COVID-19 and diabetes: counting the cost of lockdown lifestyles and limitations
Restricted access to healthcare and increased anxiety may have stored up problems for later
- People with diabetes are at a higher risk of dying with COVID-19 and those with the condition made up a third of all COVID-19 deaths in hospitals in England
- Greater restrictions on movement during lockdown for people in the vulnerable category have affected mental health, access to healthcare and the way people have been able to manage their condition
- For many, food consumption and exercise have changed during the lockdown, but nurses can advise people on how to return to a healthier lifestyle
Research findings released by NHS England show that the overall death rate for people with diabetes doubled during the early stages of the COVID-19 pandemic.
To date, one third of people who have died in hospital in England and tested positive for the coronavirus have also had diabetes, most of them type 2.
Black and Asian people with diabetes are at higher risk of dying with COVID-19
Among people with either type 1 or type 2 diabetes, men, black or Asian people, and those living in more deprived areas are at even greater risk of dying of COVID-19.
About 90% of diabetes cases in the UK are type 2 which, like type 1, poses serious risks to health if not properly managed, particularly when coupled with obesity.
The disease occurs when the body is unable to metabolise glucose. Type 2 diabetes can be controlled by diet but will often require additional medication. Early diagnosis and treatment can help prevent complications.
Type 2 diabetes: who is at risk and common symptoms
Type 2 diabetes is common and serious.
It occurs when the body is either ineffective at using the insulin it produces or when insufficient insulin is produced.
Risk factors include being overweight or inactive, and a family history of type 2 diabetes.
Once seen mainly in people aged over 40, type 2 diabetes has recently become more common in younger people, teenagers and children.
Many people have the condition without realising it, but serious conditions such as heart disease, stroke and retinopathy can develop if type 2 diabetes is not addressed.
Common symptoms include:
- More frequent urination, especially at night
- Feeling thirsty all the time
- Feeling very tired
- Genital itching
- Blurred vision
- Cuts or wounds taking longer to heal
- Treatment usually involves adjustment to diet and activity levels. Medication such as metformin may be prescribed to help lower blood sugar levels
Lockdown has caused stress and anxiety for people with diabetes
But are the dangers associated with type 2 diabetes likely to multiply because of the COVID-19 pandemic and lockdown? And will recent restrictions on exercise, food choices and access to care and support result in a surge in cases and more problems for existing patients?
23 March 2020
Prime minister Boris Johnson announces lockdown measures
Sonia Wijesundare, diabetes nurse consultant for Central London Community Healthcare NHS Trust, says many of her patients have suffered psychologically as a result of the pandemic.
In the borough of Harrow where she works, and which has a high proportion of South Asian residents, more than 21,000 people have type 2 diabetes.
‘They are worried about having diabetes and being susceptible to catching COVID-19,’ says Ms Wijesundare, who chairs the RCN diabetes forum. ‘There are high levels of stress and anxiety.’
Patients’ concerns are well-founded, she adds. Harrow has seen a high number of coronavirus-related deaths. Loss of income because of the pandemic has added to people’s anxiety.
Some of her patients have reported difficulties in buying the right food to suit their condition and have tended to eat more carbohydrates, which has led to poorer control of blood glucose levels.
And while some people have spent lockdown keeping fit with Joe Wicks or other online fitness instructors, not everyone wants, or is able, to join in.
‘There is a group of patients who don’t have access to technology or who don’t know how to use it,’ says Ms Wijesundare.
Weight gain has been common during lockdown
Lack of exercise means many people have struggled with their weight during lockdown, according to news reports. A survey of 2,254 UK residents aged 16-75 by King’s College London and Ipsos MORI found almost half of the respondents (48%) put on weight in the two months since prime minister Boris Johnson ordered everyone to stay at home.
Access to primary care has also been problematic. People with diabetes were designated ‘clinically vulnerable', meaning they were advised to follow stringent social distancing rules. If they needed support from their GP or practice nurse they were advised to telephone or email.
of 2,025 UK adults polled in April said they were eating more fruit and vegetables during lockdown
Source: Obesity Health Alliance
But getting support was not always straightforward, Ms Wijesundare says. ‘It’s very difficult for some to contact their GP because often they can’t get beyond the receptionist, who will say, “What’s the problem? I’ll get the doctor to call you”.
‘Some of our patients wanted a call that day but instead it had to be two days later or they would get no call at all.’
Clinicians are expecting 'massive' health consequences of the lockdown
That said, specialist services have been able to respond more quickly. Ms Wijesundare’s team has had telephone consultations with three quarters of the patients on the service’s caseload.
So what does all this mean for the future? Is the burden of diabetes likely to rise because of the constraints of lockdown?
RCN professional lead for public health Helen Donovan believes that the consequences of the pandemic will be ‘massive’ in relation to long-term public health outcomes.
Although the peak of the crisis may have passed and COVID-19 cases are on the decline – for now at least – mental health issues, for example, are likely to endure, with loneliness and isolation continuing for many, and access to support structures remaining limited.
Prediabetes screening will identify people at risk of developing the condition
‘Obviously that doesn’t relate just to diabetes. Any long-term condition is further affected by those sorts of issues.
‘Also, because of the overall emphasis on only seeking help in emergencies and not accessing healthcare unless you really need to, we know that people haven’t been accessing their routine appointments and check-ups.’
With health services now beginning to find extra capacity as COVID-19 cases slow, extra safeguards will be required to ensure people with diabetes are maintaining control of their condition, she adds.
