The effect of COVID-19 lockdown on the glycemic control of children with type 1 diabetes

Type 1 and Covid-19: Diagnosis, Clinical Care, and Health Outcomes during the Pandemic

The coronavirus disease 2019 (COVID-19) pandemic disrupted health care, creating challenges for people with diabetes and health care systems. Diabetes was recognized as a risk factor for severe disease early in the pandemic. Subsequently, risk factors specific for people with type 1 diabetes were identified, including age, hemoglobin A1c level, and lack of continuous glucose monitoring . Telemedicine, especially when accompanied by diabetes data, allowed effective remote care delivery. However, pre-existing racial disparities in access to diabetes technology persisted and were associated with worse outcomes. Events of the COVID-19 pandemic underscore the importance of continuing to develop flexible and more equitable health care delivery systems.

Impact of COVID-19 on diabetes care: mixed methods study in an Indigenous area of Guatemala

INTRODUCTION

SARS-CoV-2 has impacted globally the care of chronic diseases. However, direct evidence from certain vulnerable communities, such as Indigenous communities in Latin America, is missing. We use observational data from a health district that primarily serves people of Maya K'iche' ethnicity to examine the care of type 2 diabetes in Guatemala during the pandemic.

METHODS

We used a parallel convergent mixed methods design. Quantitative data (n=142 individuals with diabetes) included glycated haemoglobin (HbA1c), blood pressure, body mass index and questionnaires on diabetes knowledge, self-care and diabetes distress. Quantitative data was collected at two points, at baseline and after COVID restrictions were lifted. For quantitative outcomes, we constructed multilevel mixed effects models with multiple imputation for missing data. Qualitative data included interviews with providers, supervisors and individuals living with diabetes (n=20). We conducted thematic framework analysis using an inductive approach.

RESULTS

Quantitative data was collected between June 2019 and February 2021, with a median of 487 days between data collection points. HbA1c worsened +0.54% (95% CI, 0.14 to 0.94) and knowledge about diabetes decreased -3.54 points (95% CI, -4.56 to -2.51). Qualitatively, the most important impact of the pandemic was interruption of the regular timing of home visits and peer group meetings which were the standard of care.

CONCLUSIONS

The deterioration of diabetes care was primarily attributed to the loss of regular contact with healthcare workers. The results emphasize the vulnerability of rural and Indigenous populations in Latin America to the suspension of chronic disease care.

Impact of lockdown on children with type-1 diabetes: returning to the community was associated with a decrease in HbA1c

Background

In March 2020, a 2-month lockdown of the entire population has been declared in France to limit the spread of COVID-19. Sudden changes in daily life can impact the glycemic control of patients with type 1 diabetes (T1D), especially children and adolescents. We aimed to assess the impact of the lockdown on glycemic control in children and adolescents with T1D.

Methods

Children with T1D were prospectively recruited in two pediatric centers from May 11 to August 1, 2020. At inclusion, patients and/or parents were asked to fill in a form assessing the patient's lifestyle during the lockdown and a medical case report form was filled in by clinician. The mean of the three last glycated hemoglobin (HbA1c) values obtained before lockdown (HbA1c_mean; before March 17, 2020) was compared to the first HbA1c value measured after the lockdown (HbA1c_after; from May 11 to August 1, 2020). Univariable and multivariable analyses were performed, as appropriate, to identify factors associated with glycemic changes during lockdown.

Results

One-hundred-and-eighteen children and adolescents (median age was 14.1 years, 50% males) with T1D (median time from diagnosis was 4.1 years) were enrolled in the study. No significant difference was observed between medians of HbA1c_mean and HbA1c_after values (8.37% [7.88; 9.32%] vs. 8.50% [7.70; 9.50%], respectively; p = 0.391). Returning to the community was a protective factor [OR 0.31 (0.09-0.94); p = 0.045]. Patients having increased HbA1c were more frequently in contact with a suspected case of COVID-19 [OR 9.07 (2.15-53.66); p = 0.006], whereas patients having decreased HbA1c had the feeling of increase number of hypoglycemia [OR 0.19 (0.05-0.57); p = 0.006].

Conclusion

In our patients, HbA1c before and after the lockdown was stable. In subgroup analysis, returning to the community was a protective factor. In addition, feeling of hypoglycemia was more frequent in the patients with decreased HbA1c.

Endocrine manifestations of COVID-19 in children: A scoping review

In this review, we explore associations between SARS CoV-2 infection and the endocrine system and metabolism in children and adolescents. PubMed, Scopus and Google scholar databases were searched to identify published data on endocrine manifestations of COVID-19 in children up to 31 March 2023, including diabetes, obesity, puberty, thyroid disorders, adrenal disorders and pituitary disorders. Data on changes in disease pattern/ incidence, disease control, and other effects due to the COVID-19 pandemic, as well as effects of pre-existing endocrine conditions on severity of COVID-19 infection are presented, and practice points and research needs provided under each section.

