after injection, peaks 4 to 12 hours later, and is effective for about 12 to 18 hours.
- Long-acting reaches the bloodstream several hours after injection and tends to lower glucose levels fairly evenly over a 24-hour period.
Types of Insulin Plans
Insulin therapy plans are tailored to the individual student’s insulin needs as well as the student’s health literacy and numeracy (i.e., ability to understand the prescribed plan). Two common plans are the basal/bolus insulin plan and the fixed dose insulin therapy plan.
Basal/Bolus Insulin Plan (Adjustable Insulin Therapy)
Most students with type 1 diabetes use a basal/bolus insulin plan. This type of insulin plan, sometimes referred to as adjustable insulin therapy, reproduces or mimics the way a normally functioning pancreas produces insulin.
A coordinated combination of different types of insulin is used to achieve target blood glucose levels at meals, snacks, during periods of physical activity, and through the night.
- Basal insulin is long-acting or intermediate-acting insulin delivered once or twice a day. This type of insulin is used to control blood glucose levels overnight and between meals.
- Bolus insulin refers to a dose of rapid-acting or short-acting insulin that is given to cover the carbohydrate in a meal or snack and to lower blood glucose levels that are above target.
Students using a basal/bolus insulin plan require multiple injections during the school day, or they receive their insulin through a programmable insulin pump.
Fixed Dose Insulin Therapy
Other students may take the same doses of insulin each day with rapid-acting, short-acting, intermediate-acting, or long-acting insulin. This type of plan is sometimes referred to as fixed dose insulin therapy.
The shelf life of insulin after opening varies according to the type of insulin, the type of container (vial or pen cartridge), and how insulin is administered (through a syringe, a pen, or a pump). Review the product storage instructions on the manufacturer’s package insert and check the expiration date.
In general, most opened vials of insulin may be left at room temperature (below 86 degrees Fahrenheit) for 30 days and then discarded. Most opened disposable pens or pen cartridges may be left at room temperature for less than 30 days, depending on the type of insulin and the type of pen or cartridge. Unopened vials or pen cartridges should be stored in a refrigerator. They may be used until their expiration date and then must be discarded.
The three most common ways to administer insulin are with a syringe, an insulin pen, or an insulin pump. The manufacturers of insulin, insulin syringes, insulin pens, and insulin pumps have websites where school personnel can learn more about these products.
- Insulin syringes, available in several sizes, make it easy to draw up the proper dosage. Shorter, smaller needles make injections easy and relatively painless.
- An insulin pen holds a cartridge of insulin. Insulin pens are convenient and appropriate when students need a single type of insulin. During the school day, pens are used most often with rapid-acting insulin to cover a meal or to treat a high blood glucose level.
Generally, a user will follow these steps:
- Screw the needle onto the tip of the pen just before use.
- Dial the pen to 2 units
- Hold the pen upright and press the button on the pen to discard the air and fill the needle with insulin. Repeat if needed until a drop of insulin appears.
- Dial the pen to the prescribed dose and inject the insulin.
- Remove the pen needle and dispose of it in a sharps container.
- An insulin pump is a computerized device that is programmed to deliver small, steady doses of insulin throughout the day; additional doses are given to cover food intake and to lower high blood glucose levels. Most pumps now receive blood glucose values directly from the meter, but if not, the student must enter the blood glucose value as well, in order for the pump to calculate the bolus dose.
Rapid-acting insulin is used in the insulin pump. Students using the insulin pump will not be taking any long-acting insulin. Therefore, a pump malfunction or extended disconnection from the pump (longer than 2 hours) increases the student’s risk of developing DKA more quickly. The parents/guardians should provide the school with a backup supply of syringes and rapid-acting insulin or insulin pens in the event of a pump failure. Keep supplies in a secure location.
There are several types of insulin pumps. School personnel can be trained on each student’s pump by contacting the pump manufacturer or the student’s diabetes health care team.
