How to Handle School Lunches and Snacks for Kids with Diabetes
By Cheryl Alkon
Whether your child has type 1 or type 2 diabetes, figuring out nutrition for school and childcare is a big part of managing glucose numbers – as well as nourishing a growing body.
Whether your child is newly diagnosed or has been living with diabetes for years, knowing how carbohydrates work and how they affect blood sugar numbers is critical.
“A diabetes care and education specialist can design a meal plan that will work for your child, managing their preferences and lifestyle,” said Marlisa Brown, MS, CDCES, a dietician, President of Total Wellness, and spokesperson for the Association of Diabetes Care & Education Specialists (ADCES).
It’s important that children with type 1 diabetes understand, in an age-appropriate way, how insulin works, why it is needed, and how to dose insulin based on how many carbohydrates are in their meals. Your child should also recognize symptoms of hypoglycemia and how to treat it (such as the 15-15 rule – for younger children the 15-15 rule may need to be adapted to deliver a lower amount of carbohydrates). Beyond these basics, “give them a simple meal plan with set amounts of carbohydrates to start,” Brown said.
For kids with type 2 diabetes, “look to achieve weight loss if necessary, increase exercise, and increase fruits, vegetables, and water,” she said. Reducing carbohydrates, especially simple carbs such as white flour or sugar, and eating fewer processed or fast foods, is also recommended.
Looking for ideas for a lower-carb lunch? Check out diaTribe’s article, “The Low-Carb Lunchbox.”
For families who have been dealing with diabetes for a while, discussing carb counts is second nature. For Katherine, from North Carolina, who has lived with type 1 diabetes since she was 10, and her daughter Ellie, who was diagnosed at age 3 and is now a fourth grader, conversations about insulin and food “are just a part of who we are,” she said.
“They’re no different than things like brushing your teeth or taking a shower,” Katherine said. “Our family and (our) endocrinologist very strongly support that we eat sensibly and without restrictions. It makes it easier when the whole family eats the same way because no one feels singled out. We make desserts and have treats just like anyone else. The difference for Ellie is teaching her that sometimes we do need to wait to eat for our glucose level to come down [from the hyperglycemic range] or to not eat too many carbs all at once.”
For Heather Gordon of Knoxville, Tennessee, whose son, Tyler, 11, and daughter, Micaela, 8, were both diagnosed with type 1 diabetes before each was a year old (and who lives with type 1 herself), eating a certain way “is a way of life, for sure,” she said.
“They know about carbs, fruits, and veggies, and my son is sometimes better at estimating carb counts than I am now,” Gordon said. “They know protein is incredibly important, and that if they ask for too many chips, I’m going to make them add a fruit instead. If they eat all that and are still hungry, we can talk, but most times, by then, they are full.”
Talking to teachers and school nurses about nutrition
For very young children who are attending preschool or day care, conversations about nutrition typically happen with school staff. Vicki Flint of Epsom, England, who has lived with type 1 for 30 years, is now overseeing diabetes care for her daughter Ariella, who is 22 months and was diagnosed with type 1 at 10 months old.
“All of the staff know the basics of carb counting, and I pack Ariella’s lunch and carb count it out for her,” Flint said, who added that the staff gives Ariella her insulin via a Medtronic pump after eating since “she’s not consistent with eating.” Flint said that she and her daughter’s school staff “work together to find solutions to issues coming up.”
Ensuring school staff are aware of what your child needs to eat, when, and how to dose insulin helps keep everyone on the same page. One way to do that is to use the American Diabetes Association’s Diabetes Medical Management Plan (DMMP) form, said Crystal Woodward, the director of Safe at School for the ADA.
“Meal plans and recommendations for carbohydrate intake in the school setting should be set out by the student’s healthcare provider in an individualized DMMP or provider’s orders,” she said.
You need to fill out the DMMP each year to work with a new teacher or teachers, the school nurse, and other school personnel as needed. These templates should be specifically tailored for each child annually and signed by their healthcare provider. Some healthcare providers or schools may have their own forms they prefer to use – the important part is the information, not the format.
“Teachers and nurses should be educated on the signs of low glucose and how to treat it,” said Brown. They also need to be told and sometimes taught how to administer or oversee insulin doses. Once you have filled out the DMMP, plan a time to connect with the appropriate school staff – teachers, nurses, and anyone else, so that they fully understand everything listed in the form and see if they have any questions about it.
After some time, though, you and your child may be able to handle things more independently.
Talking to school staff about your child’s diabetes can help smooth the way for a healthy school year. Woodward encouraged parents and guardians to meet with the school nurse and other staff before the school year began or before their child returned to school after diagnosis.