Diabetes care practices and outcomes in 40.000 children and adolescents with type 1 diabetes from the SWEET registry during the COVID-19 pandemic

AIMS

This study aimed to provide a global insight into initiatives in type 1 diabetes care driven by the COVID-19 pandemic and associations with glycemic outcomes.

METHODS

An online questionnaire regarding diabetes care before and during the pandemic was sent to all centers (n=97, 66,985 youth with type 1 diabetes) active in the SWEET registry. Eighty-two responded, and 70 (42,798 youth with type 1 diabetes) had available data (from individuals with type 1 diabetes duration >3 months, aged ≤21 years) for all 4 years from 2018 to 2021. Statistical models were adjusted, among others, for technology use.

RESULTS

Sixty-five centers provided telemedicine during COVID-19. Among those centers naive to telemedicine before the pandemic (n=22), four continued only face-to-face visits. Centers that transitioned partially to telemedicine (n=32) showed a steady increase in HbA1c between 2018 and 2021 (p<0.001). Those that transitioned mainly to telemedicine (n=33%) improved HbA1c in 2021 compared to 2018 (p<0.001).

CONCLUSIONS

Changes to models of care delivery driven by the pandemic showed significant associations with HbA1c shortly after the pandemic outbreak and 2 years of follow-up. The association appeared independent of the concomitant increase in technology use among youth with type 1 diabetes.

Impact of COVID-19 pandemic on HbA1c management and results in pediatric and adult outpatients with diabetes

Objectives

Diabetes mellitus intensify the risks and complications related to COVID-19 infection. A major effect of the pandemic has been a drastic reduction of in-person visits. The aim of this study was to evaluate the impact of the COVID-19 pandemic on HbA_1c management and results among pediatric and adult outpatients with diabetes, considering the laboratory and point-of-care testing (POCT) HbA_1c measurements.

Methods

Observational retrospective study including patients from pediatric and adult diabetes units was conducted. HbA_1c results obtained in the laboratory and POCT over 3 years (2019-2021) were collected from the laboratory information system.

Results

After the lockdown, the number of HbA_1c plummeted. Children returned soon to routine clinical practice. The number of HbA_1c increased gradually in adults, especially in POCT. Globally, HbA_1c results were lower in children compared with adults (p<0.001). HbA_1c values in children (p<0.001) and adults (p=0.002) decreased between pre-pandemic and post-pandemic periods, though lower than the HbA_1c reference change value. The percentage of HbA_1c results above 8% remained stable during the study period.

Conclusions

Continuous glucose monitoring and a telemedicine have been crucial, even allowing for improvements in HbA_1c results. During the lockdown, patients with better metabolic control were managed in the laboratory whereas patients with poorer control or a severe clinical situation were attended in diabetes units by POCT. Adults returned to pre-pandemic management slowly because they were more susceptible to morbidity and mortality due to COVID-19. Coordination among all health professionals has been essential to offering the best management, especially in difficult scenarios such as the COVID-19 pandemic.

Metabolic control during the first two years of the COVID-19 pandemic in pediatric patients with type 1 diabetes: results from the German DPV initiative

AIM

To assess effects of the SARS-CoV2 pandemic on metabolic control in youth with type 1 diabetes (T1D) in Germany in a population-based analysis.

METHODS

Data from 33,372 pediatric T1D patients from the Diabetes Prospective Follow-up (DPV) registry, with face-to-face visits or telemedicine contacts in the years 2019-2021, were available. Datasets from eight time periods between March 15, 2020, and December 31, 2021, according to SARS-CoV2 incidence waves, were compared to those from five control time periods. Parameters of metabolic control were assessed with adjustment for sex, age, diabetes duration, and repeated measurements. Laboratory-measured HbA1c values and those estimated from CGM were aggregated into a combined glucose indicator (CGI).

RESULTS

There was no clinically relevant difference in metabolic control between pandemic and control time periods with adjusted CGI values ranging from 7.61% [7.60-7.63] (mean [95% confidence interval (CI)]) in the third quarter of 2019 to 7.83% [7.82-7.85] in the time period from January 1 to March 15 2020, in the other control periods, and during the pandemic, CGI values lay between these values. BMI-SDS rose during the pandemic from 0.29 [0.28-0.30] (mean [95% CI]) in the third quarter of 2019 to 0.40 [0.39-0.41] during the fourth wave. Adjusted insulin dose rose during the pandemic. Event rates for hypoglycemic coma and diabetic ketoacidosis remained unchanged.

CONCLUSIONS

We found no clinically relevant change of glycemic control or incidence of acute diabetes complications during the pandemic. The observed BMI increase may represent an important health risk for youth with T1D.

