Diabetes Overview

In this section

• I. Types of Diabetes
  • A. Type 1
  • B. Type 2
• II. Effective Diabetes Management in Schools2
  • A. Effective Diabetes Management
  • B. Planning and Implementing Effective Diabetes Management
  • C. Federal and State Laws
  • D. School Plans
  • E. Elements of Effective Diabetes Management
    • 1. Monitoring Blood Glucose Levels
    • 2. Nutrition
    • 3. Physical Activity
    • 4. Planning Beyond the School Day
    • 5. Social and Emotional Aspects of Diabetes
    • 6. Promoting Student Independence
  • F. Diabetes Management Training for School Personnel
• References

 

Diabetes is a disorder of metabolism — the way in which the body converts food into energy. The body breaks food down by digestive juices into the fuel components needed to survive, including a sugar called glucose. Glucose is the body’s main source of energy. After digestion, glucose passes into the bloodstream, where it is available for cells to take in and use or store for later use (Kinder, 2012).

In order for cells to take in glucose, a hormone called insulin must be present in the blood. Insulin acts as a “key” that unlocks “doors” on cell surfaces to allow glucose to enter the cells. Special cells (islet cells) produce insulin in an organ called the pancreas, which is about six inches long and lies behind your stomach.

For people without diabetes, the pancreas automatically produces the right amount of insulin to enable glucose to enter cells. For people with diabetes, the body does not make or properly use insulin. If glucose cannot get inside cells, it builds up in the bloodstream. The buildup of glucose in the blood - sometimes referred to as high blood sugar or hyperglycemia (which means “too much glucose in the blood”) - is the hallmark of diabetes.

When blood glucose goes above a certain level, the excess glucose flows out from the kidneys (the organs that filter wastes from the bloodstream) into the urine. The glucose takes water with it, which causes frequent urination and great thirst. These two conditions - frequent urination and unusual thirst - are usually the first noticeable signs of diabetes. Weight loss often follows, resulting from the loss of calories and water in urine.

When the body no longer make insulin is no longer made, it must be obtained from another source – insulin injections or an insulin pump. When the body does not use insulin properly, oral medications may be taken instead of, or in addition to, insulin injections. However, neither insulin nor other medications are cures for diabetes; they only help control the disease.

Diabetes management balances careful control of diet, exercise, and medication. Careful monitoring and prompt intervention are necessary to prevent life threatening hypoglycemic episodes and long-term complications such as heart disease, kidney failure, retinopathy, and serious impairment of circulation that may require amputations (Connecticut Department of Public Health, 2012)

 

I. Types of Diabetes

Diabetes occurs in several different forms. This manual focuses primarily on issues related to type 1 diabetes in children.

All children with diabetes must be allowed to participate fully in all school activities. They need the cooperation and support of school staff members to help them with their treatment plan.

 

A. Type 1 Diabetes

Type 1 diabetes usually has a very rapid onset. It was previously called Juvenile Diabetes because most people develop it as children or teenagers.

The immune system is the body’s system for fighting infection. In people with type 1 diabetes, the immune system attacks the beta cells (the insulin-producing cells of the pancreas) and destroys them. Since the pancreas can no longer produce insulin, people with type 1 diabetes need to take insulin daily to live. Type 1 diabetes can occur at any age, but it occurs most often in children and young adults.

There is no single way to treat type 1 diabetes. Because each child’s life events vary, experienced diabetes teams are necessary to set up individualized treatment plans. For treatment plans to be most successful, an insulin regimen will be tailored to the needs of the child, as will a meal plan and recommendations for physical activity. New information on diabetes management allows people with diabetes to be more liberal with food planning.

 

 

Blood glucose monitoring is essential to help assess how well the treatment plan is working. Most children can perform blood glucose checks by themselves but may need a private place to do so. Some children may need supervision from the school nurse to see that the procedure is done properly and results are recorded accurately. How often the child checks or whether he/she checks at school at all are decisions made by the child’s parents/guardians and physician and supported by school personnel.

It is the board of education’s responsibility to ensure that staff, including nursing staff, has adequate training and the updated skills necessary to best assist children with diabetes. The school nurse can then recognize when additional training is needed to perform a particular procedure and to help determine where appropriate training can be obtained.

Note: Although the terms “blood glucose testing” and “blood glucose checking” are also common terms, this manual uses the term “blood glucose monitoring.”

Symptoms of Type 1 Diabetes

Symptoms usually develop over a short period of time. They include increased thirst and urination, constant hunger, weight loss and blurred vision. Affected children may also feel very tired all the time. If not diagnosed and controlled with insulin, the child with type 1 diabetes can lapse into a life-threatening condition known as diabetic ketoacidosis (DKA).

Risk Factors

Although scientists have made much progress in predicting who is at risk for type 1 diabetes, they do not yet know what triggers the immune system’s attack on beta cells. They believe that type 1 diabetes is due to a combination of genetic and environmental factors. Researchers are working to identify these factors and stop the autoimmune process that leads to type 1 diabetes.

 

B. Type 2 diabetes

Type 2 diabetes is the most common form of the disease, representing 90-95 percent of people with diabetes. It was previously known as adult-onset or non-insulin dependent diabetes because it most often occurs in overweight adults ages 40 or older. Now, as more children and adolescents in the United States become overweight and inactive, type 2 diabetes occurs more often in young people. To control their diabetes, children with type 2 diabetes may need to take oral medication, insulin or both.

The first step in the development of type 2 diabetes is often a problem with the body’s response to insulin, called insulin resistance. For reasons scientists do not completely understand, the body cannot use insulin very well. This means that the body needs increasing amounts of insulin to control blood glucose. The pancreas tries to make more insulin, but after several years, insulin production may drop off.

Symptoms of Type 2 Diabetes

Symptoms may develop slowly or quickly, and may be similar to those of type 1 diabetes. A child or teen may feel tired, thirsty or nauseated and urinate often. Other symptoms include rapid weight loss, blurred vision, frequent infections, yeast infections and slow healing of wounds or sores. High blood pressure may be a sign of insulin resistance. In addition, physical signs of insulin resistance include acanthosis nigricans, where skin around the neck, armpits or groin appears dark, thick and velvety. On the other hand, some children or adolescents with type 2 diabetes show no symptoms at all when they are diagnosed. For that reason, it is important for parents and caregivers to talk to their health care providers about screening children or teens at high risk for diabetes.

