Emerging from COVID-19: what was the impact on diabetes care?
As we come out the other side of the COVID-19 pandemic, a webinar hosted by the International Diabetes Federation (IDF) focused on the challenges and lessons learned in different parts of the world. Lisa Buckingham reports.
Dr Gillian Booth from the University of Toronto began with a summary of findings from the IDF Diabetes Atlas report on diabetes and COVID-19 that came out in December 2022.
They found that having an HbA1c greater than or equal to 7% was associated with a 50-60% increase in the odds of hospitalisation, severe disease or death. When the odds analyses were adjusted for confounding factors such as age, sex, co-morbidities, there remained a 30-45% increase in odds of hospitalisation or severe disease, but no longer a significant correlation between HbA1c and death.
They found between a two- and threefold increase in the odds of severe disease and death in those who had an elevated blood glucose level on admission of at least 10 mmol/l (180 mg/dl). This increase persisted even after the analyses were adjusted.
Still, we have to be careful with this data, she said. There may be an element of reverse causality, where people who are very sick are more likely to have an elevated blood glucose level, known as stress hyperglycaemia and which is seen in people with and without diabetes.
With regard to diabetes subtype, there was considerable heterogeneity across studies. Some reported higher admissions in people with type 2 diabetes while others did not; a few found a higher rate of ICU admission in type 1 diabetes, but in one large study, that was explained by the presence of diabetic ketoacidosis.
After adjusting for other factors, most studies did not show a difference in ICU admission or death between type 1 and 2 diabetes.
Impact of COVID-19 on people in the UK
Professor Andrew Boulton began with the recent Diabetes UK statistics on the proportion of people in the UK living with diabetes – it has risen steeply and stands now at almost 10%. This may be, in part, due to people not coming forward and being diagnosed during the pandemic.
He moved on to discuss the 2020 paper by Partha Kar, which showed that one-third of COVID-19 deaths in the UK were in people who had diabetes; age, overall poorer glycaemic control and other comorbidities are predictors of poor outcomes, and parity of focus on all types of diabetes in all ethnic groups is needed.
A 2021 national study showed that out of 19,000 patients requiring critical-care management during the pandemic, 18.3% had type 2 diabetes and mortality was 26%. Risk of mortality was associated with younger age.
A population cohort study of people registered in UK GP practices found that of 23,804 COVID-19-related deaths, 33% occurred in those with diabetes.
Professor Boulton referred to a 2020 British Medical Journal article to make the important point that the pandemic led to the neglect of many health conditions but while cancer and heart disease were highlighted by the NHS, diabetes was not and has been neglected – we will be seeing the consequences of that for the next decade, he said.
Another paper highlighted that as well as the threats that COVID-19 presented, such as the psychological impact and poor glycaemic control, it also presented opportunities such as expansion of telemedicine, digital education programmes and improvement of in-patient diabetes services.
He finished with a 2023 paper on behalf of EURADIA (an alliance of organisations working for diabetes research, including academic and clinical researchers, healthcare professionals and patient groups), which looked at the impact of the pandemic on research funding. Naturally, clinical research swung back to infectious diseases; there was a loss of income for major diabetes associations and diabetes clinical research suffered hugely because it wasn’t possible to do it. Clinical diabetes care also suffered and a fear of hospital clinics led to poor attendance.
We have much to learn, said Professor Boulton, and we should be screening high-risk populations as this has been missed during the pandemic and we’re already seeing increased numbers because of that.
What happened in Bolivia
Dr Douglas Villarroel described the pre-existing challenges in Bolivia, including a shortage of resources and trained medical personnel, and a large gap in health equity between urban and rural populations.
There was a lockdown in the country during the pandemic and the borders were closed. This had a huge impact on the transport of goods and medical supplies. Outpatient services were significantly disrupted and a failure to provide diabetes care led to preventable complications. This was against a background where 9.2% of people in Bolivia have diabetes and 45.8% of people with diabetes do not know they have the disease. One in four were at risk of death or severe illness from COVID-19 because they were living with diabetes.
The pressure on the health system increased the inequalities in access to effective and comprehensive health services, said Dr Villaroel, and attention to non-communicable diseases was pushed aside. All of this means that they’re now seeing an increase in chronic complications of diabetes.
Finally, he touched on the impact on mental health. The increase in stress, anxiety and depression caused by lockdown and decreased mobility mean that thousands of people struggled to control their diabetes. Many couldn’t follow treatment plans or eat a healthy diet and exercise. These people have since had a higher risk of complications, especially cardiovascular.
The impact in Libya
This was summarised by Dr Kawtar Asshnneen, senior house officer at Tripoli Children’s Hospital and an IDF Blue Circle voice (the Blue Circle Voices (BCV) network is composed of people living with or affected by diabetes in countries across the seven regions of IDF).
Similarly to Bolivia, people struggled to access diabetes care and self-management was affected. New diagnoses were also limited. Dr Asshnneen also felt that online care affected good assessment of the patient, resulting in an increase in admissions for DKA.
They also noted an increase in type 2 diabetes after the pandemic subsided, as is being seen in other countries, and an increased prevalence of patients with depression and anxiety.
Availability of insulin was a problem even before the pandemic, but lockdown and the closing of airports made this problem even worse. Specific care for diabetes-related complications was also limited because hospitals were at capacity, resulting in stay-at-home care and an increase in mortality.
Another key issue in Libya, as for many countries, was Ramadan. People with diabetes should see their doctors one month beforehand to discuss fasting and adjustment of insulin doses, said Dr Asshnneen, but an increase in complications was seen during and after Ramadan because this wasn’t possible.
Diabetes associations in Ecuador
Finally, Alejandro Cabrera, an IDF Young Leader in Diabetes from Ecuador, spoke about the role of national diabetes associations during the pandemic. In normal times, they provide vital services and support. At the beginning of the pandemic, the association in Quito had to close its facilities but still supported its members as best it could. It provided virtual services to the community and sales points for supplies and insulin. Monthly talks with doctors were held on Zoom, covering various topics, and the annual diabetes camp that connects people with diabetes was held virtually.
A survey to assess the situation for children with type 1 diabetes showed that access to good nutrition was a serious problem and so the charity Life for a Child donated money to help the most affected families. Medical supplies and insulin were also sent to some families as they were struggling to access them, as well as to adults who were financially jeopardised by losing their jobs due to the pandemic. Social media was a vital tool, he said, as it was used to share information, data, nutrition tips and mental health advice.
Importantly, the diabetes associations led the COVID-19 vaccination campaign to help people with type 1 diabetes get the first doses when they became available.
Any opinions expressed in this article are the responsibility of the EASD e-Learning Programme Director, Dr Eleanor D Kennedy.
To learn more about managing diabetes before and during Ramadan, enrol on the EASD e-Learning course ‘Diabetes and Ramadan’: https://easd-elearning.org/courses/diabetes-and-ramadan/