|Year : 2021 | Volume
| Issue : 3 | Page : 344-349
Living with type 2 diabetes in COVID-19: Exploring the challenges faced
Neha Agarwal1, Rishi Shukla1, Manisha Gupta2, Mandara Muralidhar Harikar3, Anurag Bajpai4
1 Society for Prevention and Awareness of Diabetes, Kanpur, Uttar Pradesh, India; Department of Endocrinology, Regency Center for Diabetes Endocrinology and Research, Kanpur, Uttar Pradesh, India
2 Society for Prevention and Awareness of Diabetes, Kanpur, Uttar Pradesh, India
3 Independent Researcher
4 Department of Endocrinology, Regency Center for Diabetes Endocrinology and Research, Kanpur, Uttar Pradesh, India
|Date of Submission||05-Mar-2021|
|Date of Decision||21-Apr-2021|
|Date of Acceptance||27-Apr-2021|
|Date of Web Publication||30-Sep-2021|
Dr. Neha Agarwal
Department of Endocrinology, Regency Center for Diabetes Endocrinology and Research, Kanpur, Uttar Pradesh.
Source of Support: None, Conflict of Interest: None
Background: The COVID-19 pandemic seems to have influenced lifestyle behaviors and diabetes self-management practices. The aim of the present study is to determine the impact of psychological stress on various lifestyle behaviors, diabetes self-management practices, and glycemic control among Indian adults with type 2 diabetes (T2D), amidst the COVID-19 pandemic. Materials and Methods: This was a cross-sectional observational study. The data pertaining to psychological stress, lifestyle behaviors, diabetes self-management practices, and glycemic control were collected at two time-points (before and after lockdown). Results: A total of 252 T2D patients (145 males, 57.5%) with mean age 51.2 ± 9.8 years and mean diabetes duration of 8.5 ± 6.3 years participated in the study. A statistically significant decrease in body mass index (27.68 vs. 27.22 kg/m2; P < 0.0001) and an increase in HbA1c was noted in the post-lockdown period (8.31% vs. 8.70%; P < 0.0001). The mean Impact of Event Scale-Revised (IES-R) score was 19.3 ± 11.6. No significant correlation of mean IES-R score was observed with the age of the participants (r =−0.077, P = 0.224) and diabetes duration (r = 0.002, P = 0.970). Female gender (mean rank 140.4; P = 0.007) and co-existing hypertension (mean rank 132.18; P = 0.016) were associated with significantly higher IES-R score. No impact of total IES-R score was seen on the various lifestyle behaviors, diabetes self-management practices, and glycemic control. Conclusion: Psychological stress was higher among female gender and those with co-existing hypertension. Further, glycemic control worsened despite preserved diabetes self-management practices.
Keywords: COVID 19, glycemic control, stress, type 2 diabetes
|How to cite this article:|
Agarwal N, Shukla R, Gupta M, Harikar MM, Bajpai A. Living with type 2 diabetes in COVID-19: Exploring the challenges faced. J Diabetol 2021;12:344-9
| Introduction|| |
Novel coronavirus (SARS-CoV2) emerged in the Wuhan province of China, in late 2019. It spread rapidly and rampantly across the globe and was declared a pandemic by March 11, 2020. The coronavirus pandemic has already affected millions of lives and is continuing to wreak havoc. The morbidity and mortality associated with the pandemic have adversely impacted the health, social, political, and economic spheres of life.
In the absence of a definitive treatment or vaccine against coronavirus disease (COVID-19), prevention is so far the best way to limit the spread of infection. In this regard, a nation-wide lockdown was announced on March 23, 2020 to mitigate the spread of the COVID-19 disease. Strict isolation practices, restriction of travel, and limited availability of healthcare facilities have forced major lifestyle changes and generated a great concern among people. Those with chronic health-related conditions, such as diabetes, hypertension, etc., are more likely to be affected by the current lockdown.