Risk factors

Being overweight and having a family member who has type 2 diabetes are the key risk factors. In addition, type 2 diabetes is more common in certain racial or ethnic groups, such as African Americans, Hispanic/Latino Americans, American Indians, Asian Americans and Pacific Islander Americans. For children and teens at risk, health care providers can encourage, support and educate the entire family to make lifestyle changes that may delay or prevent the onset of type 2 diabetes. Such changes include reaching and maintaining a healthy weight and engaging in regular physical activity.

Taking care of diabetes is important. If not treated, diabetes can lead to serious health problems. The disease can affect the blood vessels, eyes, kidneys, nerves, gums and teeth, and is the leading cause of adult blindness, lower limb amputations and kidney failure. People with diabetes also have a higher risk of heart disease and stroke. Some of these problems can occur in teens and young adults who develop diabetes during childhood. However, research shows that these problems can be greatly reduced or delayed by keeping blood glucose levels near normal.

 

II. Effective Diabetes Management in Schools

A. Effective Diabetes Management

The goal of effective diabetes management is to control blood glucose levels by keeping them within a target range that is determined for each child. Optimal blood glucose control helps to promote normal growth and development and allows for optimal learning. Effective diabetes management is needed to prevent the immediate dangers of blood glucose levels that are too high or too low.

The key to optimal blood glucose control is to carefully balance food, exercise and insulin or medication. As a general rule, food makes blood glucose levels go up, and exercise and insulin make blood glucose levels go down. Several other factors, such as growth and puberty, mental stress, illness or injury also can affect blood glucose levels.

The key to optimal blood glucose control is to carefully balance food, exercise, and insulin or medication.

Students with diabetes must monitor their blood glucose levels throughout the day by using a blood glucose meter. The meter gives a reading of the level of glucose in the blood at the time it is being checked. If blood glucose levels are too low (hypoglycemia) or too high (hyperglycemia), students can then take corrective action such as eating, modifying their activity level or administering insulin. Low blood glucose levels, which in rare cases, can be life-threatening, present the greatest immediate danger to people with diabetes (see hypoglycemia).

Many students can 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 in the school setting to provide care for a student with diabetes. However, diabetes management is needed 24 hours a day, 7 days a week and diabetes emergencies can happen at any time. More importantly, the school nurse may not always be available. Therefore, the board of education should identify appropriate school personnel to be prepared to respond to emergencies at school and at all school-sponsored activities in which a student with diabetes participates. In this case, the school nurse should ensure proper training of qualified school employees and provide professional supervision and consultation regarding routine and emergency care of the student.

 

B. Planning and Implementing Effective Diabetes Management

Collaboration, cooperation and planning are key elements in developing and implementing successful diabetes management at school. 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.Local school districts probably have similar plans and systems in place for children with other health considerations.

To work collaboratively, the school district should assemble a school team that includes people who are knowledgeable about diabetes, the school environment and federal and state education and nursing laws. Team members may include the student, parents/guardian, the school nurse, school food service and other health personnel, administrators, the principal, the student’s teacher(s), guidance counselor and other relevant staff.

This team works together to implement the recommendations developed by the student’s personal health care team and family. The team decides who needs to receive appropriate medical information about the child, and who will be trained by the nurse to assist with monitoring and performing certain tasks. In addition, the school team should be part of the group that develops and implements the student’s Individual Health Care Plan, Emergency Care Plan, Section 504 Plan (if needed), Individualized Education Program (IEP) or other education plan that addresses the student’s developmental and educational needs so that diabetes can be managed safely and effectively in school. The plan is based in part on the student’s medical recommendations, sometimes called a Diabetic Medical Management Plan (DMMP), as well as recommendations from the team.

 

C. Federal and State Laws

A number of laws address the school district’s responsibilities to help students with diabetes on a case-by-case basis. Under certain federal laws, any school that receives federal funding must reasonably accommodate the special needs of children with diabetes. If found eligible for services, federal law requires an individualized assessment and reasonable accommodation within the child’s usual school setting with as little disruption as possible to the school’s and child’s routines, in a way that allows the child to fully participate in all school activities.

Schools have a responsibility to be knowledgeable about all relevant state and federal laws, and about how they impact policies in this area. Brief descriptions of the most relevant state and federal laws follow.

CGS 10-212a Administration of Medications in Schools. This statute pertains to the administration of medications in the school setting. This statute addresses who may prescribe medications and who may administer medications in the school setting.

The Regulations of Connecticut State Agencies Section 10-212a-1 through 10-212a-10 Administration of Medications by School Personnel and Administration of Medication During Before- and After-School Programs and School Readiness Programs.These regulations provide the procedural aspects of medication administration in the school setting. The regulations include definitions within the regulations; the components of a district policy on medication administration; the training of school personnel; self-administration of medications; handling, storage and disposal of medications; supervision of medication administration; administration of medications by coaches and licensed athletic trainers during intramural and interscholastic events; administration of medications by paraprofessionals and administration of medication in school readiness programs and before- and after-school programs.

Public Act No. 12-198 (HB 5348) An Act Concerning the Administration of Medicine to Students with Diabetes, the Duties of School Medical Advisors, the Availability of CPR and AED Training Materials for Boards of Education and Physical Exercise During the School Day.This Act allows a qualified school employee selected by the school nurse or principal to administer an emergency glucagon injection to a student with diabetes, under certain conditions and with a written authorization from the student's parents and a written order from the student's Connecticut-licensed physician. The Act also bars a school district from restricting the time or place on school grounds where a student with diabetes may test his or her blood-glucose levels, if the student has written permission from his parents or guardian and a written order from a physician.

The Act extends required educational guidelines for school districts in how to manage students with life-threatening allergies to cover students with glycogen storage disease. It requires the State Department of Education and the Department of Public Health to issue the new guidelines by July 1, 2012, and school districts to develop individualized health care and glycogen storage disease action plans for their students with the disease by August 15, 2012. The plans must allow parents or guardians of students with the disease, or those they designate, to administer food or dietary supplements to their children with the disease on school grounds during the school day. The Act bars claims against towns, school districts, and school employees for damages resulting from these actions.

