Diabetes in Schools

1. Diabetes in Schools Eric L. Johnson, M.D. Assistant Medical Director Altru Diabetes Center Assistant Professor Department of Family and Community Medicine University of North Dakota School of Medicine and Health Sciences Grand Forks, ND

2. Objectives • Understand diabetes definitions • Understand common diabetes treatments and principles • Apply principles to the needs of children and adolescents with diabetes in a school setting

3. Diabetes In Schools • 180,000 students with type 1 or type 2 diabetes • About 1 in 400-600 • Most have type 1 diabetes American Diabetes Association

4. Diabetes Definitions

5. Diabetes Definitions • Type 1 Diabetes • No known risk factors/Not preventable (maybe familial) • Autoimmune disease • Pancreas stops making insulin • Requires insulin start at diagnosis • Most diagnosed before age 25

6. Diabetes Definitions Type 2 Diabetes • Risk factors: Obesity, FH, Lifestyle, Smoking • Pancreas still makes some insulin, body is resistant • More children and adolescents diagnosed in last 10 years • Initially treated with lifestyle and pills, all eventually need insulin

7. Diabetes Mellitus-Type “1.5”Latent Autoimmune Diabetes(LAD) • Mixed features • Usually present like Type 2, progress to insulin deficiency rapidly, may develop Type 1 symptoms • May be antibody positive, variable C-peptide • ~ 10% of all Type 2 (?)

8. Diabetes Diagnosis Guidelines Category FPG (mg/dL) Normal <100 Impaired Fasting Glucose* (IFG) 100 – 125 Diabetes >126** Not to be confused with impaired glucose tolerance (IGT): 2 h OGTT 75 g at 140–200 mg/dL • ** On 2 separate occasions AND/OR A1C>6.5 American Diabetes Association

9. Monitoring Diabetes A1C • Test done in providers office every 3 to 6 months • An “Average of Blood Sugar” over months Self Monitored Blood Glucose • “Fingersticks” • Usually done several times a day

10. A1C eAG % mg/dL mmol/L 6 126 7.0 7 154 8.6 8 183 10.1 9 212 11.8 10 240 13.4 Formula: 28.7 x A1C - 46.7 – eAG American Diabetes Association A1C ~ “Average Glucose”

11. Targets for glycemic (blood sugar) control Goals of Glucose Management *<6 for certain individuals • American Diabetes Association. Diabetes Care. 2010;33(suppl 1) • Implementation Conference for ACE Outpatient Diabetes Mellitus Consensus Conference Recommendations: Position Statement at http://www.aace.com/pub/pdf/guidelines/OutpatientImplementationPositionStatement.pdf. Accessed January 6, 2006. • AACE Diabetes Guidelines – 2002 Update. Endocr Pract. 2002;8(suppl 1):40-82.

12. ADA Guidelines for Glucose Management Children and Adolescents American Diabetes Association. Diabetes Care. 2010;33(suppl 1)

13. Diabetes Control:Why? • Good statistical evidence that long term good diabetes control results in fewer complications • Eye, kidney, nerve, heart disease/stroke, amputation in adulthood • Heart Disease and Stroke #1 cause of death in Diabetes

14. Diabetes Control: Why? Other considerations: • Blood Pressure • Cholesterol Disease • Some children/adolescents will be dealing with these too

15. Diabetes Control:Why? Children/adolescents with consistently poor diabetes control: • Evaluate for psych • Evaluate for thyroid • Evaluate for celiac disease May not be purely “motivational”

16. Diabetes Treatment

17. The Diabetes Team • Physician • Nurse Practitioner or Physician Assistant • Diabetes Educator • Dietician • Eye care provider • Other specialties as needed • Many clinics have Diabetes Centers

18. Diabetes Treatments • Type 1: Insulin (injected or pump) • Type 2: Usually metformin or another oral agent, perhaps combined with insulin Combined with meal plan and exercise/activity plan

19. Meal Plans In Diabetes • Used to teach “sugar is poison” “if it tastes good, spit it out” • More modern plans are carbohydrate controlled, “heart healthy” • I tell patients dieticians will customize a meal plan for them (not “one size fits all”)

20. Insulin Programs • Most children/adolescents have type 1 • Type 1 patients are typically on multiple daily injections of insulin • Type 2 patients may be on oral medications +/- insulin once daily or multiple daily injections • Type 1 or Type 2 on insulin may be on pump

21. Types of Insulin • Rapid acting (taken with food) • Insulin aspart (Novolog) • Insulin lispro (Humalog) • glulisine (Apidra) • Short acting (taken with food) - Human Regular (R)

22. Types of Insulin • Long acting (Basal) insulin glargine (Lantus) determir (Levemir) • Intermediate acting Human NPH (N) “Background insulin”

23. Rapid (Lispro,Glulisine, Aspart) Short (Regular) Intermediate (NPH) Long (Detemir,Glargine) Insulin Time Action Curves 140 120 100 80 Insulin Effect 60 40 20 0 0 2 4 6 8 10 12 14 16 18 20 Hours adapted from R. Bergenstal, IDC

