Diabetes Care: Kovler Diabetes Center - UChicago Medicine

Diabetes Care: Kovler Diabetes Center - UChicago Medicine
Diabetes Care: Kovler Diabetes Center
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Advancing Diabetes Care and Accelerating Discovery
Managing the symptoms of diabetes can be a lifelong battle, but you don’t need to face it alone. Experts at UChicago Medicine’s Kovler Diabetes Center are ready to provide people with diabetes the comprehensive, immersive healthcare they need throughout their lifetime. We strive to help patients manage not only their diabetes, but also the challenges to social and emotional health that often accompany chronic illness.
World-Class Diabetes Care in Chicago
UChicago Medicine offers a patient-centered, science-based approach for managing insulin-dependent
Type 1 diabetes
, complex
Type 2 diabetes
,
gestational
, pre-diabetes and
monogenic diabetes
.
Our
multidisciplinary team
works with patients and referring physicians to address all the challenges of diabetes, from hypertension and vascular problems to foot conditions and kidney disease.
With a dedicated group of certified diabetes specialists, we provide the latest in
diabetes education
and teach our patients vital self-management skills. We offer
second opinions
and ongoing treatment for people living with diabetes.
What is Diabetes?
Diabetes is the most common disorder of the body’s endocrine system, and is characterized by consistently high glucose (sugar) levels in the blood because the body cannot properly process food for use as energy.
When we eat, most of the food is broken down into glucose, which the body uses for growth and energy. A hormone called insulin moves glucose from the bloodstream into individual cells, giving each cell the energy it needs to function.
In people with diabetes, one of two problems can occur:
The pancreas produces too little insulin, or no insulin.
The cells of the body do not respond appropriately to the insulin in the bloodstream.
The end result is too much glucose, or sugar, in the bloodstream. Consistently high blood sugar levels can lead to serious health problems, including blindness, kidney failure and nerve pain.
Get answers to common questions about diabetes
Our Kovler Diabetes Center Mission
The Kovler Diabetes Center continues to build on more than 100 years of diabetes patient care and research at the
University of Chicago
. Our mission is to provide holistic treatment, care and education that empower our patients to effectively manage their diabetes for a lifetime. We pursue this mission through four pillars: Clinical Care, Education, Community Outreach, and Research.
Diabetes Clinical Care
Every patient is different. Meet some of our faculty and staff members, and let’s work together to create a highly individualized treatment plan to manage your symptoms.
Types of Diabetes
Childhood Diabetes
Meet our Diabetes Care Team
Diabetes Education
We aim to equip both professionals and patients with all the available knowledge and understanding about diabetes.
Diabetes Programs, Education and Resources
Diabetes FAQ
Community Outreach
Our faculty, staff and leadership board help Kovler stay connected to the greater Chicago community. Connect with us on Facebook, Instagram, or Twitter to learn about our upcoming community events! Our partnerships with local organizations also enhance the health of the overall community and improve outcomes.
Urban Health Initiative (UHI)
Breakthrough T1D - Illinois
American Diabetes Association Illinois
Diabetes Prevention Program
Diabetes Research
Learn about the breakthrough discoveries at Kovler Diabetes Center that help scientists around the world better understand diabetes, its causes and its genetic foundation. These discoveries can be applied to measurably improve the quality of life for people with diabetes.
Diabetes Research
Monogenic Diabetes Research
Diabetes Research and Training Center
Mirmira Lab
Chicago Center for Diabetes Translation Research
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According to U.S. News & World Report's 2025-26 Rankings
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According to U.S. News & World Report's 2025-26 Rankings
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Diabetes Care at UChicago Medicine
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Diabetes Awareness: Expert Q&A
UChicago Medicine experts answer questions about diabetes; the symptoms, who is at high risk, and how our Kovler Diabetes Center helps diabetes patients through holistic treatments and education.
