The number of U.S. schoolchildren managing diabetes continues to rise, and experts predict more than a half million will have the chronic health disorder by 2060.
That means educators and school health staff will increasingly need to support students with monitoring and medical assistance throughout the school day. In the past five years, districts from Connecticut to California and Tennessee to Texas have faced civil rights complaints and, in some cases, U.S. Department of Justice investigations for not properly managing students’ diabetes in school day and after-school programs.
Dr. Henry Rodriguez, a pediatric endocrinologist and a co-chairman of the American Diabetes Association’s Safe at School Working Group, said it’s critical for educators, physicians, and families to plan together to manage students’ diabetes.
“As [doctors], we see a patient maybe for 30 to 40 minutes, three times a year if things are going according to plan,” he said. “That school nurse and that teacher see that child day in and day out throughout the school year. Many times we rely on them to indicate whether there’s an issue.”
The U.S. Department of Education has released a new resource guide for schools on how to help these students. Here’s what educators need to know about this chronic health condition.
What is diabetes?
The endocrine system governs how the body processes glucose for energy. In a healthy person, blood sugar may rise after a meal or due to illness or stress, but it stays within a narrow, stable range. If glucose levels stay high for long periods of time—usually because of a malfunction in insulin, the hormone that controls blood sugar in the body—a person is at risk for a host of health problems, including heart and kidney disease or vision problems.
- Type 1 diabetes occurs when the body does not produce enough insulin; this type often is diagnosed quite young, and is sometimes called “juvenile diabetes,” as it is the most common form among children.
- Type 2 diabetes occurs when the body loses the ability to use insulin effectively. Because it develops over time, it can sometimes be managed with diet and exercise, with or without insulin medication. While this type is sometimes called “adult onset” diabetes, its rates have been rising among children and adolescents. Growing type 2 diabetes rates have been linked to increases in childhood obesity.
How common is diabetes among young people?
Diabetes is one of the most common chronic diseases for school-age children. More than 213,000 children under age 18 had been diagnosed with some form of diabetes as of 2017. According to the Centers for Disease Control and Prevention, more than a quarter of diabetic adults under 40 in 2019 were identified while they were of school age.
If diabetes rates continue to rise as quickly as they did from 2002 to 2017, national estimates show that 526,000 people under 20 will have diabetes by 2060. That represents a 65 percent increase in type 1 diabetes and a nearly eightfold jump in type 2 diabetes. Diabetes rates, particularly for type 2, are growing fastest among students of color.
Nearly 14 percent of U.S. adults with less than a high school diploma had diabetes as of 2019, nearly twice the share among adults with postsecondary education, according to the most recent CDC data.
How does diabetes affect academic students’ school careers?
While there has been little research on the effects of diabetes on students’ test performance, studies find students with diabetes are significantly less likely to graduate from high school, enroll in, or attend college.
On a day-to-day basis, students experiencing severe blood sugar fluctuations can become exhausted and irritable; have difficulty concentrating, reading, and communicating; and need to eat, drink, or go to the bathroom more frequently. Glucose spikes and drops can also trigger behavior problems.
Is diabetes considered a disability?
Yes. Diabetes “substantially limits major life activities” and can put students at higher risk of experiencing bullying or harassment. Title II of the Americans with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973 bar discrimination against students based on their disabilities, and the Individuals with Disabilities Education Act (IDEA) provides funding for special education and support services for students with disabilities, including chronic health conditions.
Under federal law, schools must provide accommodations to help diabetic students access and participate in school.
“The needs of students with diabetes vary, as do the options for meeting those needs to ensure the student has equal access to the school’s educational program or activity,” an Education Department spokesperson said. “If a student requires assistance with their diabetes management, an elementary or secondary school might be required to train a teacher or staff member to provide that assistance. In other circumstances, the school might opt to ensure that a school nurse is available to the student with diabetes, might assign a paraprofessional to assist the student, or might determine that the student is independent in their diabetes management and requires no assistance except in the case of a medical emergency.”
