Direct impact of COVID-19 on people with diabetes
Of those admitted to hospital with COVID-19, 11–15% had diabetes, often alongside other comorbidities. In those suffering serious consequences from the virus, the two commonest comorbidities were diabetes and hypertension. The combination of diabetes and chronic kidney disease (CKD) was also particularly dangerous, resulting in a 5-times higher risk of severe COVID-19 outcomes than in those without chronic disease.
For those hospitalised with COVID-19, there is significant ongoing morbidity and mortality after discharge back into the community. From a population of 47,780 people hospitalised with COVID-19 compared with matched controls, there was significant increase in new diabetes, new major adverse cardiovascular events, CKD and chronic lung disease (Ayoubkhani et al, 2021). Nearly 30% were re-admitted and an additional 12.3% died.
Several potential mechanisms (K. Khunti, personal communication, 2021) that may contribute to an increased risk of type 2 diabetes following COVID-19 have been postulated. These include stress hyperglycaemia; direct effects of the virus on the pancreas increasing beta-cell dysfunction; pre-existing, but undiagnosed, type 2 diabetes; and treatment with in-hospital steroids. Exact mechanisms remain to be elucidated.
Professor Khunti encouraged the audience to try out the updated QCOVID® validated calculator, which takes into account vaccination status (https://qcovid.org) and can be used to identify those at highest risk of serious consequences from COVID-19 infection, so that people with diabetes and clinicians may be motivated to improve modifiable risk factors, such as poor glycaemic control.
Indirect impact of COVID on people with diabetes
Professor Khunti shared data previously published and presented by other speakers during the EASD conference that demonstrated the size of the impact of the pandemic on delivery of services by primary care. In one study, a 70% decrease in diagnoses of type 2 diabetes in a cohort of 14 million people translated to 40,000 missed or delayed diagnoses (Carr et al, 2021). Testing rates for HbA1c decreased by 77–84% during April 2020, while data from the National Diabetes Audit demonstrated that the number of people receiving all eight care processes fell from 58.5% in the 2019/20 figures to 19.2% from January to September 2020 (NHS Digital, 2020). Primary care, therefore, faces a huge challenge and Professor Khunti warned that the indirect effects of disruption to normal care were likely to be greater and more long-lasting than the direct impacts (hospitalisations and deaths).
Implications on services
Previous studies have demonstrated the impact that a year of delay in achieving tight glycaemic control will have on development and progression of complications, particularly early in the course of disease. This includes a 67% increased risk of myocardial infarction, 64% increased risk of heart failure, 51% increase in stroke and 62% increased risk of a cardiovascular composite of events (Paul et al, 2015). Nephropathy, neuropathy and retinopathy cumulative incident increase by 16%, 8% and 7% respectively.
Significant increases in mental health problems are occurring and, in relation to diabetes, good mental health is a core requirement supporting improved control, and facilitating adherence with medication and self-management, so helping people with mental health problems also needs to be a priority (Forde et al, 2021).
85% of those with diabetes have other significant comorbidities, so it is not just their diabetes care that is likely to have been suboptimal throughout the pandemic, but management of all their chronic diseases. Much can be learned from the short- and long-term impacts of previous natural disasters, such as earthquakes and hurricanes, on chronic disease, including type 2 diabetes. Even short durations of disrupted care have demonstrated significant consequences for people with diabetes. The COVID-19 pandemic disruption has already lasted much longer than any natural disaster, so the impact on UK health and the people we look after with diabetes is likely to be larger and longer lasting. Shielding and isolation for clinically vulnerable people has had both physical and mental health implications, as has suspension of routine review appointments and redeployment of specialist healthcare staff to deal with acute care, meaning that specialist advice and input to diabetes care has not been possible.
How to move diabetes care forward while the pandemic is ongoing
Professor Khunti reminded primary care teams that they need to both prioritise people for appointments and decide what care they need, so they can be stratified between face-to-face or virtual appointments. Any of the many prioritisation tools, such as the one from the PCDS (Brown and Diggle, 2020), can be used to identify those most at risk of both serious outcomes from COVID-19 and from complications of diabetes, as these people need to be managed early. Likewise, those with a new diagnosis of type 2 diabetes will benefit from being prioritised. Identifying people with multiple risk factors, even if they are in the amber (moderately poorly controlled) rather than the red (severely uncontrolled) group, should lead to an increase in the prioritisation.
Our document prioritises the red then the amber, but the point Professor Khunti made is that, in effect, several ambers should make a red – several poorly controlled risk areas should bump people up the priority list. For example, black and Asian groups, and those with higher BMI, are at risk of higher mortality and serious disease if they develop COVID-19 and are also at risk of rapid progression of their diabetes complications, including cardiovascular risk. Rises in BMI during the pandemic are well documented, including in those with non-diabetic hyperglycaemia for whom average weights that are 2–3 kg higher than in preceding years have been recorded in populations referred to the NHS Diabetes Prevention Programme (Valabhji et al, 2021).
Clinicians then need to decide, for each individual, whether a face-to-face appointment for data collection and/or blood sampling is needed, or if follow-up can be managed with virtual reviews, which may be a time-efficient way to deliver some diabetes care. For example, those needing foot assessment or with ulceration will need face-to-face review, while those wishing to discuss their mental health or who have had recent data collection may prefer the convenience of a virtual discussion.
For the priority groups, we already have the guidelines we need to improve diabetes care – we just need to implement them again, while remembering that COVID-19 may also leave a significant legacy of new heart disease and other chronic health problems that will complicate diabetes care.
As we move into the COVID and flu booster campaign, tight glycaemic control is also important to optimise the effects of COVID-19 vaccination (Marfella et al, 2021). Although the long-COVID risk is now being quantified, there are, as yet, no data specifically on whether the risk will be influenced by diabetes.
From a primary care perspective, if we paused routine diabetes reviews, we need to restart these as well as encouraging people with diabetes to attend for blood tests and retinopathy screening when these are possible. We need secondary care services up and running to provide support to primary care – including urgent specialist reviews, inpatient diabetes services, pregnancy services, foot-care services and retinopathy screening (Hartmann-Boyce et al, 2020). Professor Khunti finished with a clear call for action – primary care teams need to help people manage their diabetes and tackle their practice backlog as soon as possible, despite other ongoing workload. Although we cannot change the historical impact of the direct effects of COVID-19 in people with diabetes, we have an ongoing, important role in helping people take control of their modifiable risks, and to try to manage the indirect consequences from care delayed or missed during the pandemic. Sadly, the indirect impacts of the pandemic on the care of people with diabetes are likely to be much larger than the direct effects, and will continue to play out on physical and mental health over the next 5 years, at least.