Diabetes

(Other Health Impairment)

DEFINITION

Our nation’s special education law, the Individuals with Disabilities Education Act (IDEA) includes diabetes under “other health impairment,” which means…

“…having limited strength, vitality, or alertness, including a heightened alertness to environmental stimuli, that results in limited alertness with respect to the educational environment, that is due to chronic or acute health problems such as asthma, attention deficit disorder or attention deficit hyperactivity disorder, diabetes, epilepsy, a heart condition, hemophilia, lead poisoning, leukemia, nephritis, rheumatic fever, sickle cell anemia, and Tourette syndrome; and adversely affects a child’s educational performance.”

[34 code of Federal Regulations §300.8(c)(9)]

OTHER DEFINITIONS

Diabetes is a disease that occurs when blood glucose, also called blood sugar, is too high. Blood glucose is the main source of energy and comes from food. Insulin, a hormone made by the pancreas, helps glucose from food get into the cells to be used for energy. A person with diabetes may not make enough insulin or not use insulin properly. Glucose then stays in the blood and doesn’t reach the cells. Over a long period of time, even moder¬ately high blood glucose levels can lead to serious complications, such as heart disease, blindness, kidney failure, and amputations.

TYPES

Type 1 
Type 1 diabetes occurs when your immune system, the body’s system for fighting infection, attacks and destroys the insulin-producing beta cells of the pancreas. Scientists think type 1 diabetes is caused by genes and environmental factors, such as viruses, that might trigger the disease. Formerly called “juvenile diabetes”, type 1 is usually diagnosed in children and young adults, although it can appear at any age. People with type 1 diabetes need to take insulin every day to stay alive.

Type 2 
Types 2 is the most common type of diabetes and is caused by several factors, including lifestyle factors and genes. Type 2 diabetes usually begins with insulin resistance, a condition in which muscle, liver, and fat cells do not use insulin well. As a result, the body needs more insulin to help glucose enter cells. At first, the pancreas makes more insulin to keep up with the added demand. Over time, the pancreas can’t make enough insulin, and blood glucose levels rise. A person can develop type 2 diabetes at any age, even during childhood. However, this type of diabetes occurs most often in middle-aged and older people.

Gestational Diabetes 
Develops in some women when they are pregnant. Most of the time, this type of diabetes goes away after the baby is born. However, someone who has developed gestational diabetes is at a greater risk of developing type 2 diabetes later in life. Sometimes, diabetes diagnosed during pregnancy is actually type 2 diabetes.

Prediabetes 
Blood glucose levels are higher than normal but not high enough to be diagnosed as diabetes. Prediabetes usually occurs in people who already have some insulin resistance or whose beta cells in the pancreas aren’t making enough insulin to keep blood glucose in the normal range. Without enough insulin, extra glucose stays in the bloodstream rather than entering the cells. Over time, this can lead to type 2 diabetes.

Other Types 
Less common types include monogenic diabetes, which in an inherited form of diabetes, and cystic fibrosis-related diabetes.

(National Institute of Diabetes and Digestive and Kidney Diseases, NIDDK, 2019)

FACTS AND STATS

As of 2015, about 30.3 million Americans (9.4% of the population) had diabetes. About 1.25 million of these individuals have type 1 diabetes. It is estimated that over 20% of people with diabetes are undiagnosed. The prevalence of diabetes in Americans over the age of 65 is high at 25.2%. Diabetes is the 7th leading cause of death in the United States.

Diabetes is more prevalent among American Indian, American Native, African American, Hispanic, and Asian American racial populations.

The number of individuals with prediabetes aged 18 and older is approximately 84.1 million adults (almost 34% of the adults US population).

The 2017 Diabetes Report Card from the CDC highlights a few trends and challenges. The rate of new cases of diabetes among US adults has decreased, but the rate of new cases of diabetes among children and adolescents has increased.

(American Diabetes Association, ADA, 2018) 
(Centers for Disease Control and Prevention, CDC, 2017)

CAUSES

Type 1 diabetes occurs when the immune system attacks and destroys the insulin-producing beta cells of the pancreas. Scientists think type 1 diabetes is caused by genetic and environmental factors, such as viruses, that might trigger the disease.

