Diabetes Care: Kovler Diabetes Center

Today, I will be briefly reviewing the types of diabetes and goals of treatment, review the diabetes medical management plan, provide information about diabetes technology, and appropriate treatment of hypoglycemia, and a brief discussion of diabetes and exercise.

I just want to begin by thanking you for providing outstanding care for our children in the school setting. You are critical numbers of our care team and the students' primary advocate for their health and safety during school. I encourage you to form relationships with your child's endocrine doctor and diabetes educator, and please reach out to us if you notice when your children are struggling with their diabetes management.

So as you know, diabetes is a condition where the glucose is higher than normal. And a diagnosis of diabetes is made when the fasting glucose is 126 or higher or when the A1C, which estimates that average blood sugar over the last three months, is 6.5% or higher.

Briefly, there are two major types of diabetes. In type 1 diabetes, the pancreas is unable to make insulin because of an autoimmune condition. And in type 2 diabetes, the pancreas makes insulin but the cells of the body don't respond appropriate to this insulin because of insulin resistance. And there are many other types of diabetes that I will not be touching on today.

Because there's a significant relationship between the child's glucose control and their well-being and the need to prevent long term complications of diabetes later in life, we want to strive to keep the glucose levels in goal range. For children with type 1 diabetes, the goal A1C is at or below 7.5% for those on insulin injections and below 7% for those on a hybrid closed-loop insulin pump with a continuous glucose monitor.

The goal pre-meal glucose range is typically 90 to 130 and two-hour post-meal glucose goal is under 180. Because children with type 2 diabetes are much less likely to have hypoglycemia, the glucose goals are lower, with a goal A1C of under 6.5% and a fasting glucose of 70 to 120, and a two-hour postprandial glucose under 150. For children on a continuous glucose monitor, the goal is to keep the glucose in the goal range 70 to 180 at least 70% of the time, with spending less than 4% of the time with low blood sugar.

All of your students should be arriving to school with a Diabetes Medical Management Plan, or DMMP. This is a comprehensive document laying out the individual care plan for the student. It is essentially the doctor's orders and was developed by the healthcare provider along with the parent or guardian and specifically addresses all of the following aspects of diabetes management, including the timing and preferred way to check glucose and specific details regarding the use of the continuous glucose monitor.

The types, timing, doses, and preferred way to give insulin. Whether there are any specific dietary restrictions. What to do if a blood if a child has hypoglycemia or hyperglycemia. When to check for ketones and how to treat ketones. How to manage the diabetes around the time of physical activity. And specific instructions about how to use exercise settings in the insulin pump therapy. And emergency instructions and contacts, and how to contact the diabetes doctor. I always put my email address on these documents, and I encourage you to reach out to us if you have any questions about that plan.

In addition to the specifics of how to manage the diabetes, families are asked to describe details about the student's level of independence and self-care. For example, in the section on glucose monitoring, the family can choose full support, which means that the child requires trained diabetes personnel to check, in this case, blood glucose, supervision, or self-care, which is when the student can independently check their own blood sugar.

If your school district doesn't have a sample DMMP to provide to families to fill out, you can find an excellent form created by the American Diabetes Association in the first link here. And in addition, on the American Diabetes Association website, there is a link for basic diabetes training for non-clinical school staff.

This is a 19-module training curriculum with key information about different diabetes care tasks. And there is a guide for school personnel on the website as well. You may find this helpful when preparing the primary teacher of an elementary student with diabetes, for example, and coaches or gym teachers who want to specifically receive more in-depth training on topics like hypoglycemia.

Of note, if your school receives federal funding, Section 504 of the Rehabilitation Act of 1973 prohibits discrimination on the basis of disability and protects children with diabetes from discrimination. So schools are required to meet the needs of students with diabetes, as well as meet the needs of students without diabetes.

For example, schools should provide trained staff to monitor blood glucose levels, administer insulin and glucagon as needed, and have trained staff to provide diabetes care during field trips and all school-sponsored events. There are different state laws specifying who is authorized to administer insulin. In New York, for example, only licensed healthcare professionals, like the school nurse, can administer insulin. But in California, unlicensed school staff can administer insulin.

