Posted by: Francis Koster Published: March 20, 2024

Lengthen the Life of a Child With Pre-Diabetes (March 20, 2024)

Addressing health issues in North Carolina's K-12 schools is a major opportunity to raise our state's embarrassing national ranking for student learning while at the same time improving the length and quality of students' lives - and it can have a huge rate of financial return.

The health of America’s K-12 students has been going in the wrong direction for years now - even before Covid. Our national failure to address this is impacting the health of our kids, shortening their lives, and exploding our state and national healthcare costs – and is lowering learning at school.

North Carolina can be a national role model.

Let’s take pre-diabetes as an example.

You had better sit down – this is shocking to read.

These two maps below are showing the prevalence of diagnosed diabetes in adults 20 years and older for the years 2004 and 2021. (1)

There are two kinds of diabetes that children and adults can have. Type 1 is present at birth and is about 5%–10% of all cases of diabetes worldwide.(2)  Type 2 (the other 90% - 95%) emerges later in life. So in the map below, the vast majority are Type 2.(2)

The problem is much worse in school aged children. Many studies are now showing that during Covid the percentage of youth under 21 diagnosed with Type 2 diabetes increased around 60% from 2016 and 2021. (3)

Before type 2 diabetes is actually a full-blown disease, it quietly grows and takes over parts of a young person’s body.  This sneaky phase is called “pre-diabetic” – and most of the people who have this are enrolled in K-12 schools. They, and their parents, do not know it.

Untreated pre-diabetes typically takes 5 to 10 years to become bad enough for it to be diagnosed as diabetes, so in the 2021 map (on the right) a very large number of these 20+ year old students were either pre-diabetic or had undiagnosed diabetes during middle and high school.

The National Institutes of Health estimate that one in five students between the ages of 12 and 18 have pre-diabetes, and the number is growing rapidly. (4)

A K-12 student who has unrecognized pre-diabetes is likely to be diagnosed as a full-blown diabetic before the age of 30.  When diagnosed with diabetes around that age, their life expectancy will be 14 years shorter than their high-school pals who did not have pre-diabetes.(5)

Interventions are important! If pre-diabetes is recognized early, there are behavioral interventions that work, like teaching the student the role of proper nutrition, and ensuring lots of daily exercise that reduce or stop the development of the disease.

The current North Carolina School Health Program cannot stop this explosion of disease.

The North Carolina State Board of Education recommends that for every 750 students one school nurse be available. Due to poor funding from the state legislature, North Carolina falls short of that goal.  In 2022, our statewide ratio was 1:833 and that is just the average. Many school districts are much worse.(6)

If you look at the map below you will see how badly the shortage of school nurses impacted some school districts in 2020/21 (The last year for which I could find mapped data).

And on top of that shortage of nurses, large scale screening of the student population for the one-in-five students who are likely to have pre-diabetes is not part of today's School Nurse job description.

What this one example illustrates is that we have a rapid rise in the number of adolescents with emerging life-altering illness, and a school nursing system that is both underfunded and understaffed, and does not have the resources to focus on prevention of disease.

If we fixed this situation we would save our society an enormous amount of money. The estimated annual cost of diabetic care in America in 2022 was $412.9 billion dollars.(7)

So we are facing a public policy question: “What should the role of schools be in surveying children for common and preventable/treatable diseases that lower learning, their life expectancy, and their financial future?"

Is this "making the invisible visible" disease identification among kids the job of the school system? If not, whose job is it?

Doing a quick screening test for pre-Diabetes involves (with parental consent) taking a student’s height and weight and pricking their finger for a tiny drop of blood.  It can be done by a combination of talented folks like nursing students to prick the blood, and volunteers to capture height and weight. That is it. And if the test results indicate a likelihood of pre-diabetes, the student’s parents can be referred to a physician or Public Health Department to initiate care, and the students and their parents can be introduced to behavioral changes that can extend their children’s life many years.

There have been many studies done on what kind of changes can be made in a school environment that can save the kids, and a set of successful programs have been identified. I am quoting here from an article published by the National Library of Medicine in 2020. (8)

"Strategies implemented in effective interventions were: teachers acting as role-models and being actively involved in the delivery of the intervention, .... the availability of healthy food and beverage choices and limiting unhealthy snacks, changes in the schoolyard, in the recess rules and in the physical education classes to increase physical activity, and involving parents in the intervention via assignments, meetings, informative material and encouraging them to improve the home environment. Use of incentives for children, social marketing techniques, collaboration with local stakeholders were found to increase effectiveness.

Programs that focused only on educational sessions and material for parents, without promoting relevant environmental and policy changes, were found to be less effective. "

So we know what works, and what does not.

These solutions to this public policy tragedy and/or opportunity-to-be-seized needs to go well beyond the current thinking about the role of your school system.

How do we go forward?

If anyone is interested in doing a local test pilot project that the entire state can learn from, please reach out to me:



As I mentioned before, I would appreciate having some experienced teachers, school administrators or school board members who would be willing to spend one hour on a group phone call, during which time you would tell me which content in past newsletters was most useful, least useful, and counterproductive. I will not quote anyone – as I have mentioned, I am a retired pediatric healthcare administrator, never worked in K-12 schools, and have much to learn.  If you are willing to try to educate me, please send me contact information at


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Francis P. Koster Ed.D.

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