Schools pushed to improve diabetics' care

Policies against food, sharps in class can jeopardize vulnerable young patients.

By Victoria Stagg Elliott, amednews staff. May 20, 2002.

Shannon Oates, MD, an endocrinologist with Arnett Clinic in Lafayette, Ind., has met with school boards and written letters to teachers and principals in order to get permission for her patients with diabetes to test their blood sugar in the classroom. She has also fought for their right to have glucose tablets and food in their desk so they can deal with low blood sugar quickly.

"You've got to be a pit bull for your patients," said Dr. Oates. "My worst case was this kid who had to walk all the way across campus with low blood sugar -- about to pass out -- to get tested by the secretary.... That is not good enough."

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Physicians are increasingly having to deal with how school policies affect diabetics because of the convergence of two trends: a shift in philosophy in how type 1 diabetes is cared for and an increase in the number of young people with type 2.

For those with type 1, treatment regimens have shifted to an emphasis on tight control. Many school-age patients now find themselves having to figure out ways to receive a dose of insulin midday. In addition, there is the challenge of having to check blood sugar more frequently.

"We're having to be more aggressive now because in the past insulin shots weren't traditionally given at lunch time," said Andy Muir, MD, associate professor in pediatric endocrinology at the University of Florida in Gainesville. "With the push towards intensive control, there's a lot of people who want to give insulin and check blood sugars and really do intensive treatment for the five or six hours a day they're at school." Dr. Muir presented a workshop on the issue at the May annual meeting of the American Association of Clinical Endocrinologists in Chicago.

In addition, type 2 diabetes was unheard of in the school setting until a few years ago. Now, though, its incidence is escalating significantly in connection with the obesity epidemic.

As obesity among kids increases, so does type 2 diabetes.

"Type 2's may not be on insulin, but they'll probably still have to be testing," said Leann Olansky, MD, a professor of medicine in endocrinology at the University of Oklahoma School of Medicine in Oklahoma City.

Many schools ban food in the classroom. Lancets used for glucose monitoring are sometimes classified as weapons because of fears that they may be used to cut someone or transmit bloodborne disease.

Physicians say these kinds of policies impair their patients' ability to deal quickly with low blood sugar or monitor their status in the classroom without a trip to the school nurse or other designated adult.

"Kids bleed at school all the time. A kid testing their blood sugar should not be a big deal," said Dr. Olansky. "We need to step up our ability to treat in schools."

AACE has not taken an official position on these issues, but many of those at the annual meeting feel that it may be time for schools to become more flexible with their policies.

"The child with diabetes misses part of class, lunch or physical education on a daily basis," said Dr. Muir. "The goal is to make diabetes care as easy as possible so the patients can carry out this invasive treatment without turning their lives upside down."

Physicians are concerned about schools offering more soda and snacks and less physical activity.

Physicians concede that, in line with teachers' fears, some of their patients will use their disease to get out of class or take other privileges. But, for the most part, the policies are an onerous burden. Doctors are concerned about the distance between the classroom and the nurse's office -- particularly if a student has low blood sugar. Most adolescents also avoid asking to be allowed to see the school nurse because they don't want to bring attention to their disease.

"The children don't want to be singled out, and it's inappropriate care," said Dr. Oates.

There are signs of change. The National Assn. of School Nurses adopted a policy last year advocating easy access to blood sugar monitoring, and an increasing number of school districts are allowing it. But physicians say many schools and teachers are still skittish and instead prefer to send kids down the hall. "Some schools and some teachers are just incredibly insensitive to the needs of kids with diabetes," said Dr. Olansky.

But while many doctors are looking to improve treatment during the school day, some also want schools to play a larger role in preventing type 2, which they believe is fueled in part by the growing availability of sodas and unhealthy snacks on campuses and a decline in physical activity.

"School PE programs are disappearing," said Dr. Muir. "Kids are being targeted by marketing pressure, and they're suffering health consequences because of it."