The Americans with Disabilities Act (ADA) prohibits discrimination against any individual with a disability. Section 504 of the Rehabilitation Act of 1973 further protects the rights of children with disabilities, requiring reasonable accommodations that allow for the provision of a “free and appropriate public education” (FAPE). This legislation applies to all programs and activities receiving federal financial assistance, including public schools. Children are eligible for accommodations through Section 504 if they have a physical or mental impairment that substantially limits a major life activity. Major activities may include walking, seeing, hearing, speaking, breathing, learning, working, caring for oneself, and performing manual tasks. Children with diabetes are often considered eligible because of their special metabolic and dietary requirements. It is not required that the student receive special education services to be eligible for other services.

The Individuals with Disabilities Education Act of 1976 (IDEA) provides financial assistance to state and local agencies for educating students with disabilities. Children are eligible if they fit one or more of the 13 categories of disability and if, because of the disability, they require special education and related services. The category that most often applies to children with diabetes is Other Health Impaired (OHI). This is defined as “having a limited strength, vitality or alertness, including heightened alertness to environmental stimuli, that results in limited alertness with respect to the education environment, that 1) is due to a chronic or acute health problem; and 2) adversely affects a child’s educational performance.”

The Family Education Rights and Privacy Act of 1974 (FERPA) protects the privacy of students and their parents by restricting access to school records in which individual student information is kept. This act sets the standard for the confidentiality of student information. FERPA also sets the standards for notification of parents and eligible students of their rights with regards to access to records, and stipulates what may or may not be released outside the school without specific parental consent. Within schools, FERPA requires that information be shared among school personnel only when there is a legitimate educational interest.

Public schools in Connecticut are required to meet standards set by the Occupational Safety and Health Administration (OSHA), a regulatory agency within the United States Department of Labor. These standards include the need for procedures to address possible exposure to blood-borne pathogens. Under OSHA regulations, schools are required to maintain a clean and healthy school environment. Schools must adhere to Universal Precautions designed to reduce the risk of transmission of blood-borne pathogens, which include the use of barriers such as surgical gloves and other protective measures when dealing with blood and other body fluids or tissues.

These federal laws provide a framework for planning and implementing effective diabetes management in the school setting. School administrators and nursing personnel also should determine whether there are applicable state and local laws that should be factored into helping the student with diabetes.

 

D. School Plans

Schools have a responsibility to be knowledgeable about all relevant state and federal laws and how they affect policies in this area.

The CSDE recommends that schools develop a plan for accommodating the health needs of children with diabetes. These plans should be based in part on the student’s health care provider’s medical management plan, sometimes called Diabetic Medical Management Plan (DMMP). The DMMP is completed by the student’s parents/guardians and the health care provider. It generally includes how to recognize and treat hypoglycemia and hyperglycemia as well as specific orders for blood glucose monitoring, administration of insulin and the steps to take in an emergency.

A written school plan for each student’s diabetes management helps the student, their families, school staff and the student’s health care providers know what is expected of them. These expectations should be specified in writing in the documents below as determined by the team.

• Individual Health Care Plan (IHCP) – The IHCP describes how the school intends to meet an individual child’s daily health and safety needs in all contexts, while under the care of the school. IHCPs are developed by the school nurse, in conjunction with parents, the student, healthcare providers, and other school personnel. IHCPs are usually developed for students with multiple health needs or whose health needs require daily intervention. The plan includes a summary of health assessments, a nursing diagnosis, goals and plans of action covering the range of possible concerns. It is also used to document interventions and evaluate outcomes.
• Emergency Care Plan (ECP) – The ECP is based on the information provided by the student’s health care provider, family and school team. The ECP describes how to recognize hypoglycemia and hyperglycemia and what to do as soon as signs or symptoms of these conditions are observed. The ECP is often part of the IHCP. Emergency care plans provide specific directions about what to do in an emergency. These written plans assist the school nurse, school personnel and emergency responders react to an emergency situation in a prompt, safe and individualized manner.
• Education plans – These plans, such as the Section 504 Plan or Individualized Education Program (IEP), explain what accommodations, education aids and services might be necessary for each student.

This information should be reviewed, along with the student’s IHCP and/or 504 Plan and updated each school year or upon a change in the student’s prescribed regimen, level of self-management, school circumstances (e.g., a change in schedule) or at the request of the student or parents/guardian.

 

 

E. Elements of Effective Diabetes Management

Effective diabetes management entails:

• monitoring or checking blood glucose levels throughout the day;
• following an individualized meal plan, getting regular physical activity; and
• administering insulin and/or other medications to help keep blood glucose levels in the target range and to help prevent the onset of hypoglycemia or hyperglycemia.

Additional elements of diabetes management in school include planning for events outside the usual school day, planning for appropriate disposal of materials that come in contact with blood and dealing with the emotional and social aspects of living with diabetes.

Each student with diabetes has different needs, but school plans developed for such students are likely to include the following common elements:

• where and when blood glucose monitoring and treatment will take place (per parent/guardian written authorization and physician’s orders);
• identification of school personnel who are trained to assist the student on a daily basis and in the event the school nurse is absent or unavailable;
• location of the student’s diabetes management supplies;
• ensuring unlimited access to the restroom and water fountain;
• discussion of nutritional needs, including provisions for meals and snacks;
• issues related to full participation in all school-sponsored activities and field trips;
• accommodations such as alternative times for academic exams if the student is experiencing hypoglycemia or hyperglycemia;
• permission for absences by the local board of education, without penalty, for doctors’ appointments and diabetes-related illness; and
• maintenance of confidentiality and the student’s right to privacy.

1. Monitoring Blood Glucose Levels

Students usually check their blood glucose:
• before eating snacks or meals;
• before physical activity;
• when they have symptoms of high or low blood glucose.

Blood glucose monitoring is a necessary and useful tool in the management of diabetes. Blood glucose monitoring may be done with a small device called a blood glucose meter. Monitoring helps identify patterns in blood glucose fluctuation and detect acute problems of high or low blood sugar. Students often monitor their blood glucose every time they eat a meal to help them decide how much insulin to take at that time. There are numerous brands of monitors available, each with specific features that an individual may find useful. Since the school nurse plays an integral role in assisting children with diabetes in their tasks of daily management while at school, he or she must become familiar with the various monitors being used. To monitor glucose levels, a drop of blood is required. This can be obtained from fingers, arms and legs.