As you know, insulin is delivered by a pen, syringe, or an insulin pump to any of the areas noted in yellow, including in the upper outer thighs, buttocks, abdomen, and the backs of the upper arms. And every year, there are more and more brands of insulin on the market. So it is vital that you learn the types of insulins that your students are on. But in general, they fall under familiar categories.

The rapid-acting insulin is what you'll primarily be using during the school day, at mealtime, or to treat hyperglycemia. And this is what's also in the insulin pump. These insulins work within 15 minutes and last up to 4 hours. So if this insulin is given for the meal, the student should be eating within 10 to 15 minutes. Here's just a graphical representation for your records of the duration of insulin action for the different types of insulin.

Your students may be on one of a handful of different types of insulin regimens. The first and the most common, and this is what we do with the pump, too, is the adjustable bolus insulin therapy. With this insulin, the child receives a dose of long-acting insulin via pen or a continuous short-acting insulin infusion via the pump. And then they receive short-acting insulin for meals and snacks, which is dosed according to the number of carbohydrates that they'll be eating.

So for example, one unit of lispro insulin for every 10 grams of carbohydrates. The child also receives short-acting insulin if the pre-meal glucose is high, according to the blood glucose correction scale. For example, 1 unit of aspart insulin for every 50 points over 150. And another way of saying, this particular scale is a target glucose of 100 with a correction or sensitivity factor of 50.

The second type of insulin regimen is listed in the middle. This is the fixed bolus insulin plan, where the child receives the long-acting insulin and the hyperglycemia correction in the same way as plan number 1. But instead of using an insulin to carb ratio, the amount of insulin with each meal is fixed. So for example, the child might receive 5 units with lunch every day or 2 units with snacks.

And the third type of insulin regimen, which we really don't prescribe anymore, is when a child receives a combination of an intermediate-acting insulin and pH plus regular insulin before breakfast at home. And this is to cover the lunch needs. And then the child receives a second dose at home before dinner.

Now most of your students will be wearing an insulin pump. This is a battery-powered device that administers insulin in a steady release of rapid-acting insulin that mimics the LANTUS, or the basal insulin, but it's given as a rapid-acting insulin.

The insulin pump holds a set amount of insulin in a reservoir, and it delivers it into the body via the skin. And from there it enters the bloodstream. Insulin can be administered as a bolus for food before meals or for high blood sugar with the press of a button. The insulin pumps will calculate the doses of insulin for meal, using the insulin to carb ratio calculation and the hyperglycemia correction doses.

And some insulin pumps have an infusion set that connects the pump to the body through a tubing system. This is pictured in the top right. And some pumps adhere directly to the body through a patch with a small cannula under the skin like the pump featured in the bottom left picture on the upper arm.

There are a few different types of pumps. So some children might wear a pump and also wear a sensor, but those don't communicate with each other. But most often, children wear an insulin pump and a continuous glucose monitor that do communicate with each other. And this is called the hybrid automated insulin delivery pump or closed-loop pump. And examples of this are the Omnipod 5, Tandem with Control-IQ, Medtronic 780G, The Islet Pump. And there's a brand new pump that just hit the market in July that's called the Twiist.

So in these systems, it is important to manually bolus the student for meals and snacks, but the pump automatically increases or decreases the basal insulin delivery before and after meals in response to the blood sugar numbers on the continuous glucose monitor.

Less often, children will wear a commercially available pump and a CGM but use a non-FDA-approved open source algorithm for automated insulin delivery. And last, not really available yet, but we would love to have a pump just do everything, including mealtime insulin. But that just doesn't really happen right now in 2025.

When interacting with insulin pumps for the first time or if it's been a long time since you've had a student with an insulin pump, some key skills to master are number 1, learn how to deliver routine boluses for carbs and high blood sugar. You may find it helpful to schedule a time to meet with the child and the family before school starts to become acquainted with the pump and other diabetes technology equipment.

Two, identify signs and symptoms that the pump sight might need to be changed and know how to change that infusion set. Three, know when an injection by a pen or syringe is indicated. And it's important to have backup insulin pens or syringes for this occasion for all kids who are on insulin pump technology. And four, learn how to disconnect or suspend the pump. This is needed when the child's glucoses are dropping rapidly, or they're unable to consume enough carbohydrate to raise the blood sugar quickly, or when instructed to during physical activity like sports or PE, as noted in the DMMP.