Type 2 diabetes (T2D) is one of the most common endocrine disorders across the globe. Effective management of T2D revolves around balanced diet, regular physical activity, medication adherence, and routine health-check-up. The “new normal” introduced by the COVID-19 pandemic seems to have influenced all these measures. It is therefore predicted that glycemic control is likely to be worsened by the deranged lifestyle, poor eating habits, decreased physical activity, and psychological stress induced by the current pandemic. Several studies have reported worsened glycemic control during the quarantine period. Also, worse outcomes of COVID-19 have been reported among those with uncontrolled diabetes.
While several studies have documented the change in lifestyle factors and glycemic control in patients with T2D, it is challenging to identify a specific trend, given the heterogeneity of results obtained on different patient cohorts across the world.,,,,,, Further, majority of these studies have evaluated the influence of COVID 19 pandemic on the lifestyle, psychological stress, medical compliance, and glycemic control in isolation and not collectively.
We, therefore, aim to determine the impact of psychological stress on various lifestyle behaviors, diabetes self-management practices, and glycemic control among Indian adults with T2D, amidst the COVID-19 pandemic.
| Materials and Methods|| |
This was a cross-sectional observational study conducted in the outpatient Endocrinology clinic of a tertiary-care hospital in North India. Study participants included patients living with T2D and satisfying the following inclusion criteria: age more than 18 years, diabetes duration of at least more than 1 year, records available for at least one in-clinic visit within the 3 months’ period prior to initiation of first phase of nation-wide lockdown (October 2019 to March 2020) and after the lockdown restrictions were lifted (after 1 June 2020). Those with known pre-existing psychiatric illnesses or on drugs known to influence psychological health were not included in the study.
This observational study was performed with prior Institutional Ethics Committee approval and performed in accordance to the guidelines laid down by the Declaration of Helsinki. Written informed consent was obtained from all patients enrolled into the study. The manuscript was formatted as per the STROBE guidelines.
The data were collected at two time-points (before and after lockdown). At baseline, demographic features and clinical data including the weight, height, blood pressure, HbA1c, existence of co-morbidities, and presence of micro- and/or macro-vascular complications of T2D were sourced from computerized medical records. Weight, blood pressure, and HbA1c were measured once more at follow-up visit, after withdrawal of lockdown restrictions. Data on lifestyle behaviors, diabetes self-management practices, and psychological stress were collected from patients via a pre-designed written questionnaire at the time of follow-up.
To assess the psychological impact of the pandemic, the Impact of Event Scale-Revised (IES-R), comprising 22 self-reported questions, was included in the questionnaire. The IES-R is structured to identify three clusters of symptoms seen in post-traumatic stress disorder, namely, intrusion, avoidance, and hyper-arousal. Respondents were asked to rate each item in the IES-R on a scale of 0 (not at all), 1 (a little bit), 2 (moderately), 3 (quite a bit), and 4 (extremely) within the past 7 days. The total IES-R scores range from 0 to 88. Scores that exceed 24 have clinical implications, 24 or more are associated with a clinical concern for PTSD, 33 and above represent a best cut-off for diagnosis of PTSD, and 37 or more are high enough to suppress functioning of the immune system (even 10 years after the impact).
The coded data were entered and analyzed using IBM Statistical Package for Social Sciences (SPSS version 25.0, SPSS, Inc., Chicago, IL, USA). Forms with incomplete data were excluded from the analysis. Continuous variables were expressed as mean (SD) and categorical variables as frequencies (percentages). The data were subjected to the Shapiro–Wilk analysis to check for the normality of distribution. For non-parametric data, Mann–Whitney U and Kruskal–Wallis H tests were used to analyze categorical variables, the Wilcoxon-signed rank test was used for paired analyses of continuous variables, while Spearman correlation was used for continuous variables. A P-value of <0.05 was considered as significant.
