Reasonable Adjustments

In the UK, universities are legally obliged to provide reasonable adjustments for students with type 1 diabetes (T1D) if requested.

The reasonable adjustments for students with T1D will be particularly relevant for exams and coursework.

In the ADAPT approach, the following (minimal) adjustments must be provided to all registered students with T1D. Note that all the reasonable adjustments listed below are based on the best practise in UK education.

Adjustment 1:

At any time, including during exams, the student must be allowed to have their mobile phone on their desk to use their Continuous Glucose Monitor and/or insulin pump.

Nearly all university students with T1D will wear a Continuous Glucose Monitor (CGM). Here are some basic facts about the CGM.

• The CGM as small as a coin and is inserted in arm or belly
• The CGM helps to maintain a healthy blood glucose level
• The CGM is paired with the mobile phone device via low-energy BlueTooth
• To work, these sensors need to be really close to the user (and not on invigilator’s desk)
• They emit a signal to a paired mobile phone every 1 to 5 minutes
• The phone can also emit an alarm sound when out-of-range glucose values occur
• The phone can optionally send glucose values to relatives (e.g., parents)
• There are different brands of CGMs and they all use a different phone app

Because glucose values can change quickly, the phone and CGM should be connected all the time. CGMs can alarm patients about out of range values. The sound may disturb others. To prevent this, it is reasonable to allow the student to use headphones during the exam.

Note that apart from CGMs, many students with T1D will also use an insulin pump which can be controlled by their mobile phone. Sometimes, the phone, CGM, and insulin pump work together (e.g., as part of a so-called hybrid closed loop system). There are different configurations for different patients.

Students should always be offered a separate or less crowded exam room to give them the privacy needed to have their medical equipment, medication, etc with them without potential feeling shy or embarrassed about this. Students might need to take glucose or snacks during the exam to maintain their glucose level, but do not like others to seem do this. This makes a separate room ideal.

Note that a phone controlling diabetes technology should not be on an invigilator’s desk for the following reasons:

• The phone is part of a medical device. It is unreasonable to ask a patient to put a medical device away that gives minute-to-minute updates about their health condition.

• Due to low-energy BlueTooth, the distance between phone and device should be minimised. Low-energy BlueTooth is not the same as “normal” BlueTooth that is used for headphones and so on. The glucose sensor uses a tiny battery for two weeks to communicate with the phone, which means that the distance is short. If the phone and glucose sensor cannot communicate, the sensor is useless.

• The patient needs to be able to access the blood glucose values at all times. Blood glucose can rapidly change, especially under special circumstances, such as taking an exam. The phone can help the patient to control their blood sugar. Asking the patient to walk to an invigilator to access their own medical device is not reasonable.

• The invigilator is not trained to use the blood glucose sensor. Some sensors can only be checked after unlocking the home screen. It is unreasonable to ask an invigilator to play doctor. It also creates a liability and confidentiality issue: who is responsible for the health of the student when the invigilator is given the medical device?

Adjustment 2:

Being allowed without penalty to submit coursework up to 7 days late without further need to provide a further letter from a doctor.

Students with T1D frequently report out-of-range blood glucose and hypo- or hyperglycaemic events, which affect cognitive and emotional functioning. It takes time to recover from these periods. Given the frequency of out-of-range blood glucose values in students and given recovery time, it is reasonable to assume that students’ coursework can be delayed due to their condition.

Because of the frequency, it is reasonable to allow the students to submit late without further confirmation from a doctor.

Adjustment 3:

Being allowed to start exams later on day of exam if needed due out-of-range blood glucose.

Due to the unpredictable nature of out-of-range blood glucose, the university should allow students to delay the start of exams if needed.

Adjustment 4:

Being allowed at least 25% extra time and an opportunity for rest during exams.

Out-of-range blood glucose values and recovery from out of range values costs time. To compensate for this, at least 25% extra time should be afforded during exams.

Adjustment 5:

Access to a suitable rest/break room during exams.

People with T1D may need to take a rest due to out-of-range blood glucose values and/or inject a correction dose of insulin. For this, a suitable place next to the examination room must be present. The time for this should be subtracted from the available examination time.

Adjustment 6:

Being allowed to bring and consume food/snacks and medication at any meeting.

People with T1D may need urgent snacks to prevent blood glucose values to drop below a critical value. Further, they always need to be able to take medication when needed. Note that insulin is not only taken before meals, but also to correct for hyperglycaemia (correction doses).

Adjustment 7:

If the university provides or rents out its own accommodation, it should provide a personal medication fridge for the student.

All students with type 1 diabetes need to store insulin. Insulin must be cooled to a very specific temperature range when not used. Out of the fridge, insulin stays good for a limited time. It is important that the fridge is designed for medication and can provide the required temperature.

Other possible adjustments

The adjustments above are only a minimal set for any student with type 1 diabetes. More adjustments might be offered, depending on individual needs.

One example is to provide students with an alerting device and to inform campus security which students have T1D (and thus might suffer from hypoglycaemia, which might not be recognised otherwise). The alerter device can be used if students need urgent help due to a hypoglycaemic event.

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