- Some pumps look like a pager, and students usually wear it on their waistband, belt, or in their pocket. The pump holds a reservoir of insulin attached to an infusion set that leaves a very small needle or plastic cannula (a tiny, flexible plastic tube) under the skin. Infusion sets are started with a guide needle, then the cannula is left in place and taped with dressing, and the needle is removed. The cannula usually is changed every 2 or 3 days or when blood glucose levels remain above the target range or ketones are present. Routine site changes are a responsibility of the family and generally are done at home.
- Other pumps look like a pod or patch. These pumps are attached directly to the skin, and a guide needle inserts the cannula under the skin automatically. The student usually wears the pod on his or her abdomen, buttocks, leg, or arm. The pod contains the insulin (there is no tubing). The pod-type pump is controlled by a small hand-held computer device that is kept nearby. This type of insulin pump needs to be changed every 2 to 3 days.
Some pumps have the data from continuous blood glucose monitoring displayed on the pump screen. In some pumps, technology has been developed to allow communication between the pump and the CGM, enabling the insulin pump to rely on CGM information to reduce or stop insulin delivery if a low glucose level is anticipated. Some of the newer CGM have transmitters that display blood glucose values on tablets, smartphones, and computers.
If a student uses a CGM, verify a low blood glucose level with a finger stick. Treat the student for hypoglycemia, if needed, as prescribed in the student’s DMMP.
Trained diabetes personnel who assist with the student’s diabetes care tasks should be knowledgeable about and trained in using and operating each student’s insulin delivery system in the event that a school nurse is not available to administer insulin.
Plan for Disasters, Lockdowns, or Emergencies
The parents/guardian must provide an emergency supply kit for use in the event of natural disasters or emergencies when students need to stay at school. This kit should contain enough supplies for at least 72 hours to carry out the medical orders in the DMMP.
Follow an Individualized Meal Plan
Current nutrition recommendations for students with diabetes are designed to provide maximum flexibility to meet each student’s nutritional needs, appetite, eating habits, and schedules. Insulin regimens are then individualized to fit each student’s lifestyle. The student’s diabetes care plan, as set out in the DMMP and IHP, must be followed to avoid hypoglycemia or hyperglycemia.
The nutritional needs of students with diabetes do not differ from the needs of students without diabetes. All students need a variety of healthy foods to maintain normal growth and development. The meal plan recommended for students with diabetes is usually healthy for everyone. The major difference is that the timing, amount, and content of the food that students with diabetes eat, especially the carbohydrates (or carbs), are carefully matched to balance the action of the insulin and/or other diabetes medications that they take.
Although there usually are no forbidden foods for people with diabetes, students are advised to avoid “liquid carbs” such as sugar-containing soda and juices (including 100 percent fruit juice) and regular pancake syrup. The "liquid carbs" raise blood glucose rapidly, contain large amounts of carbs in small volumes, are hard to balance with insulin, and provide little or no nutrition. (Sugar-containing drinks are used, however, in treating hypoglycemia.)
Many students with type 2 diabetes follow a meal plan designed to help them achieve a healthy weight. These students may be prescribed a calorie target for the day as well as consistent carb amounts to aim for at each meal and snack to help manage their weight and blood glucose. Ensuring that healthy foods such as whole grains, low-fat protein and dairy, and fruits and vegetables are available is critical to their diabetes management.
With passage of the Healthy, Hunger-Free Kids Act in 2010, schools have been assisting students in achieving a more healthful diet. This legislation has resulted in sweeping changes in school meal programs, including more whole grains, fruits and vegetables, milk choices limited to low-fat or fat-free, and maximum calorie levels for all school meals based on grade level.
Carbohydrate Counting and Identifying the Carb Content in Foods and Beverages
Carbohydrate (carb) counting is the most popular meal planning approach for children and youth. This approach involves identifying and calculating the number of grams of carbohydrate the student eats and drinks in a meal or snack. Sources of carbs include: starches (breads, crackers, cereal, pasta, rice), fruits and vegetables, dried beans and peas, milk, yogurt, and sweets.
The food service manager or staff and/or the school nurse should provide the carb content of foods and beverages to the parents/guardians and the student. If the nutrient analysis is not available, the school nurse and parents/guardians should work with the district food service office to obtain this critical information.