Hello, and welcome to a special At the Forefront Live, where we will discuss diabetes and some of the efforts to treat this condition. We'll go inside the Kovler Diabetes Center and show you the incredible work they do. And we'll take you inside a laboratory, where scientists are working on treatments and possible cures. We will introduce you to doctors and researchers who will answer your questions about diabetes. That's coming up right now on At the Forefront Live. Joining me to start today's program is Dr. Lou Philipson. Dr. Phillipson is the director of the Kovler Diabetes Center and is the James C. Tyree professor of Diabetes Research and Care in the Departments of Medicine and Pediatrics at the University of Chicago. Welcome, Dr. Phillipson. Hi. Good afternoon. So tell us a little bit about the Kovler Diabetes Center. And what are some of the exciting things that are happening there? Well, we've had the name, Diabetes Center, now for going on two decades. And we're excited to continue our role here. I think the idea here was to have a holistic treatment place for care and education, that our patients could effectively manage their diabetes. We have really four pillars. Research, clinical care, education, and then outreach to the community. And all of those things I think combine to make what we have in the past called both a high tech and a high touch approach to care. Diabetes is a big problem in the United States, but it's also a big problem in our region specifically. Can you talk a little bit about some of the efforts in South Chicago, and then if you want to expand on that, to the rest of the United States, you can as well. Yeah. I think many people have made wonderful observations about health care disparities. I mean, overall, diabetes of all kinds affects about 9% of Americans. And on the South side, it's a higher percentage. It could be 10% or 11%. So it seems to preferentially afflict people of minorities and socioeconomic as well. It's reducing lifespan. Our head of our emergency room has pointed out that there's an impressive multi-year gap in lifespan in diabetes, and its complications are a big part of that difference. One of the things we're trying to do is address that lifespan for all kinds of diabetes. And one of our doctors, Dr. Celeste Thomas, has recently shown that disparity happens as well for type 1 diabetes. So we're very interested in addressing the disparities, improving identification and treatment, and improving the lives of all people with diabetes. And I know your team has done some wonderful work on outreach and just trying to work with community members and really improve those numbers. We've got work to do obviously, but you've done some wonderful work in that area. Can you talk just a little bit about the genetics of diabetes, and maybe some of the research that we see happening here at UChicago Medicine? Absolutely. We are one of the national leaders in the impact of genetics in diabetes. And there's different aspects of it. So there's what we call many genes. That's been called polygenic, which I think is the more usual thing. But rare forms of diabetes. So single genes, like what might make difference in blue eyes and brown eyes, can also be responsible for diabetes. And they come in different varieties. So there are very, very rare situations where people are born with diabetes essentially. And we have several of those folks across the country that we follow and help. And then there's a larger group of people who develop diabetes as they grow up. And those are also sometimes single genes. So we have a registry now of over 4,000 individuals. We also have a national study on atypical diabetes, where we're attempting to identify new kinds. So it's been a very exciting development with great interest from individuals and diabetes faculty all over the country. That's great. Thank you, Dr. Philipson. We do need to take a quick break. When we come back, we'll talk with young diabetes patients who will share their inspirational story. Welcome back. We are very fortunate to be joined by a young woman who's living with diabetes. Johana Kenison is not letting diabetes control her life. In fact, she's worked hard to turn the tables. Johana joins us now. Thank you very much for doing this with us today. You are welcome. So I understand that you have a pretty great story to tell. You are 13 years old. You have diabetes. And you play basketball and more recently made captain of the team. Tell us a little bit about that. I was on this team last year for sixth grade. So I already had the experience with this coach. And she's great with helping me through playing basketball. So this year, I just got made captain. That's awesome. You must be a pretty good player then. So tell us a little bit about living with diabetes. You're 13 years old. And we were talking a little bit before we did this recording, and you mentioned to me that you don't let diabetes control you. Tell me more about that. I don't let it control me because there's no reason to really be precautionist about it and like on top of it all the time because it's just going to make me like go crazy some of the times. And I just want to let it. I want to be just regular I guess. But obviously, I can't always do the same things everybody else does. But I try. Yeah. And so I don't get in trouble with the doctors or your mom, you do take precautions. You check your levels and that sort of thing, right? Yeah. So how is that? What do you do? You have to check your sugar, but you also probably watch your diet a little bit. What would you tell another kid who might be in your