24. Rapid (Lispro,Glulisine, Aspart) Long (Detemir,Glargine) Basal/Bolus Injection 140 120 100 80 Insulin Effect 60 40 20 0 0 2 4 6 8 10 12 14 16 18 20 Hours adapted from R. Bergenstal, IDC

25. Insulin Programs • Type 1 patients will take a “background insulin” (basal)(Levemir , Lantus, or NPH) once or twice daily • Type 1 patients will take a rapid acting (bolus insulin)(Novolog, Humalog, or Apidra) with meals and snacks

26. Insulin Programs • Additionally, Type 1 patients are typically instructed to take extra rapid acting insulin(bolus) to correct elevated blood sugars (correction bolus) • All type 1 patients must take insulin, as they don’t have any native circulating insulin

27. Insulin in Type 1 • Example: 13 y/o female • Basal (Lantus OR Levemir) 22 units once daily • Bolus (Apidra, Novolog, Humalog) 1 to 3 units/15gram carbohydrate with meals and snacks AND 1 extra unit/50 points to lower elevated blood sugar (correction bolus)

28. Insulin • Insulin can still be dispensed in bottles to be used with syringes (dated/cumbersome) • Most insulins are available in pen injectors (easier/portable/comfortable)

29. Insulin Pens

30. Other Diabetes Medications Oral agents in Type 2 • Metformin (most common for children or adolescents) • Sulfonylureas (glipizide, glimiperide, glyburide) • TZD’s (Actos/Avandia) • DPP-IV inhibitors (Januvia, Onglyza)

31. Other Diabetes Medications Non-insulin injectables • Symlin (Type 1 or Type 2) • Byetta (Type 2) • Victoza (Type 2)

32. Meters for Monitoring

33. Self Blood Glucose Monitors • Modern Meters • Fast (5-7 seconds), accurate • Comfort • Display • Data collected and stored • Adjustable lancet force • Alternate site testing (forearm, palm)

34. Meters

35. Meters

36. Insulin Pumps (Continuous Subcutaneous Insulin Infusion) • Pumps are excellent tools for more complex insulin management • Insulin continuous(“basal”), also deliver bolus with meals • Candidates need to be well-motivated and comfortable with electronics

37. Insulin Pumps (Continuous Subcutaneous Insulin Infusion) • Continuous Sensor devices are on market • Record blood sugar continuously • Pumps and sensors require compulsivity on the part of the user

38. Continuous glucose sensor DexCom Seven Abbott Freestyle Navigator Pump with continuous glucose sensor Medtronic Minimed Modern Pump/Sensor Technology

39. Animas Omnipod

40. Diabetes In School www. diabetes.org/schools

41. Historical Challenges • Lack of diabetes-specific trained personnel • Prohibition of students to self-mange their diabetes • Exclusion of students with diabetes from school, extra-curricular activities, sports teams • Lack of accommodations for students (water, food, bathroom, test taking) • These have been overcome in recent years

42. School Based Diabetes Management • Basic diabetes training for staff • Shared responsibilities for care, with leadership by school nurse • Self management is allowed all school settings for students (to their age-appropriate capacity)

43. Diabetes Care Plans • Specifics about the student’s diabetes and how it is managed, including health care provider contact information • Diabetes care guidelines as determined by the diabetes health care professional • Protections provided by federal and state laws (Americans with Disabilities Act) • 504 plan or IEP

44. Diabetes Care Plans • Student should be allowed to test anywhere • Student should be allowed to carry “rescue carbohydrates” or snacks • Student should be allowed to carry diabetes supplies • Student should be allowed access to water and bathroom

45. Diabetes Immediate Concerns Hypoglycemia = low blood glucose Hyperglycemia = high blood glucose Ketoacidosis uncontrolled high blood sugar, can result in dehydration, coma, death

46. Hypoglycemia (Low Blood Sugar) Symptoms of mild hypoglycemia: • Sudden change in behavior (lethargic, confused, uncoordinated, irritable, nervous, uncooperative) • Sudden change in appearance (shaky, sweaty, pale or sleepy) • Complaints of headache or weakness • Usually occurs blood sugar <70-75

47. Treatment of Mild Hypoglycemia 1. Give the student a quick-acting sugar equivalent to 15 grams of carbohydrate: • Examples: 4 oz. of juice, ½ a can of regular soda, or 3-4 glucose tablets, glucose gel • Ask parents to provide you with what works best for their child • TREAT ON THE SPOT-DON’T DELAY • Check blood glucose (BG) level 10 to 15 minutes later • Repeat treatment if BG is below student’s target range

48. Severe Hypoglycemia • Symptoms of severe hypoglycemia: • Inability to swallow • Seizure or convulsion • Unconsciousness • Uncooperative • This is the most immediate danger to kids with diabetes

49. Severe Hypoglycemia Response: • Position student on side • Contact school nurse or trained diabetes staff • Administer prescribed glucagon (injection for extremely low blood sugar) • Call 911 • Call student’s parents

50. Hyperglycemia (High Blood Sugar) • Symptoms of hyperglycemia: • Increased thirst • Frequent urination • Nausea • Blurry vision • Fatigue • Complaints of headache or weakness • Usually occurs with blood sugar >220-240