“Parents need to know to hang in there. It definitely gets easier,” said Katherine. “We were initially stressed out when we started public school because we didn’t have a dedicated nurse at each school in our county and state. In the end, I actually think this is easier. We train Ellie’s teachers at the beginning of each year, and there are several other staff members that know how to care for her. She doesn’t need to leave the classroom to ‘go to the nurse,’ and her teachers are very tuned in to what she needs and how her glucose levels are each day.”
“The children’s level of independence should be reflected in the DMMP so the school can train school staff in diabetes management to best support the individual student,” she said.
For example, Woodward said, while newly diagnosed or younger students may need the school nurse or a trained school staff member to administer insulin, older students or students who have lived with diabetes for a while can handle their own self-management.
In addition, technology such as continuous glucose monitors (CGM), insulin pumps, or closed loop systems can be extremely helpful for parents, caregivers, and school nurses to keep watch over children’s glucose values throughout the day and deliver the proper doses of insulin. Sharing CGM data can allow family members and school nurses to see what is going on with a child’s glucose and respond accordingly. Learn more about sharing your CGM data here.
To ensure your child is getting all the time and attention needed for diabetes care while not missing important educational time, the ADA recommends all students have a 504 Plan in place. A 504 plan is a result of the Section 504 federal civil rights law which ensures that all kids will be treated equally in public schools and in private schools that receive federal funding, said Woodward. Contact your child’s school’s 504 coordinator (typically the principal or a special needs administrator but may be a guidance counselor or teacher) to request a 504 plan, based on the DMMP, put in place.
How to pack school lunch boxes
For younger kids, packing a lunch may include marking the carb counts on each item so that they know what they are eating and can figure out the appropriate insulin dose. Overall, for maximum nutrition, “include a variety of choices for lunch, snack and drinks,” said Brown. “Try string cheese and crackers for snacks, a light yogurt, or a bread and fruit and some veggies on the side. You can pair that with a little low-fat dressing, for dipping.” Think about what sources of protein will fill your child up, such as deli meat, eggs, or nut or soy butters.
For drinks, pack water and low-fat milk, and avoid sugar-sweetened beverages and juices. For midmorning or after school snacks, if your child goes to an afterschool program, Brown suggests pretzels, cheese and crackers, or 100-calorie packets of snacks.
For Gordon’s daughter, Micaela, who has food allergies and injects her insulin, Gordon packs lunch for her and works with the school nurse to give injections based on the amount Gordon instructs.
Her son, Tyler, is on an insulin pump and eats at school more often, now that he is older. “Middle school has been different [than how lunch was in elementary school],” she said. “The number of sides is greatly reduced as far as options. He used to be able to get three or four veggies or fruits, and he would normally like them. Now, they get two options; one is normally a salad or baby carrots, and the other is fries or tater tots. He won’t eat their salads, as they are very small with mostly lettuce and a couple slivers of carrot. I often try to send him with an apple, banana, or mango.”
Some kids, like Ellie, pack their own lunches. She favors a sandwich, baby carrots or cucumber slices, and a piece of fruit or berries. “We give her the carb count of her meal, and she enters it into her insulin pump and is good to go,” said her mother.
How to ensure kids feel included during school lunches/snack times
Mealtime at school should be an inclusive and social activity for everyone – so how can kids with diabetes feel like they are part of the larger group?
“All foods can be fit into a diabetes meal plan,” said Brown. Also, “it’s OK to go off plan for a party or an event and partake in some foods that may not be usually included in a meal plan.”
While food allergies and the Covid pandemic have curtailed or even eliminated class or in-school parties, parents can ask about the menu for future school events or shared meals and can figure out ahead of time what carb counts are for certain foods and how to dose correctly for them.
As kids get older, at least one parent has noticed the difference in what is available at school. Whenever her son Tyler was in elementary school, “Whatever the class did, he did,” said Gardner. “He could eat whatever just as long as he bolused for it.”
Now that he’s a sixth grader, he relies on his own juice boxes or glucose tabs for lows, and lunch options at school seem to lean toward what’s in demand over what’s nutritious. “The middle school serves pizza every single day,” she said. “The move away from healthier eating is very obvious to me.”
Woodward agreed this can be challenging. “Many families prefer for their children to bring their lunches and snacks from home for a variety of reasons including access to healthier food options, satisfying the child’s personal food preferences, limited time for consuming lunch, and ease of parent or student pre-calculation of carbohydrates and other nutrition information.”
However, if your child wants to eat school lunches with higher carb counts such as pizza, Woodward advised, “the school’s food service manager and/or school nurse should provide the family with nutritional information for school meals.”
“Moderation and education is key for success,” said Brown.
For more information about what to eat for people and kids with diabetes, check out the following articles from diaTribe:
This article is part of a series on nutrition to support people with diabetes, funded in part by The Ella Fitzgerald Charitable Foundation.