| Results|| |
A total of 252 patients with T2D (145 males, 57.5%) participated in the study. The mean age of the participants was 51.2 ± 9.8 years (range 29–78 years), with mean duration of diabetes 8.5 ± 6.3 years (range 1–36 years). The baseline socio-demographic characteristics of the study participants are depicted in [Table 1]. Majority of the study participants were graduates (26.2%, n = 66), were married (97.2%, n = 245), and belonged to the middle socio-economic status (51.2%, n = 129).
|Table 1: Baseline socio-demographic characteristics of the participants (n = 252)|
Click here to view
More than half of the study participants (71.8%, n = 181) were on oral anti-diabetic drugs. Around 37.7% (n = 95) of the total participants had both diabetes and hypertension. Nephropathy was the most common micro-vascular complication (n = 65, 25.8%), and cardio-vascular disease (n = 10, 3.9%) was the most common macro-vascular complication observed in our study.
[Table 2] summarizes the patient-reported changes in lifestyle behaviors and diabetes self-management practices, before and after the lockdown imposition. No change was reported by the study participants in their duration of sleep, frequency of blood glucose monitoring, and medicine compliance. A roughly identical proportion of patients responded that their screen time and financial and family-related stress remained unchanged. On the contrary, intake of “junk food” was reported to be decreased or the same in an equal proportion of patients. Females were more likely to report decreased screen time (P = 0.022) and family-related stress (P = 0.011) compared with males.
|Table 2: Changes observed in lifestyle behaviors and diabetes self-management practices among the study participants (n = 252)|
Click here to view
The mean IES-R score of all the study participants was 19.3 ± 11.6. No significant correlation of mean IES-R score was observed with the age of the participants (r = −0.077, P = 0.224) and the duration of diabetes (r = 0.002, P = 0.970). A notable proportion of the study participants (n = 16, 6.3%) had a total IES-R score of more than 37. Around 20.2% (n = 51) had total IES-R score between 24 and 32, and 3.2% (n = 8) of the participants had total IES-R score between 33 and 36. Female gender was associated with significantly higher IES-R score compared with males (mean rank 140.4; P = 0.007), and patients with hypertension as a co-morbidity were more likely to have higher IES-R scores (mean rank 132.18; P = 0.016) [Table 3]. A significantly higher IES-R score was noted among those who had no change in their BMI (mean rank 155.97, P = 0.014). No impact of total IES-R score was seen on the various lifestyle behaviors, diabetes self-management practices, and glycemic control.
|Table 3: Determinants of psychological stress (IES-R) among the study participants (n = 252)|
Click here to view
On comparing quantitative parameters prior to and after the lockdown imposition, BMI was decreased in 151 patients (59.9%), same in 22 (8.8%), and increased in 79 (31.3%); increased HbA1c was noted in more than half of the study participants (60.3%, n = 152). On Wilcoxon-signed rank test, a statistically significant decrease was found in the BMI of the study participants (27.68 vs. 27.22 kg/m2; P < 0.0001), whereas a significant increase in the HbA1c was noted in the post-lockdown period (8.31% vs. 8.70%; P < 0.0001) [Figure 1]. No significant association was detected among patients who had an increase in HbA1c with demographic variables, presence of co-morbidities, lifestyle behaviors, diabetes self-management practices, or mean IES-R score.
|Figure 1: A. Comparison of HbA1c among the study participants before and after the lockdown period|
Click here to view
| Discussion|| |
This study highlights the determinants and influence of the prevailing psychological stress among Indian adults with T2D in the setting of COVID-19 lockdown. Also, the interplay between the lifestyle behaviors, diabetes self-management practices, and the glycemic control is explored.