Across more than a dozen civil rights resolution agreements over diabetes management, districts most frequently needed to train more staff to understand how diabetes could affect students and how to ensure schools have multiple adults on campus who can help in an emergency.
What role does technology play?
For decades, the primary way to track blood sugar was by “finger-sticking,” or pricking the skin to draw blood and directly measure glucose levels.
Now, physicians increasingly prescribe students “continuous glucose monitoring,” or CGM, systems. A sensor remains in the skin, using frequent samples of glucose in subcutaneous fluid rather than blood to estimate blood sugar levels. These measures are often relayed to a monitoring app on a smartphone or tablet, and may also be connected to an automatic insulin pump.
“You’re going from measuring maybe four to six [glucose] levels a day, to now you’ve got well over 280,” Rodriguez said. Moreover, CGMs usually display trend lines as well as individual blood sugar levels, “so it’s not just, ‘Gosh, Sally’s low right now; you can actually tell, Sally’s trending towards being low, and you can set alarms for that so that it allows individuals to intervene before there’s a major problem and becomes a crisis.”
However, CGMs are not without controversy. They can be difficult to get for low-income diabetic students, who are more likely than wealthier students to be uninsured or underinsured.
Several schools have run into trouble when staff were not trained to use the systems or thought they conflicted with other policies. In Connecticut, public schools in East Lyme, Glastonbury, and Stamford have been subject to civil rights complaints for not responding properly to diabetic alarms from the devices, according to attorney general investigations in the state.
“There’s been a lot of controversy of late, amongst the school community, in which folks have suggested that you need to have a school nurse that has a tablet that’s monitoring [diabetic students’] blood sugar 24/7, every minute,” Rodriguez said. “If a school has the capacity to do that, that’s wonderful. But it’s also important to note ... just because you can monitor in real time all the time, doesn’t mean that that’s necessary.”
It’s more important, he said, for school staff to recognize monitoring alarms and symptoms that a student is having difficulty.
For example, parents of a diabetic elementary student in Glastonbury reported receiving remote alarms that her blood sugar dropped 60 points below the safe level on one occasion and up to 200 points above on another, but “no one at the school was aware the child’s health was at serious risk,” according to the civil rights complaint.
While many schools bar students from having a smartphone or tablet in the classroom, particularly during tests, Rodriguez said they should work with parents and students to continue to monitor students’ blood sugar.
For example, a test proctor might keep a student’s smartphone, so that it is close enough to relay an alarm if the student has a major fluctuation during a long testing period. Some students may also reschedule tests if they have significantly higher or lower blood sugar at the start of a testing period.
How should schools approach support?
In the new 504 guidance resources, the Education Department noted several common school accommodations for diabetic students, including:
- access to snacks during class time;
- more frequent restroom breaks;
- making up work or exams without penalty if the student experiences a diabetic episode;
- planning for and excusing absences due to medical appointments or diabetic episodes;
- training teachers and staff to recognize signs of a blood sugar spike or crash and to be able to administer emergency glucagon (for low blood sugar) or insulin (for high blood sugar); and
- protecting students from disability-related harassment, such as being bullied for what they eat or frequent bathroom visits.
Coordination with school nurses is critical. One study of more than 100 North Carolina school districts found that diabetic students in districts with lower ratios of students to school nurses had significantly fewer absences, higher grades, and better-regulated diabetes over time.
However, school nurses have reported that schools often lack the policies, staff training, and communication with students and families that are needed to manage diabetic students’ health. They also noted that diabetic students often need more opportunities for physical activity, which can also help to manage blood sugar.
Rodriguez noted that there’s no one-size-fits-all approach to supporting diabetic students, and schools should consider how policies will affect students with different needs.
For example, Rodriguez noted that vigorous physical activity lowers all students’ health risk, and it is essential to helping students with type 2 diabetes manage blood sugar. However, students with type 1 diabetes may need additional support during physical activities to ensure their blood sugar does not drop too much.