So pump malfunctions do happen. And when they do, there is high blood sugar and a high risk of diabetic ketoacidosis from a lack of insulin infusion. The DMMP should lay out the signs and symptoms of what to do when there's concern for pump malfunction. And in general, it is recommended to give a hyperglycemia correction when the blood sugar is above 250 and recheck the blood sugar in one hour.

If the blood glucose has not started to decrease or if the CGM arrow is rising after an hour, it's recommended to change the insulin pump site and give a manual injection of insulin using an insulin pen to treat that blood sugar right away.

So I wanted to take a couple of minutes to point out a few key features for the insulin pumps that you'll most commonly see this upcoming school year, beginning with the Omnipod 5 Automated Insulin Pump. This pump is really effective for lowering glucose levels into the goal range but in automated mode.

And unfortunately, with their algorithm, oftentimes students who have had prolonged high blood sugar for a while, their maximum basal rate has been too high for too long. So the pump kicks them out of automated mode and puts them into manual mode. And so one key thing to do with this pump is to just make sure that student is in automated mode. And you can easily switch back to the automated mode with the switch mode option on the pump menu.

The background basal insulin rate is not determined by the programmed basal rates that you're going to find on the DMMP. It's actually determined by a secret Omnipod algorithm that takes into account the user's total daily dose and target glucose.

So if the blood sugars are typically high at school, one common fix is for the physician to change the target glucose to the lowest setting, which is 110, as in this pump, the target glucose can be anywhere from 110 to 150 depending on where the physician put it.

There is a variable duration of insulin action in this pump. And I do recommend utilizing the Activity Mode feature during gym and sports. This targets the blood sugar to 150 and it prevents low blood sugars. This is especially helpful with cardiovascular exercise. When students have just strength training, their blood sugar may actually rise with that activity. And so the activity mode might not be necessary. And then there's a really useful feature called Custom Foods in this pump where the family can program in the child's frequently eaten snacks and meals to simplify mealtime bolusing using the Custom Foods feature.

Second the pump that I'm going to mention here in more depth is the Tandem T-Slim and the newer Tandem Mobi, both of which use the Control-IQ Automated Insulin Delivery Algorithm. These pumps are always in automated mode, so you don't have to worry about putting them into automated mode, unless there's an issue where the child's not wearing a continuous glucose monitor or for some reason, it's just not communicating with the pump.

The automated basal insulin rates actually is based on the program basal rates that you will find on the DMMP. And their target glucose is always set to 110. The duration of insulin action is always set to five hours. And they do have an exercise mode, which, again, I do recommend utilizing with gym and sports if the kids are dropping. And this targets the blood sugar to 140 to 160.

Now on to Continuous Glucose Monitors and those alarms. So CGMs are incredible tools that monitor the change in glucose levels and alert users and their guardians to low blood sugar and reduce the burden of the painful fingersticks. The CGM alarms are prescribed by the healthcare provider with input from the student and parent. And it is recommended that the audible CGM alarms be set to be actionable in the school setting, such as for hypoglycemia when there's an acute risk.

If a CGM alarms, it is recommended to follow the instructions in the DMMP. All students, regardless of their level of independence, will require assistance when they experience severe hypoglycemia. And they should be accompanied or escorted if they're going to the health room.

As you know, CGMs are capable of sharing data real time with the parent and school nurse remotely, if desired. And while it is not required for school nurses to follow the students' glucoses remotely, it is strongly recommended as this provides an additional level of safety for the student.

It is not necessary for the school nurse to actively follow the glucose levels all day long, but to at least be aware when the alerts are going off in the remote monitoring. For legal reasons, it's recommended for the nurse to follow the glucoses on a school-owned device.

And of course, we know that the parents or guardians are following the sugars at home and that can lead to excessive phone calls and communications from families during the school day. So the parents should be reassured that there are a lot of safeguards built into the school, with a lot of adults around, and that schools are well trained to respond to urgent situations related to diabetes. For information on general treatment recommendations based on CGM, follow the DMMP And then I also just have this as an informational slide for you as well.