Risk for developing type 2 diabetes is caused by several factors including lifestyle and genes. Individuals who are not physically active and are overweight or obese are more likely to develop type 2 diabetes. Extra weight and belly fat are linked to insulin resistance. Type 2 diabetes also tends to run in families, occurring more often in African Americans, Alaska Natives, American Indians, Asian Americans, Hispanics/Latinos, Native Hawaiians, and Pacific Islander racial/ethnic groups. Genes can also increase the risk of type 2 diabetes by increasing a person’s tendency to become overweight or obese.

Scientists believe gestational diabetes may be caused by hormonal changes during pregnancy along with genetic and lifestyle factors. Hormones produced by the placenta contribute to insulin resistance, which occurs in all women during late pregnancy. Most women can produce enough insulin to overcome insulin resistance, but some cannot. As with type 2, extra weight gained during pregnancy may be linked to insulin resistance in gestational diabetes. A family history of diabetes makes it more likely a woman will develop gestational diabetes. This type of diabetes occurs more often in African Americans, American Indians, Asians, and Hispanic/Latina racial/ethnic groups.

Other causes may include genetic mutations (e.g., cystic fibrosis), hormonal diseases (e.g., hyperthyroidism), damage or removal of the pancreas, and certain medicines.

(NIDDK, 2019)

PREVENTION

There is no known way to prevent type 1 diabetes. Several clinical trials of methods of the prevention of type 1 diabetes are currently in progress or are being planned.

Studies show that people with prediabetes or high risk for type 2 diabetes can prevent or delay the onset of the disease by losing 5 to 7 percent of their body weight. Getting at least 30 minutes of physical activity 5 days a week can help in this goal alongside eating healthier with reduced caloric intake, choosing healthier foods, and drinking water instead of sweetened beverages.

For women with gestational diabetes, the risk for developing type 2 diabetes can be decreased by careful monitoring of blood glucose after the baby is born, leading an active lifestyle, making healthy food choices, breastfeeding, and getting back to a healthy weight.

People with diabetes can prevent the complications associated with the disease with proper glucose-management medications, exercise, and good diet, brushing and flossing teeth daily, maintaining good eye health and regular eye exams, monitoring blood glucose, quitting smoking, and checking feet daily.

(NIDDK, 2019)

CHARACTERISTICS

Common diabetes symptoms may include:

  • Increased thirst and urination
  • Increased hunger
  • Fatigue
  • Blurred vision or sudden changes in vision
  • Numbness or tingling in feet or hands
  • Sores, bruises, or wounds that are slow to heal
  • Unexplained weight loss

Symptoms of type 1 diabetes can start quickly, in a matter of weeks. Symptoms of type 2 diabetes often develop slowly—over the course of several years—and can be so mild that you might not even notice them. Many people with type 2 diabetes have no symptoms. Some people do not find out they have the disease until they have diabetes-related health problems, such as blurred vision or heart trouble.

(NIDDK, 2019)

Hypoglycemia, or “low blood glucose,” usually can be treated easily and effectively. The only way to know whether someone is experiencing low blood glucose is to check blood glucose levels, if possible. If it is not treated promptly, however, hypoglycemia can lead to unconsciousness and convulsions and can be life threatening. Symptoms can range from mild to severe, including:

  • Feeling shaky
  • Being nervous or anxious
  • Sweating, chills, and clamminess
  • Irritability or impatience
  • Confusion
  • Fast heartbeat
  • Feeling lightheaded or dizzy
  • Hunger
  • Nausea
  • Color draining from skin (pallor)
  • Feeling sleepy
  • Feeling weak or having no energy
  • Blurred/impaired vision
  • Tingling or numbness in the lips, tongue, or cheeks
  • Headaches
  • Coordination problems, clumsiness
  • Nightmares or crying out during sleep
  • Seizures

As soon as symptoms of hypoglycemia are observed, have 15 grams of carbohydrate to raise blood glucose and check it after 15 minutes. This may include:

  • Glucose tablets (see instructions)
  • Gel tube (see instructions)
  • 4 ounces (1/2 cup) or juice or regular soda (not diet)
  • 1 tablespoon of sugar, honey, or corn syrup
  • Hard candies, jellybeans, or gumdrops – see food label for how many to consume

