Making Indian schools type 1 diabetes friendly

Type 1 diabetes mellitus (T1D) is one of the most common chronic conditions affecting children and adolescents. Worldwide 1.85 million children and adolescents (<20 years) are living with T1D.^[1] There has been a surge in cases in the recent past, with a significant number of incident cases reported from Asian countries, including India. It is estimated that 301,000 children and adolescents are currently living with T1D (CwT1D) in India.^[1]

The standard care for CwT1D includes physiological insulin replacement with basal bolus insulin/insulin pump, intensive glucose monitoring using either continuous glucose monitoring (CGM) or frequent capillary glucose monitoring, a balanced nutrition and regular physical activity. Better glycemic control as indicated by glycated hemoglobin (HbA1c) of <7% and at least 70% time-in-range between 70 and 180 mg/dL as recommended by the International Society for Pediatric and Adolescent Diabetes (ISPAD)^[2] is associated with significant reduction of micro- and macrovascular complications, enabling a fully functional life for CwT1D. However, only a minority of CwT1D meet these goals. Only 24% out of 281 children achieved the ISPAD-recommended HbA1c in an Indian study.^[3]

Children spend nearly 6–8 h/day in school. Better management of diabetes during school hours is not only associated with a reduction of episodes of hypoglycemia and diabetes ketoacidosis but also with improved academic performance and improvement in overall glycemic control, leading to a reduction of microvascular complications. However, there are several challenges in managing school hours for CwT1D. These include the stigma or shame associated with diagnosis of T1D, teasing/bullying of CwT1D by peers and/or teachers, lack of safe and comfortable place in the school for taking insulin and monitoring glucose, unwillingness/fear on the part of school staff to take responsibility for care of CwT1D, need for parents to go to school for insulin administration, and lack of formal education of school staff on T1D.

In this issue of the journal, Soodhana et al. present results of a study on 80 teachers dealing with 97 CwT1D from Kerala.^[4] The study highlights a stark need for formal education of school teachers on T1D since 91% did not have any formal education on the same. Their knowledge on basic aspects of T1D was limited, although these numbers are small, and it is not clear if the questionnaire and its translation were validated or not. Yet, the findings of the study are relevant and indicate the effectiveness of a structured educational program in raising awareness. Thanks to the “Mittayi” program of the Kerala Government and the literacy rates of the state, it is likely that the awareness levels in Kerala are better compared to other state in India.^[5] Other studies from India have also highlighted the gaps in T1D care in schools. In a survey of 397 CwT1D, predominantly from an urban private school, less than half of the children administered an insulin bolus for a school meal, with only 1.5% being administered by school staff, just 24.4% checked glucose regularly (>1/week), and merely 16% of the times, the injection was given in a medical room.^[6] Although the private schools fared slightly better than the Government schools in this study, significant gaps still existed.

Globally, the picture is variable depending on the socioeconomic development and background incidence of T1D. European countries, in general, show a better structure. In a Danish survey, 77.2% of the respondents reported school personnel being trained in diabetes management and 78.5% schools had at least one person available for diabetes support daily.^[7] Notable deficiencies in care included lack of an individualized diabetes management plan (DMP) in nearly 40% and face-to-face interactions with parents in 62.6%. However, several surveys report deficiencies in the level of support at school, even in the developed world. In a Swedish study, despite adequate policies, significant gaps were reported.^[8] For about 57% children, there was no member of staff with principal responsibility to support diabetes care. A written DMP was present only for 60% children, and 21% of the parents regularly gave less insulin than the calculated dose to avoid hypoglycemia. An Irish study in primary schools by McCollum et al., majority of children were injecting insulin at school but only 29% staff were trained in diabetes management.^[9] The high variability of data also seems to stem from the variability of responses in survey-based studies.

Globally, the need for care and support for CwT1D is well recognized. In the USA, in compliance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act, schools are obligated to create an individualized “504 Plan” for each student with diabetes.^[10] The Children and Families Act 2014 requires every child with a chronic condition to have an annually reviewed “Individual Health Plan” in the United Kingdom. The Diabetes in Schools initiative, led by Diabetes Australia, blends digital learning modules with in-person workshops to train educators. It provides 24-h helpline access, downloadable care templates, and interactive online courses that prepare teachers to manage insulin administration and hypoglycemia effectively.

As of now, there is no dedicated legislation for T1D support in India, and T1D is not recognized as a physical disability. However, over the past few years, decisions such as a circular from the Central Board of Secondary Education^[11] allowing students with T1D to carry snacks, water, glucometers, CGMs, and insulin pumps during examinations have been a ray of hope. In 2023.^[11] The National Commission for Protection of Child Rights issued a directive urging all schools to allow glucose testing, insulin administration, and snacks during classes, and to train teachers to recognize hypoglycemia.^[12] Kerala’s “Mittayi Scheme” is India’s first government-supported comprehensive care program for children with type 1 diabetes.^[5] The scheme focuses on ensuring continuous medical and psychosocial support by linking children with pediatric endocrinologists, diabetes educators, and school authorities. It also integrates telemedicine follow-ups, parent training, and teacher awareness sessions to promote safe diabetes management during school hours. Currently, benefiting over 3,000 children, the “Mittayi Scheme” stands as a pioneering example of how public health and education systems can collaborate to create inclusive, T1D-friendly environments across India. The initiative “Diabetes Education and Awareness for Schools (IDEAS)” by the Indian Society for Pediatric and Adolescent Endocrinology is aiming to create awareness among school staff dealing with children with T1D, to empower them to help these children look after themselves.^[13] This online training module of 90 min is now available in eight languages and can be used freely by all T1D healthcare providers.

In conclusion, similar to the study by Soodhana et al.,^[4] there is a need for good quality studies clarifying the baseline status of support for CwT1D in Indian schools. To build truly type 1 diabetes friendly schools, educators must be empowered through regular diabetes training mandatory for at least half the staff. School should establish basic health infrastructure that includes a separate glucose testing area, a sharps disposable unit, and an emergency hypoglycemia kit, and must adopt models like cluster nursing (wherein a trained nurse oversees diabetes care across a group of nearby schools) or teleconsultation with pediatric endocrinologists for expert guidance. Each child should have an individualized diabetes care plan, cosigned by parents and endocrinologists, backed by legal safeguards under “Right to Education Act.” These steps can transform Indian schools from passive bystanders into active partners in diabetes care.