position? What kind of things do they need to be aware of? You really need to be aware of how much insulin you're taking and your doses. You want to make sure what your blood sugar is before you take your insulin. And make sure it's not too high or too low because if it's too low, then you want to eat something before you take your medicine and maybe take a little less medicine before you start eating if you're low. But also take more insulin if you're higher. So kind of the moral of this story is you can be careful, and you can watch things. But again, at the same time, you can enjoy your life. And you've done a pretty good job of that so far. So talk to us a little bit. One of my notes here that I saw, it was an email that came to me. It said that you tied for first place in a youth groups diabetes knowledge contest and won a prize here at Kovler Diabetes. What was the contest? Did you have to take a test? Or did you write something? Or what was that? Well, I just showed up for the Zoom meetings, and stayed through, and learned what they were teaching us about it, and answered questions about what they were asking us about. That's good. And apparently, you did quite well with that. So we got one more question for you. If another child came to you and said, hey, I've got this challenge in my life because I think you are an inspiration. What kind of advice would you give that other person? Just have a positive mindset. And don't let it control you. You can control it. So just take care of yourself. Make sure you check your blood sugars. But you can do all of these activities, and sports, and go bike riding with your friends. But obviously take your necessary things with you, like your Dexcom to check your blood sugars. Take your emergency pen. And take a snack with you. And be responsible with what you're doing. That is fantastic advice. Johana, you are an inspiration. Thank you very much for being with us today. Coming up next, our doctors will take your questions concerning diabetes. That's right after this. And welcome back. In this segment, we'll talk to physician experts and take your questions. You can type them into the comment section. We'll try to get to as many as we can here in the next few minutes. Now let's start off with each of you introducing yourselves and telling us a little bit about what you do here at UChicago Medicine. Dr. Mirmira, you're actually up at the desk with me. We are trying to be socially distant. This is why we do this. So we'll start with you. Yes. My name is Ragu Mirmira. And I'm a professor of medicine and endocrinology here at the University of Chicago. I've been here about two years now. And my sort of role here is I do see patients. I see patients several times a month. And beyond that, my focus is primarily research in diabetes and using what we call preclinical models to move new therapies into the clinical setting. Great. And Dr. Thomas, we heard your name in an earlier portion of the show. I'm going to ask you a couple of questions about what Dr. Philipson was saying here in a moment. But let's go ahead and hear about your work. So my name is Celeste Thomas. Thank you. I'm an assistant professor in the section of the Department of Medicine, the section of endocrinology. And my role here is primarily taking care of patients with all types of endocrinopathies, including diabetes. A lot of my work has involved trying to improve the quality of care of patients who are hospitalized and happen to have diabetes. And so I do that in the clinics and in the hospital. And I'm going to jump right into this, Dr. Thomas, because I think this is interesting, and it's certainly an issue that we need to address. And I know you folks in Kovler are really working hard in this area, but talk to us about health disparities, particularly when it comes to diabetes. And I thought it was kind of fascinating when Dr. Phillipson mentioned type 1 in particular. And I'm trying to figure out why that would be happening. Right. Thank you for that question. For me, it was looking at the quality of care for our hospitalized patients with diabetes. And then just observing initially these increased early complications from type So we talk about the small vessels in the body that can be impacted by diabetes and cause problems with vision, something called retinopathy. Cause problems with the kidneys and even cause nerve damage, which is that contributor to those preventable amputations, those non-traumatic amputations. And what I saw was just early, early complications and very young adults with blindness and end stage renal disease. And that was just my observation here. And then we went to the literature to understand what is being observed across the country. And there's this group of clinics for the type 1 diabetes exchange. And they are following patients as well with the diagnosis of type 1 diabetes. And one of the things that they found is that those disparities present early on in the development of type 1 diabetes. So we understand that one of the things that Dr. Phillipson mentioned was that we can have diabetes in the neonates or in an infant. And we usually think about that kind of being diagnosed before six months of age is most likely being a neonatal diabetes. Where this type 1 diabetes can be diagnosed any time in the lifespan. And when the type was looking at people diagnosed and as children, the disparities present early on after the diagnosis. And one of those things that they saw was the introduction of technology. And so the introduction of something we call continuous subcutaneous insulin infusion or insulin pumps. There's a disparity