Now, hypoglycemia, this is when the level of glucose in the blood falls too low for the body to function properly. It must be treated immediately as very low blood sugar can lead to unconsciousness and seizure if left untreated. Mild hypoglycemia is a glucose under 70, moderate is under 54, and severe is when there's a mental status change. Hypoglycemia can look like sweaty, shakey, heart racing, extreme hunger, restlessness, irritability, confusion, sleepiness, all the way to those severe symptoms.

So for all these cases, again, do not leave the child unattended. Follow the instructions in the DMMP for treatment. But in general, for mild hypoglycemia, we verify that the glucose is low and give a fast-acting carbohydrate. For older kids, we follow the rule of 15 grams of carbohydrate, check the glucose in 15 minutes. And the glucose should have risen at least 15 points and repeat every 15 minutes as needed.

For younger kids and for kids on automated insulin pump, they will need less carbohydrate to raise the sugar. And so one rule is 1 gram of glucose for every 9 pounds of body weight or instead of 15, maybe give half of that, like 8.

So many students will come with our newer user-friendly glucagon products, such as the intranasal spray and the pre-mixed subcutaneous injection of glucagon that's seen in the bottom photos here. For severe hypoglycemia, we recommend placing the child on his or her side and lifting the chin to open the airway, injecting the glucagon per the student's DMMP and calling 911 and the parent.

The student really should have a rise in their blood sugar within 15 minutes. And if they don't, you can repeat another glucagon injection. Avoid putting anything in the student's mouth if they have the altered mental status until the student is truly able to swallow.

And we're rounding the corner here, finishing up with ketones. So identifying ketones in students with diabetes is necessary to prevent DKA, the life-threatening diabetes emergency. This is when cells aren't getting the glucose because either severe insulin deficiency, we miss doses, or severe resistance to insulin in the case of type 2 diabetes, and the body starts to break down fat to use as energy. And the byproducts are ketones, which poisons the body.

And symptoms of ketones and DKA include that fruity smell on the breath, but of course, hyperglycemia. Most commonly, it's a nausea, or vomiting, or belly pain. So students may feel like they had something bad to eat the night before, but really, it's probably their insulin deficiency and they need more insulin.

So you can check for ketones using urine ketone strips or blood ketone meters. And when present, give that correction dose of insulin with an insulin pen and extra water, per the DMMP. Presume there's a pump site malfunction if the child is on an insulin pump and replace that pump site. Notify the parents and repeat the ketone check and glucose check two hours later. If the child is vomiting and can't hold down water, or appears particularly ill, or the ketones aren't improving, after a couple of hours, the child will need to go to the ER for IV hydration and further treatment.

So physical activity-- and, Peggy, I know I'm running over so just maybe stop me. I think I have just two more slides here. But physical activity will impact glucose levels and the amount of insulin needed. Follow the instructions in the DMMP. We generally want a higher target going into the exercise to prevent a low. And here's just some guidelines for your information.

And then last but not least, I just want to make a point about how we, as healthcare professionals, can combat the stigma related to chronic illnesses that our students have on a day-to-day basis. They did a poll of children with type 1-- people living with type 1 diabetes and 76% of them experienced stigma, 50% of those living with type 2.

And so one small way that we can do to combat this is to carefully choose respectful, inclusive language when addressing students with health conditions. And so here's a list of small language shifts published by the diaTribe Foundation to reduce diabetes and obesity stigma.

And some insulin pumps have an infusion set that connects the pump to the body through a tubing system. This is pictured in the top right. And some pumps adhere directly to the body through a patch with a small cannula under the skin like the pump featured in the bottom left picture on the upper arm.

There are a few different types of pumps. So some children might wear a pump and also wear a sensor, but those don't communicate with each other. But most often, children wear an insulin pump and a continuous glucose monitor that do communicate with each other. And this is called the hybrid automated insulin delivery pump or closed-loop pump. And examples of this are the Omnipod 5, Tandem with Control-IQ, Medtronic 780G, The Islet Pump. And there's a brand new pump that just hit the market in July that's called the Twiist.

So in these systems, it is important to manually bolus the student for meals and snacks, but the pump automatically increases or decreases the basal insulin delivery before and after meals in response to the blood sugar numbers on the continuous glucose monitor.