‘Because of the overall emphasis on only seeking help in emergencies and not accessing healthcare unless you really need to, we know that people haven’t been accessing their routine appointments and check-ups’
Helen Donovan, RCN professional lead for public health
Similarly, more screening may be necessary to detect those with prediabetes, where blood glucose levels are high but lower than the threshold for diagnosing the disease.
1 in 3
of 2,025 adults polled in April said they were eating more confectionery, cakes, biscuits and savoury snacks
Source: Obesity Health Alliance
‘We need to use risk stratification approaches in local surgeries and communities to try and identify those who may have diabetes,’ says Ms Donovan. Comfort eating or increased alcohol consumption during lockdown may prove to have caused considerable harm to the nation’s health.
Ms Wijesundare agrees that coronavirus is likely to have a lasting impact on diabetes care. ‘Patients with diabetes who contracted COVID-19 will require a lot of extra support,’ she says. ‘Their general health will be poorer and it will take a long time for them to recover. It will be a slow process.’
Helping people return to healthier lifestyles: advice for non-specialist nurses
Encourage patients who have concerns about their diabetes to contact their GP or diabetes team
Encourage self-care RCN professional lead for public health Helen Donovan advises encouraging patients to take on self-care, including healthy eating and exercise. ‘There’s plenty of evidence that those things have a positive effect on people’s health as well as their overall well-being.’ She stresses that self-care does not mean no care. ‘It means we support people to look after themselves’
Know your patient ‘You need to understand who you are talking to and how to advise them,’ says diabetes nurse consultant Sonia Wijesundare. ‘That’s key because patients get fed up when you suggest something they can’t do. One exercise doesn’t fit all’
Ask about sleep patterns ‘If you don’t sleep, your diabetes worsens,’ says Ms Wijesundare. ‘There are lots of studies about how sleep affects insulin resistance, regardless of how long you’ve had diabetes’
Encourage peer support, virtually if necessary ‘We did some online group consultations with patients,’ Ms Wijesundare says. ‘With ten patients in a group it saves nurses time as well’
Remember psychological well-being People with diabetes experience disproportionately high levels of mental health problems such as anxiety and depression, according to Diabetes UK. The charity’s resources on diabetes and psychological care include tips on how to have a ‘quality conversation’ about emotional health
Self-care silver linings have been detected
While lockdown may have had a detrimental and lasting impact on diabetes and other long-term conditions, there are some reasons for optimism, Ms Donovan says.
For example, although there is some evidence of weight gain during lockdown, research by the Obesity Health Alliance found a rise in consumption of fruit and vegetables among people of all ages eating while confined at home, and a reduction in fast food consumption, which typically is high in calories, fat and salt.
‘From a self-care perspective, there is perhaps a glimmer of hope we can hang on to there.’
The pandemic has also necessitated an increase in remote consultations and although accessing services in that way may not suit all patients with diabetes, it could save money. Diabetes UK says the NHS in England and Wales already spends 10% of its budget on treating diabetes so finding cost-effective ways of managing a possible rise in cases will be vital.
‘When services have embraced remote consultations in the past, I think sometimes patients have felt it’s not the same,’ Ms Donovan says. ‘But lockdown might help people realise it’s the way forward.
‘So although there’s a lot of concern I think there are causes to be a little bit optimistic about the ways we can manage some services in the future.’
‘Lockdown has forced me to reconsider how to deal with my own health’
Poet and writer Adam Horowitz was cycling home one day six years ago when he swerved to avoid a car and crashed.
He broke both arms and three ribs. The fractures healed but he believes the accident was the catalyst for the type 2 diabetes he has lived with ever since.
Comfort eating in the wake of the crash, combined with a family history – his father also has diabetes – as well as being overweight, appear to have triggered his condition.
‘I was probably prediabetic at that point but for two months after the accident I was off my head on tramadol to cope with the pain,’ he says. ‘Coming off tramadol, I propped myself up with sugar.’
Metformin, canagliflozin and a strict diet helped bring his blood glucose levels largely under control.
But lockdown and self-isolation have been challenging. Mr Horowitz lives alone in a remote part of rural Gloucestershire but doesn’t drive and the nearest town is several miles away.
Lockdown brought some initial logistical worries
‘The most immediate thing was getting to the pharmacy for medication because I’m not supposed to go. In the end I managed to find friends who were willing to pick up my medication or leave it somewhere I could easily collect it.’
Maintaining a healthy diet has been tricky, especially early on in lockdown.
‘There was no money coming in because I work freelance and all the things I tend to do such as workshops and poetry readings soon fell apart.’
A farm shop a mile and a half away up a steep hill has proved useful for sourcing fresh food. And reaching the farm on foot is good exercise, Mr Horowitz says.
But the psychological impact of lockdown has been tough. ‘The first few weeks were pretty terrible, I must admit.
‘But things have picked up as time’s gone on. I tend to be a bit depressive anyway, but my mood has lifted during lockdown. It’s forced me to reconsider a lot of things and think about getting exercise and really pushing myself.’
How would he sum up the effect of lockdown on his diabetes?
‘It has forced me to consider how to deal with my own health and to be more independent about the whole thing because I can’t rely as much on the GP or the nurse, or on other people. I’ve had to become a lot more disciplined.’
Daniel Allen is a health journalist
- Obesity Health Alliance: How are COVID-19 measures affecting the food environment?
- Diabetes UK: Diabetes and psychological care
- NHS England: NHS expands offer of help to people with diabetes during coronavirus outbreak