in the introduction of that technology. And there's also a disparity in the introduction of continuous glucose monitoring systems. And so that seemed like a problem that we could solve, which would be to introduce those technologies into our patient's care and see if we could address some of those disparities. And I think that's something that clearly you as a physician, you probably see this a lot just with health care disparities in general. We talked about type 2. And Dr. Mirmira, I kind of want to get your thoughts on this too because I think a lot of times, we think about disparities, health care disparities with type 2 because food deserts and food swamps. There are lack of grocery stores, or what food supply is available isn't necessarily the most healthy. So that's kind of a common thing I think that people think about. But it goes quite a bit deeper than that obviously with what Dr. Thomas was mentioning with type 1. That's a great point because it's really access to quality food. And it's access to health care and the latest technologies. In type 2, we tend not to use pumps as much, but we do use glucose monitoring devices. We do use sort of new medications that you don't use in type 1, like pills and other types of injections. So it's access to a lot of this. So it gets very complicated for both diseases in terms of the disparity and access to, as I said, quality food and quality health care. Absolutely. So I don't want to disappoint our viewers because we are already getting questions from viewers. So we always try to get to as many as possible. I'm just going to start in on those if that's OK with the two of you. And let's go with you, Dr. Thomas, first as we enter into the lightning round of questions from viewers. What should you look for regarding your feet for type 2 diabetes? I guess just things to be aware of. So this is a great question. And I'm so pleased because this is one of those things that we talk about how those amputations and those diabetic foot ulcers can be preventable. And the way that we prevent it is by doing that kind of self foot exam. So one of the things that the health care team will do, at least annually, is to examine for sensation. So there are a couple of ways that we can see. Has there been a decrease in sensation? And for those individuals who have noticed a decrease in sensation and even before then, just kind of looking at those feet. So one of the challenges is that if you can't feel something, then you can have an injury and not be aware of the injury. And so if you're looking at the foot, then you can see if there's an injury there and seek care before there's evidence of an infection. And so if there is anyone out there who already has kind of that neuropathy. So in addition to that foot exam, think about what we're exposing the feet to. And so we want to make sure that we're using those closed toe shoes. And unfortunately, when there's that neuropathy, even in the house, because there can be objects on the floor, that you want to have a hard sole shoe. In addition, when you're putting your shoe on, if there's still that sensation in the hand. You want to either kind of hit that shoe against a hard object or put your hand into the shoe. And make sure there are no foreign objects in the shoe. And that way, we can avoid some of those injuries and ulcers, which then can lead to preventable amputation. That's really great advice. And I imagine a lot of people probably wouldn't even think of that. Dr. Mirmira, here is one for you. I'm 66 years old with type 2 diabetes and chronic pancreatitis. Which of the modern injectable medications could be considered for my type 2 management? Yeah. So right now, we have several injectable medications for type 2 diabetes. And certainly, insulin. That's been around for a long time. But even within the insulins, now we have really more technologically advanced insulins that can come on at different times after injections. And I think we look at insulin as sort of a mainstay, particularly in people with diabetes and other complications, such as pancreatitis. There are other medications. You hear about them. There are a lot of commercials for them, like Ozempic and others. We tend not to use them so much in patients with hepatitis because we're concerned sometimes a little bit about those medications actually causing pancreatitis. But they are very useful medications in the right individuals because they actually can cause substantial weight loss. And that, of course, has impact in terms of blood glucose control. And they've also now been shown to reduce risk of cardiovascular disease, which is something that's associated with diabetes as well. But we have lots of oral medications that are also quite good now. So not just injectables. And so we like to do combinations of injectable medications with oral medications. And they work really well in people with type 2 diabetes. Fantastic. Dr. Thomas, we're going to come back with you to you on this one. I am 70 and told I'm pre-diabetic. I take 1,000 milligrams of metformin twice daily. Morning blood sugars are still in the 130s. Is that acceptable for prediabetes? Last A1C was 6.7. And I told you, our viewers sometimes get very specific, but they do ask great questions. We have great viewers. That's wonderful that you're taking the metformin and monitoring the glucose levels. An A1C of 6.7. So you want to talk to your health care team about that because that may actually be consistent with a diagnosis of diabetes. And so you want to know what your glucose levels are perhaps in the morning and two hours after meals. So sometimes, you