Around 30.1% (n = 76) of our patients reported an IES-R score of more than or equal to 24, which corresponds to a “high” symptom level that may warrant clinical concern. Not only can the increased psychological stress levels result in direct biological consequences such as increased blood lipids and glucose in circulation, elevated blood pressure, and persistent inflammation, but also in indirect consequences, such as poor self-care, which can contribute to worse diabetic outcomes. High stress levels in patients with T2D have been repeatedly demonstrated by recent studies, with the prevalence of mental stress of any kind been shown to be as high as 87% and 93% during the pandemic. Significantly higher levels of stress were noted in female patients, a trend that has been demonstrated by several previous studies, in which females with T2D have been noted to have poorer sleep quality, greater anxiety, and worries of being infected with COVID-19., We also found that patients with hypertension as a co-morbidity had higher IES-R scores. Given that hypertension is more prevalent in older adults, the combined effect of elderly age, underlying T2D, and hypertension can understandably trigger stress, further compounded by reports that patients with hypertension might have a poorer COVID-19 prognosis.
Similarly, we also observed significantly higher stress levels in patients who had no apparent variation in their BMI. It is likely that patients who were more stressed about the impact of pandemic on their glycemic control and overall health possibly followed healthier lifestyle habits.
However, it can be argued that due to underlying T2D, patients could have already had high levels of stress at baseline. In fact, a recent study done by Arigo et al. studying the prevalence of PTSD symptoms in patients with poorly controlled diabetes and no history of psychiatric diagnosis or treatment found a similar IES-R total score of 19.17. Additionally, the majority of our patients had poorly controlled diabetes (63.37% of the patients (n = 154) had baseline HbA1c more than 7.5), which makes baseline stress a confounder for the high stress levels reported.
An unexpected finding, although replicated by similar studies,,,, was the preservation of compliance to medications and the frequency of self-monitoring of blood glucose during the lockdown period. Although potential disruptions in the supply chain and the difficulties involved in accessing healthcare and pharmacy services were expected to worsen the burden on patients with chronic conditions such as T2D, the detection of mostly unchanged compliance to therapy is an encouraging finding, plausibly explained by early reports of worse COVID-19 outcomes in patients with T2D, made widespread by online and television media.
Despite preserved diabetes self-management practices, we observed an increase in HbA1c in our study, which has been predicted early on in the pandemic. A study on 101 patients with T2D in Turkey found an increase in most metabolic parameters studied, including the BMI, HbA1c, fasting and post-prandial blood glucose, urea, and creatinine. Similarly, a study on 114 patients in Italy found an increase of >0.3% in 26% of the patients during the 8-week lockdown period. On the contrary, in a study performed by Sankar et al., no significant change in HbA1c was found. Although we found no significant associations between HbA1c and demographic or lifestyle factors, minor, unmeasured factors, such as a sedentary lifestyle as reflected by increased screen time reported by over 42% of the patients, could be at play. The odds of having a poor glycemic control was found to be 2.7 times higher in patients with T2D using screens for longer than 2 h. Females were more likely to report increased screen times, which could have been a coping mechanism to deal with the increased stress, plausibly related to their societal roles as caregivers, doctors, nurses, and midwives. Increased HBA1c in the setting of decrease in BMI could plausibly be explained by the catabolic state induced by uncontrolled diabetes.
A mixed effect on lifestyle changes with equal proportions reporting either an increase/decrease or an unchanged effect was observed in our study. Similarly, conflicting results on the status of patients with T2D during the pandemic have been reported by other studies performed in India and abroad. Around that 86.5% of the participants reported a decreased or unchanged intake of unhealthy diets. According to a study performed by Sankar et al., more than 80% of the study population reported no major change in their overall dietary adherence. Likewise, 80% of the study population in a study by Nachimuthu et al. reported good diet control and exercise. In our study, the improved dietary habits reported by 42.5% of the patients are a promising update. Increased time and propensity to create home-cooked meals, family-bonding with activities such as cooking,, and the closure of restaurants could be likely contributory factors, further driven by the motivation to sustain healthy-eating practices in an effort to ward off the risks of infection. Also, the majority (61.5%) of the patients in the present study reported no change in the duration of sleep. It could perhaps be attributed to a plausible decrease in work stress, commute times, and hence, available free time.
Although this was a single-center study and patients were consecutively recruited, the study sample comprised a good cross-section of all ages, diabetic duration in years, socio-economic statuses, and co-morbidities, thus making it generalizable to the population at large.