Sustained Improvement in Glycemic Control in Emerging Adults with Type 1 Diabetes 2 Years After the Start of the COVID-19 Pandemic

INTRODUCTION

Although there were initial concerns that the public health response to the COVID-19 pandemic would adversely affect glycemic control in people with type 1 diabetes, several early continuous glucose monitor (CGM) studies reported an unexpected slight improvement in glucose metrics. Early emerging adulthood (roughly spanning the ages of 18-24 years) is often a vulnerable time in the life of a person with type 1 diabetes. Here, we set out to determine how the care and glucose management of emerging adults with type 1 diabetes changed over a period of approximately 2 years from the start of the COVID-19 pandemic.

METHODS

This was a retrospective study of a tertiary referral, multidisciplinary young adult diabetes clinic, spanning before and after the 777-day state of emergency in the City of Toronto.

RESULTS

Of 130 emerging adults with type 1 diabetes (80 male, 50 female; mean age 21.0 ± 2.1 years), baseline pre-pandemic HbA_1c values were available for 120 individuals. During 24.9 ± 5.4 months of follow-up before and after the start of the COVID-19 pandemic, HbA_1c fell from 8.5 ± 1.7% (69.3 ± 18.8 mmol/mol) to 8.1 ± 1.9% (65.2 ± 20.5 mmol/mol) (P < 0.05), with change in HbA_1c from pre-lockdown levels being sustained throughout the second year of the pandemic. Over the same period, CGM use rose from 43% to 83%, primarily through increased uptake of intermittently scanned CGM, which is covered through the Ontario Drug Benefit program. Change in HbA_1c was most evident in Dexcom G6 real-time CGM users - 0.7 ± 1.2% (- 9.8 ± 17.1 mmol/mol) (P < 0.01 vs. self-monitoring of blood glucose).

CONCLUSION

Among emerging adults with type 1 diabetes attending a multidisciplinary clinic in a high-income country, glycated hemoglobin levels are on average 0.4% (4.1 mmol/mol) lower than they were before the pandemic. This reduction in HbA_1c is unlikely to be a consequence of early strict lockdowns given the length of time of follow-up. Rather, improved glycemic control coincided with increased utilization of wearable diabetes devices.

The incidence and causes of acute hospitalizations and emergency room visits in adolescents with type 1 diabetes mellitus prior to and during the COVID-19 pandemic: a single-centre experience

INTRODUCTION

Type 1 diabetes mellitus (T1DM) is one of the most common chronic diseases in childhood. Because acute glycaemic com-plications account for most concerns in the management of T1DM in children, special attention during the challenging time of the global COVID-19 pandemic is required to prevent deteriorations resulting in acute hospitalization.

AIM OF THE STUDY

is to assess how the COVID-19 pandemic influenced the incidence and causes of acute hospitalizations and emergency room visits in adolescents with established type 1 diabetes mellitus, and to characterize the admitted population.

MATERIAL AND METHODS

The study was conducted as a retrospective evaluation of acute hospitalizations of 39 T1DM patients between 15 and 17 years of age in the period 2018-2021.

RESULTS

No difference was noted in the incidence of acute hospitalizations and DKA or the biochemical parameters of adolescents with T1DM between the pre-COVID (23 patients in 2018-2019) and COVID period (16 patients in 2020-2021). It is, howev-er, worth underlying that 6/11 (55%) patients hospitalised in 2021 experienced diabetes deterioration as a result of emo-tional distress - a phenomenon that was not present in the pre-COVID era. After excluding of the hospitalizations due to psy-chosocial causes, a significant decrease in the number of acute hospitalizations in the COVID period was observed.

CONCLUSIONS

We suppose that increased parental supervision during the pandemic might have prevented some of the episodes of severe disease decompensation, but this was masked by the sharp increase in hospitalizations due to emotional distress. Our data confirmed that psycho-emotional status is an important factor in the treatment of T1DM.

Diabetes and COVID-19: Short- and Long-Term Consequences

When the corona pandemic commenced more than two years ago, it was quickly recognized that people with metabolic diseases show an augmented risk of severe COVID-19 and an increased mortality compared to people without these comorbidities. Furthermore, an infection with SARS-CoV-2 has been shown to lead to an aggravation of metabolic diseases and in single cases to new-onset metabolic disorders. In addition to the increased risk for people with diabetes in the acute phase of COVID-19, this patient group also seems to be more often affected by long-COVID and to experience more long-term consequences than people without diabetes. The mechanisms behind these discrepancies between people with and without diabetes in relation to COVID-19 are not completely understood yet and will require further research and follow-up studies during the following years. In the current review, we discuss why patients with diabetes have this higher risk of developing severe COVID-19 symptoms not only in the acute phase of the disease but also in relation to long-COVID, vaccine breakthrough infections and re-infections. Furthermore, we discuss the effects of lockdown on glycemic control.

