Spotlight on glycemic control during the pandemic

Several new studies showed that among patients with type 1 diabetes, glycemic control improved and diabetic ketoacidosis decreased during COVID-19 lockdowns, while patients with type 2 diabetes showed the opposite trend during the pandemic.

Several recent studies looked at the differential impact of COVID-19 pandemic lockdowns on patients with type 1 diabetes or type 2 diabetes.

An analysis of hospitalizations for diabetic ketoacidosis (DKA) in England, published by The Lancet Diabetes & Endocrinology on Sept. 2, found they were higher during the pandemic relative to previous years and that the rise was driven by patients with type 2 diabetes. The study included 8,553 DKA admissions that occurred in March to June 2020, 8,729 in July to October, and 10,235 in November to February 2021. For patients with type 1, DKA admissions were reduced by 19%, 14%, and 25% in those respective time periods compared to previous years. However, among patients with type 2, admissions increased by 57%, 30%, and 50%, respectively, compared to previous years. DKA admissions of those without previously diagnosed diabetes were also up in all age groups. (The authors were unable ascertain the type of diabetes in these patients.) “These excess DKA admissions might reflect both direct and indirect effects of the pandemic, including: delays in presentation due to either health-care or patient factors, changes in behaviours that are permissive to presentations with DKA in susceptible individuals, the severity of acute illness with SARS-CoV-2 infection making acute metabolic decompensation of hyperglycaemia more likely, or a direct pancreatic effect of SARS-CoV-2,” the study authors said.

Additional evidence that lockdowns were associated with improved glucose control among type 1 diabetes patients and the opposite among type 2 patients came from a review published by Diabetology & Metabolic Syndrome on Sept. 7. It included 33 observational studies of pandemic glycemic control (25 studies with 2,881 type 1 patients and eight studies with 1,823 type 2 patients). Seventy-two percent of the type 1 diabetes studies found significant improvements in glycemic control (12% found that it worsened, and 16% found that it was stable). In contrast, HbA1c deterioration was the most common result of the type 2 diabetes studies, at 50%, versus 25% improved and 25% stable. The authors cited several possible explanations for the findings, including changes in eating, exercise, and access to health care. “What is striking about the results is that in almost all cases, [type 1 diabetes] patients had digital diabetes management available during the lockdown,” they noted.

Another review, published Sept. 22 by Diabetes Research and Clinical Practice, supported the finding that control of type 1 diabetes in those with digital tools improved during the pandemic. It included 17 studies with 3,441 type 1 diabetes patients who used either continuous or flash glucose monitoring (FGM) systems. During lockdown, the patients' time with blood glucose in the range of 70 to 180 mg/dL (3.9 to 10 mmol/L) increased by 3.05% while their time above 180 mg/dL (10 mmol/L) or 250 mg/dL (13.9 mmol/L) declined by 3.39% and 1.96%, respectively (P<0.0001 for all). The time below targeted ranges did not change significantly. The study authors noted several possible explanations for the findings, including that the association of COVID-19 with diabetes may have caused patients to pay more attention to management and that other studies have found more regular patterns of nutrient intake and sleep during lockdowns. They highlighted the finding from another study that during lockdown, glucose control improved in FGM users who worked from home but not in those who continued their usual working activities.

Significant proportions of diabetes patients, most with type 2, reported that the pandemic negatively affected their glycemic management in a study published by BMJ Open on Sept. 2. It included 667 adult patients in the U.S. (18% with type 1 diabetes) who took insulin and/or secretagogues, surveyed in spring 2020. Almost a quarter reported experiencing difficulties affording housing, 28% struggled to maintain sufficient food to avoid hypoglycemia, and 19% and 17% reported challenges with access to diabetes therapies and testing strips, respectively. Nearly half reported decreased physical activity. The study found few statistically significant differences by diabetes type, but the study authors did note some variation, including higher rates of forgetting to take medication and experiencing severe hypoglycemia among those with type 2. The latter finding “suggests that important deficiencies—irrespective of the pandemic situation—may exist with regard to hypoglycaemia education, management behaviours and/or primary care in people with type 2 diabetes when compared with their type 1 diabetes counterpart,” they said.