This study also had a few limitations. First, lifestyle factors were self-reported, which could make the study susceptible to response bias. Secondly, baseline stress levels were not measured, which could have helped tackle the confounder of stress associated with diabetes itself. Thus, more studies that compare pandemic-related stress with pre-pandemic levels are warranted. Moreover, case–control studies that determine the effect of stress due to the pandemic in the general population serving as controls would help delineate the true effect of T2D in exacerbating the psychological impact too. Indeed, the use of IES-R on the general population (around 93.6% of the respondents did not suffer from any chronic illness) in China in February 2020 revealed the rather alarming psychological impact of COVID-19 outbreak, with a sample mean score of 32.98 (SD = 15.42), with significantly higher scores seen in females. To comprehensively understand the unchanged/improved status of medical compliance and its role in glycemic control, studies that cross-check diabetic outcomes with the regional availability of medicines/glucose strips/presence of tele-medicine in the area would be welcome, to direct policy-making and the future course of action.
To conclude, it was observed that psychological stress was higher among female gender and those with co-existing hypertension. A mixed influence of COVID 19 lockdown was observed on the lifestyle behaviors. Further, despite preserved diabetes self-management practices, worsened glycemic control was seen among the study participants. Given the fact that the diabetes-related morbidity and mortality may long outlive the challenges fraught by the pandemic, we should be cognizant of the risks posed by the silent pandemic of diabetes and prepare accordingly.
Financial support and sponsorship
Conflicts of interest
N. A., M. H., and R. S. conceptualized and planned the study. N. A. and M. H. were involved in data collection. N. A. and M. H. did literature review, statistical analysis, and drafted the initial manuscript. A. B. and R. S. critically reviewed the manuscript and would act as guarantor of the paper.
| References|| |
Nishiura H, Jung S, Linton NM, Kinoshita R, Yang Y, Hayashi K, et al
. The extent of transmission of novel coronavirus in Wuhan, China, 2020. J Clin Med2020;9:330.
WHO Declares COVID-19 a Pandemic | Acta Bio Medica Atenei Parmensis [Internet] [cited December 14, 2020]. Available from: https://www.mattioli1885journals.com/index.php/actabiomedica/article/view/9397. [Last accessed on 2021 March 1].
Ghosal S, Sinha B, Majumder M, Misra A. Estimation of effects of nationwide lockdown for containing coronavirus infection on worsening of glycosylated haemoglobin and increase in diabetes-related complications: A simulation model using multivariate regression analysis. Diabetes Metab Syndr 2020;14:319-23.
Roncon L, Zuin M, Rigatelli G, Zuliani G. Diabetic patients with COVID-19 infection are at higher risk of ICU admission and poor short-term outcome. J Clin Virol 2020;127:104354.
COVID-19 pandemic: A double trouble for Indian adolescents and young adults living with type 1 diabetes | SpringerLink [Internet] [cited December 14, 2020]. Available from: https://link.springer.com/article/10.1007/s13410-020-00869-6. [Last accessed on 2021 March 1].
Vandenbroucke JP, von Elm E, Altman DG, Gøtzsche PC, Mulrow CD, Pocock SJ, et al
; STROBE Initiative. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): Explanation and elaboration. PLoS Med 2007;4:e297.
Weiss DS. The impact of event scale: revised. Cross-Cult Assess Psychol Trauma PTSD2007;XXVI:219-38.
Horowitz M. Handbook of Stress: Theoretical and Clinical Aspects. New York: Free Press; 1982. p. 757-74.
Hackett RA, Steptoe A. Type 2 diabetes mellitus and psychological stress—A modifiable risk factor. Nat Rev Endocrinol 2017;13:547-60.
Ghosh A, Arora B, Gupta R, Anoop S, Misra A. Effects of nationwide lockdown during COVID-19 epidemic on lifestyle and other medical issues of patients with type 2 diabetes in North India. Diabetes Metab Syndr 2020;14:917-20.