Hyperglycemia, also called “high blood glucose,” is a seri¬ous manifestation of diabetes that may be caused by too little insulin, illness, infection, injury, stress or emotional upset, inges¬tion of food that has not been covered by the appropriate amount of insulin, or decreased exercise or activity. In the short term, hyperglycemia can impair cognitive abilities and adversely affect academic performance. Free and unrestricted access to liquids and the restroom must be provided, as high blood glucose levels increase urination and may lead to dehydration if the student cannot replace the fluids. High blood glucose symptoms include:

  • Increased thirst
  • High levels of sugar in urine
  • Frequent urination

Children react differently to having diabetes. They may be accepting, resentful, open to discussing it, or attempt to hide it. Often, the same child 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 as others. Increasingly, depression is being recognized as quite common among children and teens generally, and even more so in those with diabetes. Health care providers and school personnel must be aware of emotional and behavioral issues and refer students with diabetes and their families for counseling and support as needed.

(ADA, 2019)

MEDICAL TREATMENT

Managing diabetes is a daily effort. Regular and frequent monitoring of blood glucose, blood pressure, and cholesterol levels is essential. To survive, people with type 1 diabetes must have insulin delivered by injection or a pump. Many people with type 2 diabetes can control their blood glucose by following a healthy meal plan and exercise program, losing excess weight, and taking regular medication. Many people with diabetes also need to take medications to control their cholesterol and blood pressure. Diabetes self-management education (DMSE) is an integral component of medical care.

(NIDDK, 2019)

PROGNOSIS

There is no cure for diabetes, but it can be controlled by regular exercise, healthy eating habits, medicine, regular checkups, and weight loss, if necessary. Individuals can manage their diabetes and live a long and healthy life by taking care of themselves each day.

Diabetes can affect almost every part of the body. Therefore, it is necessary to manage blood glucose levels, also called blood sugar. Managing blood glucose, as well as blood pressure and cholesterol, can help prevent the health problems that can occur when an individual has diabetes. A health care team can create a diabetes self-care plan for individuals to manage their diabetes.

(NIDDK, 2019)

EDUCATIONAL IMPLICATIONS

Diabetes must be managed 24 hours a day, 7 days a week. For students with type 1 diabetes, and for some with type 2 diabe¬tes, that means careful monitoring of their blood glucose (sugar) levels throughout the school day and administering multiple doses of insulin therapy. As a result, the school health team, which includes the school nurse, teachers, office personnel, and other school staff members, plays an important role in helping students manage their diabetes. As is true for children with other chronic diseases, students with diabetes are more likely to succeed in school when students, parents, school nurses, principals, teachers, other school personnel, and the student’s health care providers (or personal health care team) work together to ensure effective diabetes management. At its core, effective school-based diabetes management requires two things:

  • All school staff members who have responsibility for a student with diabetes should receive training that provides a basic understanding of the disease and the student’s needs, how to identify medical emergencies, and which school staff members to contact with questions in case of an emergency.
  • A small group of school staff members should receive training from a qualified health care professional such as a physician or a nurse in student-specific routine and emergency care so that a staff member is always available for younger or less-experienced students who require assistance with their diabetes management (e.g., administering insulin, checking their blood glucose, or choosing an appropriate snack) and for all students with diabetes in case of an emergency.

Some students who need insulin during the school day are able to administer it on their own; others will need supervision; and others will need someone to administer the insulin for them. The school nurse and/or trained diabetes personnel should provide this help in accordance with the Diabetes Medical Management Plan and the nursing care plan.

Written plans outlining each student's diabetes management help students, their families, school staff, and the student's health care providers know what is expected of them. These expectations should be laid out in written documents, such as a:

  • Diabetes Medical Management Plan, developed by the student's personal health care team and family
  • Quick Reference Emergency Plan, which describes how to recognize hypoglycemia and hyperglycemia and what to do as soon as signs or symptoms of these conditions are observed
  • Education plans, such as the Section 504 Plan or Individualized Education Program (IEP)
  • Care Plan or Individual Health Plan generated by the school nurse that provides instructions to faculty and staff.