Less often, children will wear a commercially available pump and a CGM but use a non-FDA-approved open source algorithm for automated insulin delivery. And last, not really available yet, but we would love to have a pump just do everything, including mealtime insulin. But that just doesn't really happen right now in 2025.

When interacting with insulin pumps for the first time or if it's been a long time since you've had a student with an insulin pump, some key skills to master are number 1, learn how to deliver routine boluses for carbs and high blood sugar. You may find it helpful to schedule a time to meet with the child and the family before school starts to become acquainted with the pump and other diabetes technology equipment.

Two, identify signs and symptoms that the pump site might need to be changed and know how to change that infusion set. Three, know when an injection by a pen or syringe is indicated. And it's important to have backup insulin pens or syringes for this occasion for all kids who are on insulin pump technology. And four, learn how to disconnect or suspend the pump. This is needed when the child's glucoses are dropping rapidly, or they're unable to consume enough carbohydrate to raise the blood sugar quickly, or when instructed to during physical activity like sports or PE, as noted in the DMMP.

So pump malfunctions do happen. And when they do, there is high blood sugar and a high risk of diabetic ketoacidosis from a lack of insulin infusion. The DMMP should lay out the signs and symptoms of what to do when there's concern for pump malfunction. And in general, it is recommended to give a hyperglycemia correction when the blood sugar is above 250 and recheck the blood sugar in one hour.

If the blood glucose has not started to decrease or if the CGM arrow is rising after an hour, it's recommended to change the insulin pump site and give a manual injection of insulin using an insulin pen to treat that blood sugar right away.

So I wanted to take a couple of minutes to point out a few key features for the insulin pumps that you'll most commonly see this upcoming school year, beginning with the Omnipod 5 Automated Insulin Pump. This pump is really effective for lowering glucose levels into the goal range but in automated mode.

And unfortunately, with their algorithm, oftentimes students who have had prolonged high blood sugar for a while, their maximum basal rate has been too high for too long. So the pump kicks them out of automated mode and puts them into manual mode. And so one key thing to do with this pump is to just make sure that student is in automated mode. And you can easily switch back to the automated mode with the switch mode option on the pump menu.

The background basal insulin rate is not determined by the programmed basal rates that you're going to find on the DMMP. It's actually determined by a secret Omnipod algorithm that takes into account the user's total daily dose and target glucose.

So if the blood sugars are typically high at school, one common fix is for the physician to change the target glucose to the lowest setting, which is 110, as in this pump, the target glucose can be anywhere from 110 to 150 depending on where the physician put it.

There is a variable duration of insulin action in this pump. And I do recommend utilizing the Activity Mode feature during gym and sports. This targets the blood sugar to 150 and it prevents low blood sugars. This is especially helpful with cardiovascular exercise. When students have just strength training, their blood sugar may actually rise with that activity. And so the activity mode might not be necessary. And then there's a really useful feature called Custom Foods in this pump where the family can program in the child's frequently eaten snacks and meals to simplify mealtime bolusing using the Custom Foods feature.

Second the pump that I'm going to mention here in more depth is the Tandem T-Slim and the newer Tandem Mobi, both of which use the Control-IQ Automated Insulin Delivery Algorithm. These pumps are always in automated mode, so you don't have to worry about putting them into automated mode, unless there's an issue where the child's not wearing a continuous glucose monitor or for some reason, it's just not communicating with the pump.

The automated basal insulin rate actually is based on the program basal rates that you will find on the DMMP. And their target glucose is always set to 110. The duration of insulin action is always set to five hours. And they do have an exercise mode, which, again, I do recommend utilizing with gym and sports if the kids are dropping. And this targets the blood sugar to 140 to 160.

Now on to Continuous Glucose Monitors and those alarms. So CGMs are incredible tools that monitor the change in glucose levels and alert users and their guardians to low blood sugar and reduce the burden of the painful fingersticks. The CGM alarms are prescribed by the healthcare provider with input from the student and parent. And it is recommended that the audible CGM alarms be set to be actionable in the school setting, such as for hypoglycemia when there's an acute risk.

If a CGM alarms, it is recommended to follow the instructions in the DMMP. All students, regardless of their level of independence, will require assistance when they experience severe hypoglycemia. And they should be accompanied or escorted if they're going to the health room.