If the food service manager or the school district does not have this information, there are additional resources to help identify the carb content in foods and beverages. The school can identify a registered dietitian nutritionist (RDN) to work with the food service staff to make this information available. To locate an RDN in your area, visit the Academy of Nutrition and Dietetics website at Find an Expert.
The U.S. Department of Agriculture (USDA) maintains a “National Nutrient Database” containing nutrient information on well over 8,000 foods and beverages. The Food and Drug Administration (FDA) requires “Nutrition Facts” labels on packages for most prepared foods such as breads, cereals, canned and frozen foods, snacks, desserts, drinks, etc. These labels include the carbohydrate content as well as other nutrient values for each serving in the package.
Meal Planning Approaches
Most students with diabetes have an individualized meal plan using a method of carbohydrate counting. The meal plan takes into account the student’s nutritional needs, insulin plan, oral medications, and physical activity level.
There are two methods of meal planning using carb counting: (1) following a consistent carb intake meal plan and (2) adjusting insulin for changing carb intake. This information will be provided in the student’s DMMP.
Method 1—Following a Consistent Carb Intake Meal Plan. Students who follow a consistent carb meal plan aim for a set amount of carb grams at each meal and snack and do not adjust their mealtime insulin for the amount of carb intake (e.g., 60 grams of carbs at each lunch). The student’s personal diabetes health care team helps determine the amount of carbs that is right for each student at each meal. This method of meal planning is often used by students who take an intermediate-acting insulin in the morning or students who receive a preset amount of rapid- or short-acting insulin at lunch.
Students who follow a consistent carb meal plan need to maintain consistency in the timing and content of meals and snacks. The student should eat lunch at the same time each day. Snacks often are necessary to achieve a balance with the peak times of insulin action and with physical activity.
Method 2—Adjusting Insulin for Changing Carb Intake. Students who use multiple daily injections or an insulin pump usually use this method of meal planning. This method requires adjusting insulin doses to cover the amount of carbs the student will consume by using an insulin-to-carb ratio and an insulin correction factor (sometimes called an insulin sensitivity factor). These factors are individualized for each student and specified in the DMMP. This method gives the student with diabetes more flexibility with eating and requires a good understanding of the student’s insulin therapy and carb counting.
See the worksheet examples in Advanced Insulin Management: Using Insulin-to-Carb Ratios and Correction Factors (PDF, 211 KB) for instructions on how to compute the insulin dose using a student’s insulin-to-carb ratio and insulin correction factor. Some students now may use a blood glucose meter that performs bolus calculations automatically. Insulin-to-carb ratios and insulin correction formulas are pre-programmed into the device.
Other Dietary-Related Medical Conditions
A small percentage of students with diabetes may have other medical conditions that require dietary restrictions. For example, some students with type 1 diabetes may have celiac disease. They should not eat any food products that contain gluten or that have been prepared in a gluten-contaminated environment. Gluten is found in many grains, including wheat, rye, and barley, which are found in many pastas, cereals, and processed foods. These dietary restrictions should be outlined in the student’s DMMP. School food service staff will also need to be made aware of a student’s need for gluten-free meals.
Some students with type 2 diabetes may need to limit fat for control of weight and/or lipids. Still others may need to limit salt intake to help manage high blood pressure.
Promote Regular Physical Activity
Physical activity is a critical element of effective diabetes management. Everyone can benefit from regular physical activity, but it is even more important for students with diabetes. In addition to maintaining cardiovascular fitness and managing weight, physical activity can help lower blood glucose levels.
Students with diabetes should participate fully in physical education classes and team or individual sports. To maintain blood glucose levels within the target range during extra physical activity, students will need to adjust their insulin and food intake. To prevent hypoglycemia, they also may need to check their blood glucose levels more frequently before, during, and after engaging in physical activity. The student’s DMMP should specify when physical activity should be restricted because the blood glucose level is either too high or too low or if ketones are present.
Physical education teachers, sports coaches, and staff supervising recess must be able to recognize the symptoms of hypoglycemia and be prepared to call for help in case of a hypoglycemia emergency. The student’s Emergency Care Plan for Hypoglycemia, a quick-acting source of glucose, and the student’s blood glucose meter should always be available, along with plenty of water.