Influence of the SARS-CoV-2 pandemic on paediatric patients with type 1 diabetes mellitus after one year of follow-up

OBJECTIVES

Lockdown during the SARS-CoV-2 pandemic generated uncertainty regarding its effects on the control of type 1 diabetes (DM1). Our study aims to evaluate the influence of the pandemic on the control of paediatric patients with DM1.

METHODS

Longitudinal, retrospective, observational study in patients with DM1 attended between 15/10/2019 and 15/03/2020. Data were collected at that visit and at the three subsequent visits. The second was remote in 50% of cases. The variables analysed were: type of insulin therapy, time in range (TIR), time in hypoglycaemia (THypo), time in hyperglycaemia (THyper), coefficient of variation (CV), glycosylated haemoglobin, insulin requirements and anthropometric data.

RESULTS

157 patients were recruited. At the post-lockdown visit, the TIR increased and the THyper decreased with respect to the first (p<0.00) and second (p<0.00) visits. Patients treated with subcutaneous infusion showed a higher TIR at the third visit (p=0.03) and lower insulin requirements at the fourth visit (p=0.03) compared to patients treated with multiple doses. Patients with a remote visit presented a higher TIR (p<0.00), a lower THyper (p=0.00) and lower insulin requirements (p=0.01) at the next visit. Patients aged less than 6 years presented a lower glycosylated haemoglobin (p=0.01) and insulin requirements at the third (p=0.03) and fourth (p=0.01) visits, and a lower increase in body mass index (p=0.03) over the year.

CONCLUSIONS

Metabolic control improved at the post-lockdown visit. Patients treated with subcutaneous infusion, those who had a remote visit during strict lockdown and those aged less than 6 years had a better evolution.

Telemedicine for the Clinical Management of Diabetes; Implications and Considerations After COVID-19 Experience

Telemedicine is a clinical approach that was seldom used in the day-to-day practice, if not only in certain settings, before the COVID-19 pandemic. As stated by the WHO, telemedicine is: the delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies (ICT) for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, …. Telemedicine has actually represented the most useful and employed tool to maintain contacts between patients and physicians during the period of physical distance imposed by the pandemic, especially during the lockdown. Diabetes in particular, a chronic disease that often needs frequent confronting between patient and health professionals has taken advantage of the telehealth approach. Nowadays, technological tools are more and more widely used for the management of diabetes. In this review results obtained by telemendicine application in type 1 and type 2 diabetic individuals during COVID-19 are revised, and future perspectives for telemedicine use to manage diabetes are discussed.

The impact of COVID lockdown on glycaemic control in paediatric patients with type 1 diabetes: A systematic review and meta-analysis of 22 observational studies

INTRODUCTION

The COVID lockdown has posted a great challenge to paediatric patients with type 1 diabetes (T1D) and their caregivers on the disease management. This systematic review and meta-analysis sought to compare the glycaemic control among paediatric patients with T1D (aged under 18 years) pre- during, and post-lockdown period.

METHODS AND MATERIALS

We did a systematic search of three databases (PubMed, Embase, and the WHO COVID-19 Global literature) for the literature published between 1 Jan 2019 to 10 Sep 2022. Studies meeting the following inclusion criteria were eligible for this study: (1) a COVID-19 related study; (2) inclusion of children aged 18 years old or under with established T1D; (3) comparing the outcomes of interest during or after the COVID lockdown with that before the lockdown. Study endpoints included mean difference (MD) in HbA1c, blood glucose, time in range (TIR, 70-180 mg/dl), time above range (TAR, >180mg/dl), time below range (TBR,<70mg/dl) and glucose variability (coefficient of variation [CV]) between pre-lockdown and during lockdown and/or between pre- and post-lockdown period. The MD and its corresponding 95% CI of each endpoint were pooled using random-effect model considering the potential between-study heterogeneity in COVID restrictions and T1D management.

RESULTS

Initial search identified 4488 records and 22 studies with 2106 paediatric patients with T1D were included in the final analysis. Compared with pre-lockdown period, blood glucose was significantly decreased by 0.11 mmol/L (95%CI: -0.18, -0.04) during lockdown period and by 0.42 mmol/L (95%CI: -0.73, -0.11) after lockdown. The improvement was also found for TIR, TAR, TBR, and CV during and post-lockdown (all p values<0.05) except for the post-lockdown TBR (p =0.35). No significant change in HbA1c was observed during and post- lockdown period when compared with the pre-lockdown value. There was moderate to high between-study heterogeneity for most of the analyses.

CONCLUSION

Compared with pre-lockdown period, there was significant improvement in T1D paediatric patients' glucose metrics during and post-lockdown. The underlying reasons for this positive impact warrant further investigation to inform future paediatric diabetes management.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022359213.