As you know, CGMs are capable of sharing data real time with the parent and school nurse remotely, if desired. And while it is not required for school nurses to follow the students' glucoses remotely, it is strongly recommended as this provides an additional level of safety for the student.

It is not necessary for the school nurse to actively follow the glucose levels all day long, but to at least be aware when the alerts are going off in the remote monitoring. For legal reasons, it's recommended for the nurse to follow the glucoses on a school-owned device.

And of course, we know that the parents or guardians are following the sugars at home and that can lead to excessive phone calls and communications from families during the school day. So the parents should be reassured that there are a lot of safeguards built into the school, with a lot of adults around, and that schools are well trained to respond to urgent situations related to diabetes. For information on general treatment recommendations based on CGM, follow the DMMP And then I also just have this as an informational slide for you as well.

Now, hypoglycemia, this is when the level of glucose in the blood falls too low for the body to function properly. It must be treated immediately as very low blood sugar can lead to unconsciousness and seizure if left untreated. Mild hypoglycemia is a glucose under 70, moderate is under 54, and severe is when there's a mental status change. Hypoglycemia can look like sweaty, shakey, heart racing, extreme hunger, restlessness, irritability, confusion, sleepiness, all the way to those severe symptoms.

So for all these cases, again, do not leave the child unattended. Follow the instructions in the DMMP for treatment. But in general, for mild hypoglycemia, we verify that the glucose is low and give a fast-acting carbohydrate. For older kids, we follow the rule of 15 grams of carbohydrate, check the glucose in 15 minutes. And the glucose should have risen at least 15 points and repeat every 15 minutes as needed.

For younger kids and for kids on automated insulin pump, they will need less carbohydrate to raise the sugar. And so one rule is 1 gram of glucose for every 9 pounds of body weight or instead of 15, maybe give half of that, like 8.

So many students will come with our newer user-friendly glucagon products, such as the intranasal spray and the pre-mixed subcutaneous injection of glucagon that's seen in the bottom photos here. For severe hypoglycemia, we recommend placing the child on his or her side and lifting the chin to open the airway, injecting the glucagon per the student's DMMP and calling 911 and the parent.

The student really should have a rise in their blood sugar within 15 minutes. And if they don't, you can repeat another glucagon injection. Avoid putting anything in the student's mouth if they have the altered mental status until the student is truly able to swallow.

And we're rounding the corner here, finishing up with ketones. So identifying ketones in students with diabetes is necessary to prevent DKA, the life-threatening diabetes emergency. This is when cells aren't getting the glucose because either severe insulin deficiency, we miss doses, or severe resistance to insulin in the case of type 2 diabetes, and the body starts to break down fat to use as energy. And the byproducts are ketones, which poisons the body.

And symptoms of ketones and DKA include that fruity smell on the breath, but of course, hyperglycemia. Most commonly, it's a nausea, or vomiting, or belly pain. So students may feel like they had something bad to eat the night before, but really, it's probably their insulin deficiency and they need more insulin.

So you can check for ketones using urine ketone strips or blood ketone meters. And when present, give that correction dose of insulin with an insulin pen and extra water, per the DMMP. Presume there's a pump site malfunction if the child is on an insulin pump and replace that pump site. Notify the parents and repeat the ketone check and glucose check two hours later. If the child is vomiting and can't hold down water, or appears particularly ill, or the ketones aren't improving, after a couple of hours, the child will need to go to the ER for IV hydration and further treatment.

So physical activity-- and, Peggy, I know I'm running over so just maybe stop me. I think I have just two more slides here. But physical activity will impact glucose levels and the amount of insulin needed. Follow the instructions in the DMMP. We generally want a higher target going into the exercise to prevent a low. And here's just some guidelines for your information.

And then last but not least, I just want to make a point about how we, as healthcare professionals, can combat the stigma related to chronic illnesses that our students have on a day-to-day basis. They did a poll of children with type 1-- people living with type 1 diabetes and 76% of them experienced stigma, 50% of those living with type 2.

And so one small way that we can do to combat this is to carefully choose respectful, inclusive language when addressing students with health conditions. And so here's a list of small language shifts published by the diaTribe Foundation to reduce diabetes and obesity stigma.