Students using pager-type insulin pumps may disconnect from the pump for sports activities; the pod-type pump remains attached. If students keep the pump on, they may set a temporary reduced insulin delivery rate or suspend use of insulin while they are playing. School personnel should provide the student with a safe location for storing the pump when the student does not wear it. The student’s DMMP and IHP should include specific instructions for pump use during physical activity.
Help to Maintain a Healthy Weight
Maintaining a healthy weight is very important for students with diabetes to help manage blood glucose levels and to establish habits for managing their weight as they grow older. Healthy habits include being active every day and choosing healthy foods for meals and snacks.
More children and adolescents in the U.S. are either overweight or obese than ever before. This excess weight is placing more students at risk for type 2 diabetes. School personnel can help all students reach and maintain a healthy weight by encouraging them to make healthful lifestyle choices while they are young. They also can provide nonfood rewards and encourage healthy foods for class parties.
Working with the school wellness committee and the school-parents organization (e.g., Parent Teacher Association [PTA]/Parent Teacher Organization [PTO]), the parents/guardians can help by encouraging schools to offer healthy food choices at breakfast and lunch and in vending machines, to sell nonfood items for school fundraisers, and to include physical education in the school curriculum. All foods sold at school during the school day now need to meet nutrition standards. The Smart Snacks in School regulation applies to foods sold a la carte, in the school store, and vending machines.
Plan for Special Events, Field Trips, and Extracurricular Activities
Meeting the needs of students with diabetes requires advance planning for special events such as classroom parties, field trips, and school-sponsored extracurricular activities held before or after school. The school food service staff can assist in the planning, especially when a student requires a modified snack or bag lunch for the event.
Although there usually are no forbidden foods in a meal plan for students with diabetes, school parties often include foods high in carbohydrates and fats. Serving more nutritious snacks will be healthier for all students and will encourage good eating habits. The parents/guardians should decide whether the student with diabetes should be served the same food as other students or food provided by the parents/guardians. If possible, give the parents/guardians advance notice about parties so they can incorporate special foods in the student’s meal plan or adjust the insulin dosage.
Students often view field trips among the most interesting and exciting activities of the school year. Students with diabetes must be allowed to have these school-related experiences. Although it is not unusual to invite the parents/guardians to chaperone field trips, parental/guardians attendance can never be a prerequisite for participation by students with diabetes.
The school nurse or trained diabetes personnel should accompany the student with diabetes on field trips. They should ensure that all of the student’s snacks and supplies for checking blood glucose, administering insulin, and treating hypoglycemia are packed and taken on the trip. Diabetes management strategies for school-sponsored field trips should be included in the student’s health care and education plans.
The plan for coverage and care during school-sponsored extracurricular activities and field trips that take place outside of school hours also should be carefully noted in the student’s health care and education plans. As with field trips, the school nurse or trained diabetes personnel must be available at these activities.
Deal with Emotional and Social Issues
Students with diabetes must not only deal with the usual developmental issues of growing up but also with learning to manage this complex chronic disease. Diabetes affects every facet of life, complicating the task of mastering normal developmental challenges.
For the most part, students with diabetes do not want to be singled out or made to feel different from their peers. Diabetes care tasks, however, can set them apart and make them feel angry or resentful about having diabetes. Depression is being recognized as quite common among children and teens and even more so in those with diabetes.
Students react differently to having diabetes. They may be accepting, resentful, open to discussing it, or attempt to hide it. Often, the same student will experience all of these feelings over time. School personnel should be aware of the student’s feelings about having diabetes and identify ways to ensure the student is treated the same way as others.
Sometimes, students feel pressured to please their care providers but cannot always comply with their requests. To appease their parents/guardians or members of their personal diabetes health care team, students may report fictitious blood glucose levels and/or ketone results. Others use their diabetes to assert their independence and control and do not comply with their diabetes care plan.
Still other students may be afraid or embarrassed by the potential for hypoglycemia and do not take all their insulin to avoid a low blood glucose. If this is a concern, the parents/guardians and the student’s personal diabetes health care team can check the information in the memory of the blood glucose meter or the insulin pump for problems or inconsistencies.