want to check to see if your glucose levels are above the target range after eating as well. And so generally, the American Diabetes Association recommends that fasting glucose level to be between 80 and 130. These ranges are individualized because we do want to avoid low blood sugars. So in people who are at risk for low blood sugar, we'll adjust. But metformin generally doesn't cause low blood sugar. And so being on that dose of metformin seems appropriate. Your health care team will evaluate whether or not you need any adjustments based on kidney function. But one of the things that we just mentioned that we want to consider as well are what are those things we might call comorbid conditions. So if you've ever been told that you had coronary artery disease, or if you've ever been hospitalized with something called heart failure, then you want to know if there's another medication that could potentially be added to the metformin to reduce your risk for those complications. Great questions so far. These have been really good. Here's another one. So this one is for you, Dr. Mirmira. So why is it as you get older, that if you eat something sweet or certain medications can make the urine have a sweet smell or fruity smell? Does that necessarily mean that you have diabetes and should be checked? Is that something people should be alarmed about? So a couple of things. First off, as you get older, your risk of diabetes increases. So the prevalence of diabetes is higher in older individuals than in younger individuals. So that's something we should all be aware of. But beyond that, the term, diabetes mellitus, literally means sweet urine. And so that was really how the disease was identified and defined back a thousand years ago roughly. And so certainly, if that happens, and you do smell sweet urine-- you know, anybody who's older I think should be having regular checkups with their physician. And I think that's something that you should alert your physician to. It may or may not mean anything, but it should be checked. Yeah. Always when in doubt, talk to your physician. And we certainly encourage that. Dr. Thomas, here's another good one. I was diagnosed with type 2 diabetes two years ago today I have been doing well with maintaining my sugar. But two weeks ago, my sugar level skyrocketed skyrocketed, and it will not stabilize. So my question is, what can I do to keep such episodes from reoccurring? What you can do is kind of the same thing that we had learned from the Diabetes Prevention Program, which is introducing some exercise, some adequate sleep, and then looking at that plate and deciding if there are certain things that are in the glass, especially sweetened beverages with sugar, or even the big culprit would be high fructose corn syrup. So avoiding sweet beverages. Avoiding sweetened teas. And then making sure you're having that healthy plate with lots of vegetables and whole grains being the primary carbohydrate. And then whatever we'd make is our habit, having that be those healthy foods. And then having some of those concentrated sweets as we come upon the holidays. Having those be more occasional as opposed to the habits. I'm sorry. I'm so glad you brought up holidays because I think that's a real challenge for a lot of folks. And I apologize for interrupting you, but can you kind of talk a little bit about that, expound on that, and just maybe give people something to keep in their arsenal to battle it because that's hard. Right. So I think it's important to celebrate, especially now that we are able to have even our five-year-olds kind of vaccinated against the COVID-19. But we also have to think about portions. And so I think we don't want to completely avoid things. Everyone has to know what's good for them as an individual and what's that amount that they can tolerate. And don't feel frustrated by having some slightly elevated glucose levels. But what you don't want to do is not check. So you want to know what your glucose levels are. It's empowering. So you can know should I have that extra slice, or should I avoid it this time? That is great advice. We we're about out of time, but I do have one more question that I want to get to. So Dr. Mirmira, I'm going to throw this one to you. A question about Lantis. What is the proper time to take it? Every time I have a new doctor, they change it. One now says to take I've mostly taken one dose of Is one better than the other? And I again, we always kind of defer to your physician, but if you have any thoughts. So the best thing I can say is that good physicians will tailor diabetes regimens. There isn't always one way to do something. Generally, we give Lantis once a day. It could be in the evening. It could be in the morning. There are some people, just because of variations from individual to individual, where more than one injection a day might be appropriate. Typically, no more than two. And then of course, as I mentioned, there are newer insulins now that really eliminate the need for twice a day, whether it's Atlantis or some other type of insulin. So there are some new insulins that can do that too. So again, I think good physicians tailor diabetes regimens for individuals, their lifestyles, and how they respond. Yeah. I think this again illustrates why it's really important to establish that relationship with your physician, build that relationship, and be open with your physician because that's what you all are there for. You want to talk to your patients. And it certainly is helpful, I think, to establish those lines of communication. Well, you are fantastic. Thank you very much. You're