Self-monitoring

The benefits of allowing blood glucose self-monitoring are significant. Students learn better when their blood glucose levels are within the proper range. It is important for schools to address the issue of locations of self-monitoring, as Connecticut law bars a school district from restricting the time or place on school grounds where a student with diabetes may test his or her blood-glucose levels, if the student has written permission from his parents or guardian and a written order from a physician. Students who self-monitor in the classroom or in other locations outside the school health office can more readily adjust their blood sugar levels. They spend less time out of class and thus lose out on fewer learning opportunities provided to children without diabetes. They also gain independence and self-confidence, and experience fewer stigmas when monitoring is treated as a regular occurrence.

The CSDE’s Guidelines for Blood Glucose Self-Monitoring in School(see Appendix G) provides valuable guidance to school districts regarding self-monitoring blood glucose and is located on the CSDE Health Promotion Services/School Nurse Web site.

Appropriate Blood Sugar Levels

For a person who does not have diabetes, a normal fasting blood glucose level is 70-100 milligrams/deciliter (mg/dl). It will increase after meals, but usually not higher than 140 mg/dl. Blood sugar levels in a child with diabetes will vary depending on insulin action times, food consumed, activity level and illness. The student’s diabetes health care professional will advise the child’s family on an appropriate target range. The goal is for the blood sugar to fall within the target range the majority of the time. It is common for children with diabetes to experience fluctuations of their blood sugar levels outside their target range. The child’s diabetes care plan should include his/her target range and outline corrective actions when the blood glucose level is outside the target range.

An important way to understand how well diabetes is being managed is by tracking the Estimated Average Glucose (eAG). EAG is the new way of reporting A1C test, the test that reports the average blood glucose over a period of two to three months. A1C is reported as a percentage value; whereas, eAG uses the same units (mg/dl) as glucose meters. Using eAG may help students gain a better idea of how well they are taking care of their diabetes, if they are meeting their target range and can help their health care provider know if changes need to made (American Diabetic Association, 2012).

Understanding Hypoglycemia (low blood glucose)

Hypoglycemia is one of the most frequent complications of diabetes and can happen very suddenly.

Hypoglycemia, also called “low blood glucose” or “low blood sugar,” is one of the most frequent complications of diabetes and can happen very suddenly. Hypoglycemia is a blood glucose level less than 70 mg/dl. This is the greatest immediate danger to students with diabetes; sometimes it cannot be prevented. Hypoglycemia occurs when a student’s blood glucose level falls too low, usually as a result of administering too much insulin, skipping or delaying meals or snacks, not eating enough food as prescribed in the meal plan, exercising too long or too intensely or a combination of two or more of these factors. It is more likely to occur before lunch, at the end of the school day or during or after physical education classes. Hypoglycemia usually can be treated easily and effectively with food, non-diet drinks or glucose tablets. If it is not treated promptly, however, hypoglycemia can lead to unconsciousness and convulsions. Early recognition of its symptoms and prompt treatment, in accordance with the student’s IHCP, are necessary for preventing severe symptoms that may place the student in danger. The information contained in the ECP, should be provided to all school personnel who have responsibility for the student with diabetes (see Appendix A for sample health care plans).

Students should never be left alone or sent anywhere alone (or with another child) when experiencing hypoglycemia.

Not all students, especially young children, will recognize the symptoms of hypoglycemia with every episode. Therefore, school personnel should be familiar with the symptoms and treatment so that an urgent problem can be handled appropriately. Hypoglycemia can impair thinking abilities and sometimes can be mistaken for misbehavior. If a student has a sudden change in behavior, becomes lethargic, combative, or unconscious or is having a seizure or convulsion, presume that the student has hypoglycemia. Treat the situation as a hypoglycemic emergency and check the student’s blood glucose level immediately. If a blood glucose meter is not available in the immediate area, or if the blood glucose level is otherwise unknown, treat the student for hypoglycemia. The student should never be left alone or sent anywhere alone when experiencing hypoglycemia .

What to Do for a Child who is Showing Signs and Symptoms of Mild Hypoglycemia (40-70mg/dl)

Optimally, check blood glucose before treating a child suspected of hypoglycemia. When in doubt, treat. If the child’s hypoglycemia is above 40 mg/dl, give the child some quick-acting sugar (15 grams of carbohydrate), such as one of the following:

• ½ cup (4 fluid ounces) of juice;
• ¾ cup (6 fluid ounces) of REGULAR (not diet) soda;
• 3-4 glucose tablets;
• 4-5 small jelly beans or gum drops;
• 1 mini box of raisins; or
• 1 cup (8 fluid ounces) low fat or skim milk.

What to Do for a Child with Moderate Hypoglycemia (less than 40mg/dl) but Responsive

If the child’s blood glucose levels are 40 mg/dl or less and the child is still responsive and able to swallow and follow directions, double the treatment amounts indicated above. If the child has difficulty following directions or eating, but can swallow, administer an entire tube of glucose gel in between his or her cheek and gums and gently rub to be sure the sugar is being absorbed. Follow with food.

In any of the above cases, check blood glucose 15 minutes after treatment. If the blood glucose result is still less than 70 mg/dl or if the child still has symptoms, repeat the quick sugar treatment and blood glucose testing cycle until the child is symptom free and the blood glucose result is above 70 mg/dl. This can be summarized as the “Rule of 15.” Give 15 grams of carbohydrate, wait 15 minutes and then recheck. If the blood glucose is still less than 70 mg/dl, repeat the cycle giving another 15 grams of carbohydrate and rechecking in 15 minutes.

“Rule of 15”
• Give 15 grams of carbohydrate.
• Wait 15 minutes, and then recheck blood glucose.
• If still less than 70 mg/dl, repeat another 15 grams of carbohydrate.
• Wait 15 minutes and then recheck.

When the child feels better and blood glucose levels have risen to above 70 mg/dl, give one of the following if the child’s next meal is more than one hour away and if the child will be participating in active play or sports:

• 4 graham cracker squares with peanut butter or cheese;
• 6 saltine crackers with peanut butter or cheese; OR
• an equivalent combination of carbohydrate (15 grams) and protein (1 oz.).

The child may return to class after the blood glucose is above 70 mg/dl and he or she no longer has symptoms.