Students with diabetes are at risk for developing eating disorders, and school staff should be aware of this. Some students, particularly females, may omit insulin as a quick way to lose weight, putting them at risk for hyperglycemia and ketoacidosis. Binge eating and bulimia are also seen in students with diabetes. If there are concerns that a student may have an eating disorder, notify the school nurse or the parents/guardians.
Diabetes can be a focal point for conflict within families. It is important to minimize diabetes-specific family conflict to promote optimal health and quality of life outcomes. The student’s personal diabetes health care team and school health team must be aware of emotional and behavioral issues and refer students with diabetes and their families for counseling and support as needed.
One of the biggest challenges for students with diabetes is gradually becoming more independent from their parents/guardians. Yet diabetes may compromise independence, because the parents/guardians are concerned about their child’s ability to perform self-care tasks and take responsibility for their diabetes. The parents/guardians, who are ultimately responsible for their child’s well-being, may be reluctant to allow normal independence in children or teens who have not been able to take care of themselves properly. This parental concern can lead to increasing struggles with dependence, oppositional behavior, and rebellion.
Current research suggests, however, that when parents/guardians provide support and stay involved with their teen’s diabetes management tasks throughout adolescence, students achieve better health outcomes. Teamwork or “interdependence” between the parents/guardians and their child is an effective strategy.
To deal with psychosocial aspects of diabetes in students, there are many resources available. When problems are observed, the school health team and the student’s diabetes health care team may need to refer the family to a counselor experienced in working with families living with diabetes.
Understand Why Diabetes Self-Management is Important
Diabetes care depends upon self-management. The student’s competence and capability for performing diabetes-related care tasks should be specified in the Diabetes Medical Management Plan (DMMP) and then applied to the school setting by the school health team, as outlined in the student’s Individualized Health Care Plan and any education plan. Although students must receive assistance with and supervision of their diabetes care when needed, it is equally important to enable students to take on the responsibility of diabetes self-management with ongoing guidance and support from the parents/guardians, the student’s personal diabetes care team, and the school health team. The age for transfer of responsibility from caregiver to student varies from student to student and from task to task, because students develop and mature at different rates.
Students’ abilities to participate in self-care also depend upon their willingness to do so. It is medically preferable that students be permitted to perform diabetes care tasks in the classroom, at every campus location, or at any school activity.
Although the ages at which students are able to perform diabetes care tasks are highly individualized and differ for each student, their ability and levels of self-care generally occur as follows:
- Toddlers and preschool-aged children are unable to perform diabetes care tasks independently and will need an adult to provide all aspects of diabetes care. Many of these young children will have difficulty recognizing hypoglycemia, so it is important that the caregiver be able to recognize and provide prompt treatment. Children in this age range, however, usually can determine which finger to prick, choose an injection site, and are generally cooperative.
- Some elementary school-aged students are able to perform their own blood glucose monitoring, but most will require supervision. Older elementary school-aged students are beginning to self-administer insulin with supervision but may not yet have the cognitive capacity to adjust insulin doses based on blood glucose readings. Understanding the complex interactions among insulin, nutrition, and physical activity on blood glucose levels may not develop until early adolescence. Unless students have hypoglycemic unawareness (inability to tell when their blood glucose level is low), most should be able to let an adult know when they are experiencing hypoglycemia; however, this can depend on the distractions that are occurring in the school environment and the student’s overall level of well-being.
- Middle- and high school-aged students should be able to perform self-care tasks depending upon the length of time since diagnosis and level of maturity, but they always will need help when experiencing hypoglycemia. As older students mature, they should be encouraged and empowered to perform diabetes care tasks on their own.
Ultimately, each person with diabetes becomes responsible for all aspects of self-care, including blood glucose monitoring and insulin administration. Regardless of their level of self-management, however, all students with diabetes may require assistance when blood glucose levels are out of the target range. Regardless of their age, there are times when all students who have diabetes need someone else to help them with their diabetes care tasks. Learning to ask for support and help is an important element of learning self-advocacy as a person living with diabetes.