Many students will be able to handle all or almost all of their diabetes care by themselves. Others, because of age, developmental level, or inexperience, will need help from school staff. The school nurse is the most appropriate person to coordinate care for students with diabetes. Each student with diabetes has different needs, but the education-related plans developed for such students are likely to address the following common elements:

  • Where and when blood glucose monitoring and treatment will take place
  • Identity of trained diabetes personnel who are trained to conduct blood glucose checking, insulin and glucagon administration, and treatment of hypoglycemia and hyperglycemia
  • Location of the student’s diabetes management supplies
  • Free access to the restroom and water fountain
  • Nutritional needs, including provisions for meals and snacks
  • Full participation in all school-sponsored activities and field trips, with coverage provided by trained diabetes personnel
  • Alternative times for academic exams if the student is experi¬encing hypoglycemia or hyperglycemia
  • Permission for absences, without penalty, for doctors’ appoint¬ments and diabetes-related illness
  • Maintenance of confidentiality and the student’s right to privacy

With some insulin regimens, it is important to maintain consistency in the timing and content of meals and snacks. The student should eat lunch at the same time each day. Snacks are often neces-sary for a child with diabetes and must be eaten to balance the peak times of insulin action. A missed or delayed snack could result in hypoglycemia. The student’s nursing care plan or education plan (504, IEP, or other education plan) should show the timing of meals and snacks and an alterna¬tive plan for unusual or unforeseen circumstances. 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. With proper planning for coverage by trained diabetes personnel and possible adjustments to their insulin regimen and meal plan, students with diabetes can participate fully in all school-related activities.

(NIDDK, 2019) 
(ADA, 2019)

ORGANIZATIONS

American Diabetes Association (ADA) 
http://www.diabetes.org 
2451 Crystal Drive, Suite 900 
Arlington, VA 22202 
1-800-342-2383

This association's mission is to prevent and cure diabetes and to improve the lives of all people affected by the condition. It funds meritorious research, hosts a national conference, publishes the latest scientific findings, and provides education and other services to people with diabetes, their families, health care professionals, and the public. It has local chapters that plan and carry out educational, service, fundraising programs, as well as, diabetes classes and summer camps for children and teenagers. In addition, ADA collects information on physicians and researchers who treat/study the condition and disseminates this information to its membership, as well as providing referrals to state and local chapters.

Juvenile Diabetes Research Foundation International (JDRF) 
https://www.jdrf.org 
26 Broadway, 14th floor 
New York, New York 10004 
800-533-2873 
info@jdrf.org

This foundation's mission is to support and fund research to find a cure for type 1 diabetes and its complications. It awards research grants for laboratory and clinical investigations and sponsors a variety of career development and research training programs for new and established investigators. JDF also collects information on physicians and researchers who treat/study the condition and decimates this information through their research newsletter and offers referrals to other resources. Finally, JDF hosts a national conference and coordinates a parent-to-parent matching program.

Joslin Diabetes Center 
https://www.joslin.org 
1 Joslin Place 
Boston, MA 02215 
617-309-2400 or 1-800-JOS-LIN1 (1-800-567-5461)

The Joslin Diabetes Center in Boston provides a full range of services for children and adults with diabetes, providing the medical care, training, and support they need to live with this disease. The center and its affiliates offer a number of programs to help youngsters with diabetes and their families better manage the disease. In addition to traditional medical appointments, Joslin Diabetes Center offers educational programs that include summer camps and weekend retreats as well as family-focused programs geared to three different age groups--preschoolers, school-age children, and adolescents. A new program at a center affiliate in Illinois offers counseling services for young children and adolescents with diabetes and serves as a resource for their families. Educational materials include books to help children adjust to life with diabetes as well as manuals for parents and professionals on caring for young children with diabetes.

Barbara Davis Center for Childhood Diabetes 
http://www.barbaradaviscenter.org 
1775 Aurora Court 
MS #A140 
Aurora, CO 80045 
303-724-2323 (clinic) or 303-724-6836 (research)

The Barbara Davis Center for Childhood Diabetes, affiliated with the University of Colorado Health Sciences Center, is the largest diabetes and endocrine care program in Colorado with unique facilities and resources for clinicians, clinical researches, and basic biomedical scientists working to help patients with type 1 diabetes. The center provides state-of-the-art clinical diabetes care to a majority of children and many adults within the Rocky Mountain Region.