What to Do for A Child who is Showing Signs and Symptoms of Severe Hypoglycemia

Be sure the child is lying down in a safe area protected from injury. Position the child on his or her side. Call 911 and the appropriate emergency contacts, as described in the student’s ECP. Follow the steps outlined in the ECP, including use of glucagon or the treatment specified in the medical orders. Instaglucose may also be placed inside cheeks and rub in. Do not attempt to put anything between the teeth. As the child regains consciousness, nausea and vomiting may occur.

What is Glucagon?

Glucagon is a hormone that causes the liver to release sugar into the blood. It is used to raise the blood sugar when a child is unable to take liquids or food by mouth because of severe sleepiness, unconsciousness or seizure activity. Glucagon must be injected with a syringe into the skin like insulin. It should be administered as soon as possible. Glucagon is the medically endorsed treatment of choice for severe hypoglycemia. Other options and alternatives include glucose gel or other glucose supplements. It is important to remember that the risk of not giving Glucagon is more life-threatening than giving it under these emergency conditions. 

 

If the school nurse is absence or unavailable, “qualified school employees” may administer glucagon to a student with diabetes who may require prompt treatment in order to protect against serious harm or death. No “qualified school employee” shall administer medication unless:

• such qualified school employee annually completes any training required by the school nurse and school medical advisor in the administration of medication with injectable equipment used to administer glucagon;
• the school nurse and school medical advisor have attested, in writing, that such qualified school employee has completed such training; and
• such qualified school employee voluntarily agrees to serve as a qualified school employee (Public Act No. 12-198 An Act Concerning the Administration of Medicine to Students with Diabetes, the Duties of School Medical Advisors, the Availability of CPR and AED Training Materials for Boards of Education and Physical Exercise During the School Day) .

If glucagon is not ordered, glucose gel may be an appropriate substitute for non-nursing school staff. Glycemic effects of glucagons are short lived so once the student is able to swallow, a carbohydrate liquid (such as juice, low-fat milk) should be given according the student’s IHCP or ECP.

Understanding Hyperglycemia (High Blood Glucose)

Symptoms of hyperglycemia:

• Increased thirst
• Frequent urination
• Nausea
• Blurred vision
• Fatigue

Hyperglycemia, also called “high blood glucose,” or “high blood sugar,” is a serious manifestation of diabetes that may be caused by too little insulin, illness, infection, injury, stress or emotional upset, ingestion of food that has not been covered by the appropriate amount of insulin or decreased exercise or activity. High blood glucose symptoms include increased thirst, frequent urination, nausea, blurry vision, and fatigue. In the short term, hyperglycemia can impair cognitive abilities and adversely affect academic performance. Over a long period of time, even moderately high blood glucose levels can lead to serious complications, such as heart disease, blindness, kidney failure and amputations.

Hyperglycemia does not usually result in acute problems. If, however, the student fails to take insulin, if a pump malfunctions and fails to deliver or delivers less insulin or if either physical or emotional stress causes the insulin not to work effectively, there will be a breakdown of fat, causing ketones (organic compounds that result when body fat is broken down for energy) to form.

Ketones will initially be cleared by the kidneys into the urine, but if there are more than the kidneys can handle, they will build up in the blood and may result in diabetic ketoacidosis (DKA). This complication will cause a fruity breath odor, nausea, vomiting, stomach pain and, if untreated, deep breathing and increasing sleepiness. Students who use insulin pumps can go into DKA within hours if their pumps stop delivering insulin appropriately.

DKA can be prevented if the student’s urine or blood is checked for ketones during times of illness, especially if vomiting occurs, or whenever the blood glucose level exceeds the target range provided in the IHCP. The test involves dipping a special strip into the urine and comparing the resulting color to a color chart or by blood ketone testing.

Treatment of hyperglycemia may involve drinking extra water or diet drinks or administering supplemental insulin in accordance with the student’s healthcare provider’s orders. 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.

The student’s blood glucose level should be monitored closely until it returns to the target range specified in the IHCP. If treatment does not lower blood glucose levels and clear the ketones, if vomiting occurs or if the student is lethargic or experiences breathing difficulties, the school nurse or qualified school employee should call the parents/guardian or call for medical assistance, as outlined in the IHCP/ECP. Treatment guidelines for ketones and when to call parents should be listed in the student’s IHCP/ECP. Information about the symptoms and treatment of hyperglycemia, contained in the ECP should be provided to all school personnel who have responsibility for the student with diabetes (see Appendix A for sample health care plans).

Administering Insulin

Students with type 1 diabetes and some students with type 2 diabetes require insulin to be given at regular times each day. Some students may need additional or corrective dosages of insulin to treat hyperglycemia or to cover a rise in blood glucose levels. The IHCP should specify the dosage, delivery system and schedule for insulin administration, which will differ for each student as prescribed by their health care provider, as well as specify who will administer prescribed insulin and under what circumstances.

 

 

Today, new types of insulin and new delivery systems do a better job of keep blood glucose levels within target range. These options may require closer monitoring and possibly more assistance for students with diabetes. There are several types of insulin that are used in combination to treat people with diabetes. These different types of insulin have been manufactured either to have immediate (rapid-acting or short-acting insulin), intermediate or long (basal insulin) onset and duration of action in the body. A coordinated combination of insulin is used to allow for adequate treatment of diabetes at meals, snacks, during periods of physical activity and through the night (see Appendix C for types and characteristics of insulin.)

Opened vials of insulin should be refrigerated or may be left at room temperature for 30 days after opening. Unopened vials should be stored in the refrigerator and are good until the expiration date (see Appendix C for insulin storage and disposal.)

Insulin Administer Techniques

• Insulin syringes make it easy to draw up the proper dosage and shorter, smaller needles make injections easier and relatively painless.
• An insulin pen looks like a fountain pen. The pen holds a cartridge of insulin and a needle is screwed onto its tip just before use. Insulin pens are convenient and most appropriate when children need a single type of insulin.
• An insulin pump is a computerized device that looks like a pager and is usually worn on the student’s waistband or belt. The pump is programmed to deliver small, steady doses in insulin throughout the day. Additional doses are given to cover food or high blood glucose levels. The pump holds a reservoir of insulin attached to a system of tubing called an infusion set. Most infusion sets are started with a guide needle, then the plastic cannula (a tiny flexible plastic tube) is left in place, taped with dressing and the needle is removed. The cannula is usually changed every two or three days or when the blood glucose levels remain above target range. More students are opting for insulin pump therapy to keep blood glucose levels in better control (see Appendix C for information on insulin delivery systems).