Alessi J, de Oliveira GB, Franco DW, Brino do Amaral B, Becker AS, Knijnik CP, et al
. Mental health in the era of COVID-19: Prevalence of psychiatric disorders in a cohort of patients with type 1 and type 2 diabetes during the social distancing. Diabetol Metab Syndr 2020;12:76.
Sankar P, Ahmed WN, Mariam Koshy V, Jacob R, Sasidharan S. Effects of COVID-19 lockdown on type 2 diabetes, lifestyle and psychosocial health: A hospital-based cross-sectional survey from South India. Diabetes Metab Syndr 2020;14:1815-9.
Joensen LE, Madsen KP, Holm L, Nielsen KA, Rod MH, Petersen AA, et al
. Diabetes and COVID-19: Psychosocial consequences of the COVID-19 pandemic in people with diabetes in Denmark—What characterizes people with high levels of COVID-19-related worries? Diabet Med 2020;37:1146-54.
Bornstein SR, Dalan R, Hopkins D, Mingrone G, Boehm BO. Endocrine and metabolic link to coronavirus infection. Nat Rev Endocrinol 2020;16:297-8.
Arigo D, Juth V, Trief P, Wallston K, Ulbrecht J, Smyth JM. Unique relations between post-traumatic stress disorder symptoms and patient functioning in type 2 diabetes. 2020 [Internet] [cited December 14, 2020]. Available from: https://journals.sagepub.com/doi/abs/10.1177/1359105317727839.
Kovil R, Shah T, Chawla M, Karkhanis S, Padhye D, Sanghvi A, et al
; RACE Indian Author Group. Patient reported changes in metabolic health during lockdown: A cross sectional digital connect survey in people with type 2 diabetes. Diabetes Metab Syndr 2020;14:1907-12.
Joshi R, Atal S, Fatima Z, Balakrishnan S, Sharma S, Joshi A. Diabetes care during COVID-19 lockdown at a tertiary care centre in India. Diabetes Res Clin Pract 2020;166:108316.
Fisher L, Polonsky W, Asuni A, Jolly Y, Hessler D. The early impact of the COVID-19 pandemic on adults with type 1 or type 2 diabetes: A National Cohort Study. J Diabetes Complications 2020;34:107748.
Önmez A, Gamsızkan Z, Özdemir Ş, Kesikbaş E, Gökosmanoğlu F, Torun S, et al
. The effect of COVID-19 lockdown on glycemic control in patients with type 2 diabetes mellitus in Turkey. Diabetes Metab Syndr 2020;14:1963-6.
Biancalana E, Parolini F, Mengozzi A, Solini A. Short-term impact of COVID-19 lockdown on metabolic control of patients with well-controlled type 2 diabetes: A single-centre observational study. Acta Diabetol 2021;58:431-6.
Roy S, Bhattacharjee K. Effect of screen time on glycaemic control of type 2 diabetes patients during COVID-19 outbreak: A survey based study. 2020.
Singhai K, Swami MK, Nebhinani N, Rastogi A, Jude E. Psychological adaptive difficulties and their management during COVID-19 pandemic in people with diabetes mellitus. Diabetes Metab Syndr 2020;14:1603-5.
Franz MJ. The dilemma of weight loss in diabetes. Diabetes Spectrum 2007;20:133-6.
Nachimuthu S, Vijayalakshmi R, Sudha M, Viswanathan V. Coping with diabetes during the COVID-19 lockdown in India: Results of an online pilot survey. Diabetes Metab Syndr 2020;14:579-82.
Ruiz-Roso MB, Knott-Torcal C, Matilla-Escalante DC, Garcimartín A, Sampedro-Nuñez MA, Dávalos A, et al
. COVID-19 lockdown and changes of the dietary pattern and physical activity habits in a cohort of patients with type 2 diabetes mellitus. Nutrients 2020;12:2327.
Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al
. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. Int J Environ Res Public Health [Internet]. 2020;17:1729.
[Table 1], [Table 2], [Table 3]