The transition from high school to college is often a challenging time for emerging adults and their caregivers. For many incoming first-year students, it is the first time that they are away from home without adult supervision and support. They may never have been responsible for laundry and meal preparation. It may be the first time that they share a room. Class schedules and the 24/7 opportunities of campus life can lead to significant alterations in sleep and meal schedules. The demands of a chronic illness such as type 1 diabetes add complexity to this transition. The student must find the right balance between studying, socializing, acclimating to a new environment, and managing diabetes. As a health-care provider, you should begin the dialogue regarding this transition at least one year in advance so that the appropriate education is provided and provisions such as accommodation requests are submitted.
Under the protections of the Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act of 1973, it is typical for a written 504 plan to be in place for students in grades K-12. Although there will not be a formal written plan in college and beyond, these protections extend into postsecondary education settings and apply to housing as well as the classroom setting. It is the student’s responsibility to seek out the services, and, although not required, housing and academic accommodations are often helpful and should be considered. The first step to obtaining accommodations is to register with the Office of Disability Services on campus. The office will guide the student through the necessary steps. Colleges typically require documentation that includes confirmation of diabetes diagnosis (with reasons why it is a disability) and a description of the requested accommodations with rationale as to why they are needed. Each college will likely have standard forms, but if not, the American Diabetes Association’s “Going to College with Diabetes: A Self Advocacy Guide for Students” is one resource for sample letters. Keep in mind that some things, such as missed classes due to illness, may already be built into the institution’s general policies. Sample accommodations include:
It is important to determine what types of health-care services are available at and near school. Before leaving for college, the student should meet with their diabetes provider to discuss recommendations for local diabetes care as well as a plan for obtaining prescriptions and diabetes supplies. It is best to have a copy of their insurance card for urgent medical care needs that may arise.
College students are vulnerable to illness due to sleep deprivation, poor eating habits and stress. Many students will be independently managing diabetes for the first time in the setting of an acute illness. The diabetes provider should review sick day management guidelines and create a sick day plan to include recommended frequency of glucose and ketone monitoring, steps to prevent dehydration, and circumstances requiring contact of the health-care team. Most importantly, students should know when they should seek out assistance. They should encourage their roommates and family to check in with them during illness.
Navigating the dining hall with diabetes can be overwhelming. The student should meet with a dietitian for recommendations prior to leaving for college. They should also contact the college dining services in advance to request information about food options, available meal plans, whether nutrition information is (or can be) posted in the dining hall, and hours of operation. If nutrition information is unavailable, the student can utilize internet or app-related resources, such as Figwee Portion Explorer and CalorieKing Food Search.
Late-night eating is commonplace in college and typically includes higher-carb and higher-fat foods. It is important to review how to best manage insulin doses to cover these food choices. In addition, encouraging students to keep nutritious foods in the dorm room and helping them anticipate these situations in advance can help promote healthier choices.
Engaging in physical activity is an essential part of a healthy lifestyle and is an important component of diabetes management. Students should follow previous recommendations for glucose management when physically active. If they are new to physical activity, it is recommended to monitor glucose readings before, during and up to several hours after physical activity. Adjustments to carbohydrate intake and insulin dosing should be considered to prevent hypoglycemia. It’s critical to remind students of the importance of always carrying fast-acting carbs, monitoring glucose and having a means of staying hydrated during physical activity.
Once young adults are at school, it’s important to create a new support system and communication plan that may include the roommate, caregiver and resident hall assistant. Students may have different levels of comfort in disclosing their diabetes to their roommate and/or the resident hall assistant, but this can be very beneficial. For example, a roommate who has basic information about diabetes—especially the signs, symptoms and treatment of hypoglycemia—can offer assistance if needed. It is also important to have an emergency plan. For instance, it’s necessary to find out if a roommate will be willing to learn how to administer glucagon and call 911 in the event of severe hypoglycemia.
A number of students will be managing their diabetes with the use of a continuous glucose monitor (CGM) while at college. If the student is sharing CGM data with a caregiver, an emergency contact should be identified in the event that the caregiver’s call goes unanswered. The student should consider creating a contact list for communication between the roommate(s) and the student’s family. It’s common for students to become overwhelmed or struggle with managing diabetes. Providers can assist in developing realistic expectations about the stress of this transition. It’s also helpful to make sure they are aware of on-campus support, such as counseling, and encourage them to use these services if needed. Many campuses have support organizations, such as the College Diabetes Network.
Diabetes supplies (Table 1) should be organized and stored in a designated location. The student should share the location of the glucagon emergency kit and fast-acting carbohydrates with their roommate and resident advisor. It is important that they understand that some of these will be needed to treat hypoglycemia and should be “off limits” to others.
Anticipatory guidance about sexual health should be provided to all students before departing for college. All students should be counseled on safer sex practices. Women should be counseled on the risks of fetal anomalies with poor glycemic control and the importance of using reliable contraception. Some men may be hesitant to discuss erectile dysfunction due to its sensitive nature. The provider should start an honest discussion regarding any current issues as well as risk of development and recommended management of future issues.
There is an increased risk of hypoglycemia with alcohol consumption due to the inhibition of hepatic gluconeogenesis. It is important to emphasize that in the event of severe hypoglycemia, glucagon is ineffective. In addition, some signs of intoxication mimic those of hypoglycemia. For the student with diabetes, it is of the utmost importance to provide them with the guidance to drink alcohol safely. The following are recommendations:
• Avoid consuming alcohol alone
• Carry treatment for hypoglycemia
• Do not consume alcohol on an empty stomach
• Limit intake to one to two drinks over the course of the entire evening
• Monitor glucose frequently
• Wear diabetes identification
• Consider decreasing insulin doses
The transition to successfully managing diabetes in college can be full of challenges, and being well-prepared is essential. The support and education provided by the diabetes care team plays a vital role in ensuring a healthy and successful transition.
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