The prevalence of Type 1 Diabetes in Texas children is estimated at between 1 in 400 and 1 in 500 children. This would predict that about 182 AISD students have Type 1 Diabetes. In SY 2012-13, 115 students were case managed by RNs for Type 1 Diabetes. Older students who successfully self-manage their condition may not receive case management if they choose not to receive it; however the school RN is always available if needed. Students with this condition generate a large number of time-intensive health contacts to monitor and manage blood glucose levels daily in the school setting. SHS staff report blood glucose levels to nurse managers according to protocol. Nursing managers guide decisions related to the individualized care plans, given glucose levels. They work closely with Dell Children’s Medical Center pediatric endocrinologists and the SHS Medical Director to insure proper care for students.
Obesity is the major risk factor for Diabetes Type 2. Texas Youth Risk Behavior Survey data for 2011 indicate that 15.6% of Texas high school students describe themselves as obese (BMI>95%ile) and 16% describe themselves as overweight (BMI >85%ile, <95%ile) (http://www.dshs.state.tx.us/chs/yrbs/query/yrbss_form.shtm). The Texas Department of State Health Services estimates that based on measures of body mass index (BMI), approximately 22% of Texas children are overweight, and an additional 15% are obese (37% high BMI). Although Type 2 diabetes is found in all ethnic groups, a disproportionate number of African American, Hispanic and American Indian persons are diagnosed. Children who are diagnosed with Type 2 diabetes are typically overweight/obese.
Type 2 Diabetes Vulnerability Screening
The Texas legislature has mandated that school nurses screen students for Type 2 Diabetes vulnerability based on acanthosis nigricans (AN), a skin discoloration associated with insulin resistance. Students with the skin discoloration receive additional health assessments such as body mass index and blood pressure. Those students with a grade 4 skin discoloration or the discoloration in combination with another factor such as elevated blood pressure are referred for medical follow-up. During School Year 2012-13, of the 26,258 students in grades 1,3, 5, and 7 screened, 2276 (8.7%) were referred to health providers. This suggests that at a minimum over 7500 AISD students (8.7% of 86,500 students) have an identifiable risk factor for developing diabetes due to having acanthosis nigricans. However the likelihood of having acanthosis nigricans increases with age, so students in high school likely have an even higher prevalence of acanthosis nigricans. For more information on AN please refer to the state legislative report (https://rfes.utpa.edu/resources/TRAT2DC_Legislative_Report_2013.pdf). Children with overweight and obesity are also at risk for additional current and future medical problems. Children with overweight/obesity are identified through the Fitnessgram’s BMI assessment. This measure indicates 34,000 AISD students are challenged by overweight or obesity.
Based on findings returned from medical providers, only about 6% of students referred to a medical provider are found to be within normal limits, 50% of the students referred are found to be obese, and about 20% are found to be vulnerable for type 2 diabetes.
Children’s/AISD Student Health Services, working collaboratively with the AISD Assistant Director of Comprehensive Health Services, Administrative Supervisor of Physical and Health Education, and 504 Coordinators, has been developing an obesity case management program and is targeting its use for the more than 3000 students who are severely obese (BMI>99th%ile).
Student Fitnessgram data has been integrated into the student’s health record via the Student Health Information System (SHIS). School nurses now have access to the student’s BMI measures. Progress has also been made in improving the collaboration process between AISD Physical Educators and nurses for referring students to medical care who are identified with a BMI> 99th percentile.
A multiyear increasing trend in diabetic health contacts is evident. The Return to Class rate for all diabetic health contacts was 94.2%. For students whose blood glucose level was out of range for their care plan, the Return to Class rate was 94.2%.
Much of the RN’s time is spent on case management for students with special health needs such as asthma, diabetes, epilepsy or severe food allergies. Kristen Pokky, RN, makes a huge impact in the lives of her students. Recently she had a student on her campus that was a paraplegic from a motor vehicle accident years back. He did not have a ramp at the family home for him to get in and out of the house by himself. He relied on family members to carry him. His mom and primary care giver was deported and other family moved out of the house. This left the student a prisoner in his own home. Kristen made many phone calls to find a resource to build a ramp for the student. She was put in touch with Lt. Robert Kimmons of the Austin Fire Department. Together they made a plan for a fire truck and a group of fire fighters to canvas the neighborhood on a day they were sure the student would be at home. The firefighters went door to door looking for and installing smoke detectors. At the student’s home smoke detectors were installed and the firefighter inquired about how the student got in and out of his home. Curiously, early in the summer a ramp was built for the student. Of course no one is taking credit for it. Together with a teaching assistant and campus social worker, Kristen has been able to get a metro pass for this student and a gym membership with the clearance of his physician, to help with transfer training and upper body strength. There is a contact at the gym who is personally working with the student. They are also in the process of helping this student get a new wheelchair, apply for SSI and section 8 housing. There are many more examples where this came from. Kristen views her job as a privilege and an honor to be in a position to help these young people. She says that “Persistence pays off in the end”.