 

 

Some students who need insulin during the school day are able to administer it on their own; others need supervision; and some need someone to administer the insulin for them. The school nurse should provide this help in accordance with the IHCP. School personnel who are responsible for the student’s care should be knowledgeable about the student’s insulin delivery system and how to respond to an emergency.

When a school nurse is not available to administer insulin and the student is not able to administer his/her own insulin, the school needs to develop alternative plans. In some circumstances, the parent or other immediate family member (such as the grandparent) is available to come into school during the school day to administer the child’s insulin. When the school nurse or parent is not available to administer the insulin, the plan may identify a school nurse in a nearby school that would be available for both routine administration of insulin or emergencies.

For students with type 2 diabetes, treatment may commonly involve oral medication and less frequently, administration of insulin.

 

2. Nutrition

Nutrition is one of the cornerstone treatments of diabetes. The goals of nutrition therapy include an adequate caloric and nutritional intake for growth and development and the balance of food with insulin and activity to achieve target blood glucose levels.

Children with diabetes have the same nutritional needs as children without diabetes. A meal plan must be developed to meet the individual needs of the child, taking into consideration food preferences, cultural influences, family eating patterns and schedules, weight, activity level and insulin action peaks. All family members can benefit from these healthy eating guidelines.

MyPlate is the United States Department of Agriculture’s (USDA) food guidance system to translate the Dietary Guidelinesfor Americans into a healthy eating plan. MyPlate emphasizes consuming more fruits, vegetables, whole grains and low-fat dairy. MyPlate illustrates the five food groups that are the building blocks for a healthy diet using a familiar image—a place setting for a meal. The five food groups include:

• fruits;
• vegetables;
• grains;
• protein foods; and
• dairy (USDA, 2012).

For more information about MyPlate, visit the USDA’s Web site.

 

 

The recommendations in the Dietary Guidelines and MyPlate are for Americans ages 2 and older. MyPlate helps individuals use the Dietary Guidelines to:

• Make smart choices from every food group.
• Find balance between food and physical activity.
• Get the most nutrition out of calories.
• Stay within daily calorie needs (USDA, 2011, ChooseMyPlate).

 

 

Special Nutrition Issues

• School Meals: Children with diabetes may participate in the USDA school nutrition programs, e.g., National School Lunch program, School Breakfast Program and Afterschool Snack program. Parents/guardians can review school menus ahead of time and request modifications for their child as needed, based on a medical statement provided by a licensed physician. Parents/guardians are encouraged to contact the school food service director for more information on school meals.
• After School: Children should have a snack readily available if staying after school. Parents/guardians are responsible for providing the snack and should notify school personnel that the child may need to eat during the session. A physician’s order may also be necessary.
• School Parties: Children with diabetes should be included in school parties; however, this may require advance planning. Sweets can be eaten on a special occasion such as a birthday party or Halloween party. The carbohydrates should be included as part of the child’s meal plan. The parent/guardian should provide a list of foods for special occasions in the child’s meal plan, if the parents/guardians have not supplied an alternate snack for their child.
• Field Trips: Whenever on a field trip, children should have a snack readily available. Bus drivers and chaperones should be notified by the school staff that the child has diabetes and may need to eat a snack during the trip. Parents are responsible for providing the snack. (For information on general guidance for field trips, see Planning Beyond the School Day).

Following an Individualized Meal Plan

The nutritional needs of students with diabetes do not differ from the needs of students without diabetes. Both should eat a variety of foods to maintain normal growth and development. The major difference is the timing, amount and content of food eaten by students with diabetes are carefully matched to the action of the insulin.

The CSDE recommends that children see a Registered Dietitian (preferably a Certified Diabetes Educator) once a year to create an individualized meal plan based on carbohydrate counting or an exchange system. The student’s meal plan is designed to balance nutritional needs with the insulin regimen and physical activity level. There are usually no forbidden foods for people with diabetes. The meal plan should include three meals and two to three snacks with a specific amount of carbohydrate. The meals and snacks should be timed appropriately with the peak of the child’s insulin. Each child needs a certain amount of carbohydrate based on age, size, gender and activity level.

Carbohydrate counting involves calculating the number of grams of carbohydrate or choices of carbohydrate the student eats. This information can be obtained from nutrition information on food labels and is used to determine the amount of insulin the student needs to control blood glucose for any given meal or snack.

The exchange system groups foods in six categories, each with a set nutritional value. A meal plan is prepared that recommends several exchanges or servings from each group for each meal and snack. The exchange system ensures that the meal plan is consistent in portion size and nutrient content while offering a wide variety of foods from each group. Students using this approach consume a prescribed number of exchanges at meal and snack times.

A missed or delayed snack could result in hypoglycemia.

With some insulin regimens, it is important to maintain consistency in the timing and content of meals and snacks. The student should eat meals at the same time each day. Snacks are often necessary 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 also must have immediate access to a quick-acting form of glucose, such as juice or glucose tabs or gel.

Accommodating Special Dietary Needs in School Nutrition Programs

Substitutes or modifications to school meals can only be made with appropriate documentation from the child’s physician. The CSDE's guide, Accommodating Special Dietary Needs in School Nutrition Programs, provides detailed information for the USDA’s school nutrition programs on providing meals for children with special dietary needs, based on federal laws, USDA regulations and Connecticut laws. School nutrition programs include the following:

• Afterschool Snack Program
• Child and Adult Care Food Program: At-Risk Supper Program implemented in schools
• Fresh Fruit and Vegetable Program
• National School Lunch Program
• School Breakfast Program
• Special Milk Program

 

3. Physical Activity

Physical activity is an important part of the overall management of diabetes. The benefits of physical activity include cardiovascular fitness, long-term weight control, social interaction and the promotion of self-esteem fostered by team play. Additionally, physical activity can help to lower blood glucose.

Physical activity is a fundamental part of a healthy lifestyle for all children including those with diabetes. Children with diabetes can participate in gym class and after-school sports. Health care providers may suggest adjustments in medication and food for appropriate blood glucose control. Physical education instructors and sports coaches must be able to recognize and assist with the treatment of hypoglycemia. Families are encouraged to include more physical activity at home.