great. That's all the time we've have for this segment. We're going to take a quick break. When we come back though, we're going to travel inside the lab to look at some of the exciting research that's happening here at UChicago Medicine. And welcome back. Research is an exciting part of what happens here at UChicago Medicine. In fact, our research scientists in the labs are among some of the very best in the country. And one area of research where our experts constantly are working is of course, diabetes. Today we're going to take a look inside one of our labs with an expert guiding us. And Dr. Ryan Anderson is joining us for a quick tour of the lab and to tell us a little bit about what's going on there. First of all, welcome. Thank you, Dr. Anderson. Thank you for having me. Great. So let's just start off. I understand you have a little bit of a show and tell set up for us. What do we have to look at today? We'll start over here at the show and tell kind of a pet store of research. So in the lab, we study the development and the function of the pancreatic islets, which are key for studying the disease, diabetes, and the pathogenesis of diabetes. And we use a range of different models in the lab to move all the way from singled cell organisms, like bacteria, which we can use as a tool, up through more advanced organisms, like zebrafish, that have their own unique experimental advantages. Up through mice, which are a mammalian system that are more closely related to humans than zebrafish are. And then of course, the closest model that we use to humans are cells and micro-organs isolated from humans. So we've also got human islets here in a tissue culture dish. And all systems that we use in the lab can be exploited for their unique characteristics and advantages for doing sort of experimental medicine in a research lab. So tell us a little bit about the zebrafish. I know you have some things on the microscope back there that you wanted to show us. What is the advantage of using zebrafish? Well, the great advantage of using zebrafish is first off, they are a vertebrate organism that share much of basic body plan and organ structure with humans. And so they can be a very good model for humans. But the experimental advantages are that we can use the zebrafish embryo as a sort of a miniature in vivo system to study cells like pancreatic beta cells in their natural context. And in addition, we can study how those cells develop from the singled cell zygote, all the way up to the complete organism. And so when we understand those processes by which cells can develop, we can exploit those to make new cells for therapeutic purposes. So zebrafish have the advantage that they produce a lot of progeny that we can study. And that those progeny can be manipulated genetically very easily. And those embryos are basically transparent. So we can look into the internal organs of the organism while it's still alive and study how they're functioning and how they're developing. And you have an example that you're going to show us on the microscope right here? I do. So similar to this Petri dish here, these are some embryos that were collected a couple of days ago. So they are two days post fertilization. And if you look down here at the bottom of the microscope, this is just the Petri dish full of embryos. And each one of these embryos is just a couple of millimeters long. But by two days, this embryo, if you now look over here at the monitor, this is being projected from a camera on the microscope. And this is a living zebrafish two days old. And you can see that it already looks like a fish. It's got a head. It's got the tail. It's got the eyes. And you could even see the beating heart here. But what we're particularly interested in is the development and the function of the pancreas and the pancreatic islet and the cells that are in that pancreas that make insulin. And so these fish have been genetically modified, so that they have a fluorescent pancreatic islet. So if I turn on the fluorescent light here, and you look at the picture of the embryo, you can now see this green spot here. So I'll just flip it off and then back on. So we're illuminating these with fluorescent lights. And a molecule that's being produced in the pancreas in those beta cells is now emitting fluorescent green light. So these are about 50 cells at this stage in the zebrafish's life. And they're already making insulin. And those cells are functioning to regulate the blood glucose in those animals. Interesting. Well, I tell you, I know we only gave you about five minutes, and we could probably spend hours in the lab. And we are going to actually do a follow-up with you because I'd love to do that in the future. But thank you very much for that fascinating look at some of the science that's happening around diabetes treatment and cures. That's all the time we have for the program today. If you want more information about diabetes and diabetes care, please visit the Kovler website at kovlerdiabetescenter.org. Thanks for watching. I hope everyone has a great day.
School Nurses & Other Personnel Supporting Diabetes Care
In this informative video, school nurses will learn essential strategies for supporting students with diabetes in the school setting. From recognizing signs of low or high blood sugar to developing familiarity with diabetes technology, this 20-minute video briefly reviews some of the day-to-day tasks necessary to ensure students' safety so they may have a successful learning experience and participate in extracurricular activities.
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.