Naomi Berrie Diabetes Center 
Columbia-Presbyterian Medical Center 
Russ Berrie Medical Science Pavilion 
http://www.nbdiabetes.org 
1150 St. Nicholas Avenue (at 168th Street) 
New York, NY 10032 
212-851-5494

The Naomi Berrie Diabetes Center (NBDC) is the research, teaching, and clinical services unit of the Columbia-Presbyterian Medical Center at Columbia University. It offers state-of-the-art multidisciplinary and humanistic clinical care for both adults and children with diabetes, coordinated by an endocrinologist. Educational, nutritional, and psychosocial counseling focuses on helping the patient and family to cope effectively with diabetes management. Research programs at the center focus on the biologic basis of diabetes and the prevention of type 1 and type 2 diabetes. Children's programs include a pediatric insulin pump support group and a teen/children's diabetes class. There is also a Kid's Corner at the NBDC website.

USDA/ARS Children's Nutrition Research Center 
Baylor College of Medicine 
https://www.bcm.edu/departments/pediatrics/sections-divisions-centers/childrens-nutrition-research-center 
1100 Bates Street 
Houston, TX 77030 
713-798-6767 
cnrc@bcm.edu

The Children's Nutrition Research Center (CNRD) is a cooperative venture between the Baylor College of Medicine, Texas Children's Hospital, and the U.S. Department of Agriculture/Agricultural Research Service. CNRC researchers study nearly every aspect of children's nutrition, and data from the center's research are used to make dietary recommendations to improve the health of children. The center investigates the nutritional needs of pregnant and nursing women and children from conception through adolescence, establishes nutritional guidelines, and studies regulatory controls of children's body weight and body composition and childhood dietary habits that contribute to long-term health and prevention of diseases such as diabetes, based on changes in diet.

Endocrine Society 
https://www.endocrine.org 
2055 L Street NW, Suite 600 
Washington, DC 20036 
202.971.3636 
888.363.6274 
info@endocrine.org

The mission of the Endocrine Society is to promote the understanding of hormonal communication at the molecular, cellular, and systems level to prevent, diagnose, and treat disease, and improve the quality of life. The society disseminates new knowledge leading to the prevention, treatment, and cure of diseases including diabetes. The society publishes four major peer-reviewed journals about endocrinology and metabolism. In partnership with the American Association of Diabetes Educators, the society has produced an interactive satellite broadcast, available on its website, that updates medical professionals on the latest breakthroughs in diabetes management. The society's website offers several articles on children and type 2 diabetes.

RESOURCES

American Medical Association 
The American Medical Association (AMA) provides abstracts of articles related to children with diabetes are available on the AMA website. These articles cover topics such as adolescent type 2 diabetes, latex, hypersensitivity, and clinical management of children and teenagers with diabetes.

Diabetes Division of the University of Massachusetts Medical School 
The Diabetes Division of the University of Massachusetts Medical School teaches students, nurses, and physicians to provide the best possible care for patients with diabetes and to carry out research that will aid in preventing and curing this disease. Of particular interest on the website are two forms for parents of children with diabetes that may be printed out - one for the babysitter and one for the teacher. These forms are in an easy-to-follow format. They give parents guidelines to follow to inform caretakers that their child has diabetes, what that means, warning signs preceding insulin reactions, important phone numbers to call and what to do in an emergency, what snacks children should have and when, and other important information.

Friedman School of Nutrition Science and Policy 
The Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy at Tufts University was established 1979 with the mission of bringing together biomedical, social, political, and behavioral scientists to conduct research, educational, and community-service programs to improve the nutritional health and well-being of populations throughout the world. Their mission is to generate trusted science, educate future leaders, and produce real world impact in nutrition science and policy.

Websites for Children

Children with Diabetes 
Children with Diabetes is an online resource with comprehensive information for children with diabetes and their families. The mission of Children with Diabetes is to promote understanding of the care and treatment of diabetes, especially in children; to increase awareness of the need for unrestricted diabetes care for children at school and daycare; to support families living with diabetes; and to promote understanding of research into a cure.

Other Resources

“Helping the Student with Diabetes Succeed” 
Use this comprehensive guide designed to empower school personnel, parents, and students to create a safe learning environment and equal access to educational opportunities for all children with diabetes. Download and print the PDF version or order the school guide. To learn more, read these in-depth articles from School Nurse News on topics related to helping students manage their diabetes. See other resources section for companion training modules.

Last updated March 2020.