 

 

Carbohydrate Replacement for Physical Activity

Blood glucose should be checked according to the physician’s recommendations so that proper measures can be taken to keep the level in the appropriate range. The following chart illustrates the action that should be taken to maintain blood glucose safely with physical activity. It provides guidelines for students with both Type 1 and Type 2 diabetes requiring insulin for management of their diabetes.

Type of Activity:	If Blood Glucose Prior to Activity is:	Then Eat the Following Carbohydrate Before Activity:
Short Duration Less than 30 minutes	Less than 100 Greater than 100	15 grams carbohydrate No carbohydrate necessary
Moderate Duration 1 hour	Less than 100 100-180 180-240	25-50 grams carbohydrate plus protein source 15 grams carbohydrate No carbohydrate necessary
Strenuous 1-2 hours	100-180 180-240	25-50 grams carbohydrate plus protein source 15 grams carbohydrate
Note: If Blood glucose is above 240, physical activity should be restricted according to students’ DMMP, IHCP or ECP.

 

4. Planning Beyond the School Day

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 students with diabetes can participate fully in all school-related activities.

While there are no forbidden foods for children or teens with diabetes, school parties often include foods high in carbohydrates and fats. Providing more nutritious snacks will be healthier for all students and encourage good eating habits. Parents/guardians should decide whether students with diabetes should be given the same food as other students or food the parents provide. Parents should be given advance notice of parties to incorporate special foods in the meal plan or to adjust the insulin regimen.

With proper planning students with diabetes can participate fully in all school-related activities

Students often view a field trip as one of the most interesting and exciting activities of the school year, and students with diabetes must be allowed to have these school-related experiences.

Students with diabetes often need support from an adult on school trips. Although it is not unusual to invite parents to chaperone field trips, parental attendance is not a prerequisite for participation by the student with diabetes. If parents do not accompany their child on field trips, the school nurse needs to determine the level of health care needed on this trip and whether or not it is necessary for a nurse to participate. Often a nurse is not needed on the trip; however, school personnel need to be properly trained to accompany the student with diabetes off-site and ensure that all the student’s supplies are brought along with the student as specified in their IHCP or ECP. This includes snacks and supplies to treat hypoglycemia.

The plan for coverage and care during extracurricular activities should be included in the student’s IHCP, 504 plan, IEP, or other education plan. As with field trips, qualified school employees must be trained to ensure student safety and trained in responding to routine and emergency care.

Transportation Issues

Similar to other school activities away from the school building, advanced planning is necessary for meeting the needs of students with diabetes while being transported to and from school. School bus drivers need to be aware that they often may have students with health care needs riding the buses and should be educated on diabetes and, in particular, the signs of hypoglycemia. School bus drivers also need to understand how to handle an emergency. The IHCP and ECP should address how emergencies will be managed on school transportation. In most situations, this plan will allow for the student to have access to food, supplies and equipment on the bus, if needed.

5. Social and Emotional Aspects of Diabetes

The diagnosis of diabetes in a child can have a significant impact on the entire family. In many cases, the diagnosis of diabetes, like other chronic health diseases, is a major event for both the child and the family. Each individual in the family is affected and feelings experienced often follow a similar pattern although all reactions are unique and may occur at different times for different families. These feelings may linger if they are not recognized and expressed. Dealing with feelings openly can help the child and the family learn to face the daily challenges and facilitate acceptance of having diabetes. The feelings described below may be present in all families who have a child with diabetes.

Denial

“This can’t really be happening.” “I don’t need to take my insulin today.”

“It’s not that serious.” “No one has to know I have diabetes.”

The child or family member may find it difficult to even talk about diabetes. It may be too painful to face. This can interfere with the medical team’s ability to educate and treat the child. At times, the child or the parent/guardian may try to hide their feelings to be “strong” or not to upset the others. This denial may make the child’s ability to adjust to the daily struggles much more difficult.

Sadness

The child or family member may cry, feel depressed, or hopeless. Feeling sad is normal, and brief periods of sadness can occur for years after diagnosis. It is important for the child or family member to express their sadness and to openly share their feelings. They should be encouraged to seek professional help if they feel depressed or hopeless for a long period of time.

Anger

“Why me? or Why my child?”

“Why do I have to do it all?”

“It isn’t fair!”

Anger may be vented toward nurses, doctors, God, spouse, friends, siblings, teachers, the list is endless. Although this also is a normal feeling, it may interfere with the child or the family member’s ability to adjust to the daily pressures of managing diabetes. If it is having a major impact on the child or the family as a unit, individual counseling may be helpful.

Fear

“What will this mean for my child’s life?”

“What’s going to happen?”

“How can we ever leave him alone?”

There are so many fears that are expressed by the family and the child. Parents/guardians fear the increase in responsibility and the expenses. They worry about the future, and doubt their ability to manage diabetes every day. Siblings fear they may “get” diabetes too. T he child with diabetes fears hospitals, injections, finger sticks, low blood sugars and even death. He/she may fear being different from friends. All these fears are certainly justified, but can be allayed if they are openly discussed and support is given as needed.

Guilt

“What did I do to deserve this?”

“If I just hadn’t eaten so much sugar.”

“The diabetes may have come from my side of the family.”

Parents/guardians commonly feel that they “gave” their child diabetes. This idea often persists even though we know other factors also play a role in the onset of diabetes. The child may feel diabetes is a punishment for bad behavior. Such feelings are very common at the time of diagnosis. As time goes on, the child feels guilty if he/she “sneaks” extra candy, skips doing blood tests, lies about blood glucose results or does not “follow the rules.” Parents/guardians feel guilty whenever they have to enforce the “rules” of self-management or deny their child a “treat”. The opportunities to feel guilty are always there. Parents/guardians and children need to be supported in their efforts each day.

Acceptance

“I don’t like having diabetes but I guess I can handle it.”

“The shots aren’t so bad, I just wish I could eat whatever I want.”

This stage may take a long time to reach and some may never come to accept diabetes as part of their life. A well-adjusted family learns to cope with the endless demands and struggles diabetes can add to their life. They feel more confident and hopeful. Sadness and anger may still occur but these periods are temporary. The family needs to seek out resources in the community and within their family to ease the burden of daily management. Dealing with all of these emotions can be a challenge for the family with diabetes. They must come to the understanding that diabetes should not prevent a child from living a full and active life. They are not alone. There are many resources available in the community and many other families traveling the same road.

Factors Causing Emotional Distress at Diagnosis of Diabetes in a Child

• Uncertainty about the outcome of the immediate situation.
• Feelings of intense guilt and anger about the occurrence of diabetes.
• Feelings of incompetence and helplessness about the responsibility for managing the illness.
• Loss of valued life goals and aspirations because of illness.
• Anxiety about planning for an uncertain future.
• Recognition of the necessity for a permanent change in living.

6. Promoting Student Independence

While it is very important to provide students with assistance and supervision of their diabetes care as needed, it is equally important to enable students to take on the responsibility of learning diabetes self-management and control. Age alone should not be the guideline used to assume that a child is ready to accept responsibility for managing components of diabetes care. It is important to realize that children develop at different rates.

Adults must recognize that responsibilities related to diabetes depend not just on age, but also on the development of the individual as well as the circumstances at individual schools.

Student ability to participate in self-care also depends upon their willingness to do so. As students are ready, they can assume more responsibility for their care. Children need to be encouraged and supported to gradually assume diabetes self care as they mature and demonstrate confidence. Adults must be sure that when the responsibility is given that children are willing to accept it. Keep in mind that children’s ability or desire to perform certain diabetes related tasks may vary. It is normal for them to regress and depend on an adult to handle the responsibility of their diabetes care. Parents, school nurses, relatives and other reliable adults must be sensitive to these needs and remain supportive to children with diabetes.

Health care providers must provide written orders stating the need and the capability of students to conduct self-testing. Such an order will permit a student to self-test their blood glucose on school grounds. The school nurse and/or other school personnel should collaborate with the student and family to ensure that the student’s ability to self-test will result in effective diabetes management and complies with OSHA’s Universal Precautions.

The CDSE’s Guidelines for Blood Glucose Self-Monitoring in School is located on the CSDE website.

Students’ competence and capability for performing diabetes-related tasks are determined by the health care provider and parents/guardians and supported by the school team. Diabetes care includes and depends on self-management. Ultimately, persons with diabetes, when appropriate, become responsible for all aspects of self-care, including blood glucose monitoring and insulin administration. Regardless of their level of self-management, students with diabetes may require assistance when blood glucose levels are out of the target range.

To help determine how much responsibility students with diabetes can handle, it is helpful to understand the childhood development stages. Adults must recognize that responsibilities related to diabetes depend not just on age, but also on the development of the individual as well as the circumstances at individual schools. The charts below provide guidelines for determining the average age for assuming diabetes related skills. These are general recommendations, but children must be evaluated individually. Independence takes time and requires support and supervision from adults. Children who have a network of adults to support and assist them with diabetes management may maintain better diabetes control.

General Guidelines: Age-Appropriate Responsibilities

Age	Developmental Characteristics	Diabetes-Related Responsibility
3-7 years	Imaginative/concrete thinkers Cannot think abstractly Self-centered	Parent supervision for all tasks Is generally cooperative for blood glucose tests and insulin shots Inconsistent with food choices Gradually learns to recognize hypoglycemia Not much concept of time
7-12 years	Concrete thinkers Capable of more logic and understanding More curious More social More responsible	Can learn to test blood glucoses At age 10 or 11, can draw up and give shots on occasion Can make own food choices Can recognize and treat hypoglycemia By 11 or 12 years, can be responsible for remembering snack, but may still need reminders. Alarm watches may promote independence.
12-18 years	More independent Behavior varies Body image important Away from home more More responsible Capable of abstract thinking	Capable of doing the majority of shots and blood tests but may still needs some parental supervision and review at times to make decisions about dosage Knows which food to eat Gradually recognizes the importance of good sugar control to prevent later complications May be more willing to inject multiple shots per day

 

F. Diabetes Management Training for Qualified School Employees

Diabetes management training provides information on the necessary care for students with diabetes during the school day and during before- and after-school activities. The CSDE recommends training of qualified school employees when a student is diagnosed with diabetes, when a student with diabetes is enrolled in the school, or when appropriate. Training should be ongoing and include regular refresher sessions.

Suggested Components

• Introduction to the child’s IHCP, ECP and DMMP.
• Type 1 and 2 diabetes: what it is, how it is managed (if not covered at planning meeting.)
• Monitoring tools: blood glucose monitor, insulin pump, written records, etc.
• Signs and symptoms of hypoglycemia and hyperglycemia.
• Procedures for routine care of the individual student.
• Emergency procedures (such as, administration of glucose tabs, gel or glucagon injection).
• Overview of universal health and safety guidelines (OSHA) and disposal of supplies.
• Monitoring techniques (for those who may do finger sticks or arm sticks.)

Following the initial training, school nurses often provide the ongoing training needs of qualified school employees and students (see Appendix A for staff training record).

 

References

Appendix C

American Nurses Association and National Council of State Boards of Nursing. Joint Statement on Delegation

American Diabetes Association. (2011). Diabetes Statistics.

American Diabetes Association. (2012). Estimated Average Glucose (eAG).

American Diabetes Association. (2012). Children with Diabetes: Information for School and Child Care Providers

American Diabetes Association. (2012). Living With Diabetes .

Connecticut Board of Examiners for Nursing. Declaratory Ruling on Delegation by Licensed Nurses to Unlicensed Assistive Personnel

Connecticut Board of Examiners for Nursing. Declaratory Ruling on LPN Scope of Practice

Connecticut Department of Public Health. (2012). Chronic Disease: Diabetes Prevention and Control Program .

Connecticut Department of Labor, Division of Occupational Safety and Health (CONN-OSHA)

Connecticut State Department of Education. (2012). Guidelines for Blood Glucose Self-Monitoring.

.Connecticut State Department of Education. (1989). Connecticut Advisory School Health Council. Roles and qualifications of school health personnel.

Kinder, C.N. (2012). Yale-New Haven Teacher’s Institute. Biomedical Engineering and Diabetes.

Public Act No. 12-128 An Act Concerning the Administration of Medicine to Students with Diabetes, the Duties of School Medical Advisors, the Availability of CPR and AED Training Materials for Boards of Education and Physical Exercise During the School Day .

United States Department of Agriculture. (2012). Choose MyPlate

KidsHealth from Nemours. (2012). Type 1 Diabetes: What is it?