Diabetes during the COVID-19 pandemic: A global call to reconnect with patients and emphasize lifestyle changes and optimize glycemic and blood pressure control.

Individuals with diabetes, obesity, and hypertension are at heightened risk of adverse outcome of coronavirus‐associated disease 2019 (COVID‐19). Data from many studies show that patients with diabetes have increased risk of admission in intensive care units and of mortality. Hypertension is highly prevalent in patients with COVID‐19 and was the most common cardiovascular comorbidity in a meta‐analysis, contributing to increase in mortality. Further, in a retrospective analysis of French patients with COVID‐19, obesity (BMI >30 kg/m2) and severe obesity (BMI >35 kg/m2) were present in 47.6% and 28.2% of cases, respectively. In this study, patients with higher BMI values were at greater risk for invasive mechanical ventilation than those who were nonobese. These data show high mortality risk in COVID‐19 patients with diabetes, hypertension, and obesity. COVID‐19 prevalence is likely to vary with different ethnic groups, country, socio‐economic stratum, and healthcare support.

Many countries or parts of countries are under “lockdown,” restricting movements of individuals. Such approaches are likely to have undesirable effects on patients with diabetes: on exercise, on diet, on obtaining adequate supplies of medicines, insulin, and glucose‐testing reagent strips, and on interaction with healthcare providers (HCPs). In addition, psychological impacts of the COVID‐19 pandemic including anxiety and depression affect more than half of the population. All these factors may destabilize glycemic and blood pressure control and may worsen obesity. A recent analysis from mathematical modeling in India predicts that lockdown will cause substantial increase in glycosylated hemoglobin (HbA1c) and future diabetes‐related complications. Patients with diabetes having poorly controlled glycemia may in turn be at greater risk for COVID‐19 complications and mortality.

Patients with diabetes often have insufficient health education to modify drug/insulin dosages when it is difficult to communicate with or visit their primary HCPs, particularly in disadvantaged and marginalized populations, and in elderly without support. , Increases in blood glucose or blood pressure levels with little expert help and inadequate knowledge to control them is likely to further increase psychological stress in patients.

Fortunately, we have reached a threshold of use of telemedicine services, including video chats, telephone calls, and short messaging services to impart advice and guide treatment. Telemedicine studies before the COVID‐19 pandemic show that these communication strategies can effectively lower HbA1c. In a 4‐year follow‐up of a study of nearly 1000 persons with diabetes randomized to a telemedicine self‐management behavioral intervention, all‐cause and diabetes‐related hospitalizations were reduced by 11% and 17%, respectively, with consequent cost‐savings. The call for “an immediate digital revolution to face this crisis” of COVID‐19 seems eminently appropriate.

Importantly, there is good evidence to emphasize control of glycemia and hypertension as telemedicine goals, and reasonable strategies have been outlined. Approaches to exercise within confined spaces and to healthy diets can be encouraged. Patients should try to maintain their previous schedule of meal timings and should adhere to their medication regimens. Education about changes in doses of drugs and insulin can be imparted to empower patients in self‐management of their diabetes and hypertension, emphasizing use of self‐monitoring of glucose and blood pressure levels and ongoing communication with HCPs. An emphasis on the potential of improved outcome of COVID‐19 when diabetes and hypertension are under good control is reasonable. In developing countries, keeping financial implications in mind, low‐cost therapies and simple treatment regimens should be prescribed to underprivileged and underserved populations. Efforts should be made to reconnect with patients and impart appropriate prevention and management advice.

In our clinical practices, we already have begun such efforts and have seen benefit. We encourage all our readers to follow such approaches.

糖尿病、肥胖症和高血压患者发生新冠病毒相关疾病不良后果的风险增加。来自多项研究的数据显示, 糖尿病患者在重症监护病房住院的风险和死亡率都有所增加。高血压在COVID‐19患者中非常普遍, 在meta分析中也是最常见的心血管合并症, 导致死亡率增加。此外, 在对法国COVID‐19患者的回顾性分析中, 肥胖(BMI >30 kg/ m2)和严重肥胖(BMI >35 kg/m2)分别占47.6%和28.2%。在本研究中, 体重指数较高的患者比非肥胖者有更大的有创机械通气风险。数据显示COVID‐19合并糖尿病、高血压和肥胖的患者死亡风险较高。COVID‐19的患病率可能会因不同的民族、国家、社会经济阶层和医疗保健支持力度而有所不同。

许多国家或国家的部分城市处于“封锁”状态, 限制个人行动。这样的方法可能会对糖尿病患者产生不良影响:包括锻炼、饮食、如何获得充足的药物、胰岛素和葡萄糖测定剂试纸, 以及与医疗保健人员(healthcare providers , HCPs)的互动。此外, 还有COVID‐19大流行所导致的心理影响, 包括焦虑和抑郁, 它们可能影响到一半以上的人口。所有这些因素都可能影响血糖和血压的稳定, 并可能加剧肥胖。印度最近通过数学建模进行的一项分析预测, “封锁”将导致糖化血红蛋白(HbA1c)以及未来的糖尿病相关并发症大幅增加。此外, 血糖控制不佳的糖尿病患者可能会面临更大的新冠肺炎并发症和死亡风险。

糖尿病患者往往没有足够的医学知识来调整药物/胰岛素剂量, 当难以与医疗保健人员沟通时, 特别是在处境弱势和边缘化的人群中, 以及在孤立无援的老年人中。在缺乏专家帮助和知识不足的情况下, 血糖或血压水平的上升可能会进一步增加患者的心理压力。

幸运的是, 我们已经可以使用远程医疗服务, 包括视频聊天、电话和短信服务, 以提供建议和指导治疗。COVID‐19大流行之前的远程医疗研究表明, 这些沟通策略可以有效地降低糖化血红蛋白。在一项持续四年的跟踪研究中, 对近1,000名糖尿病患者随机进行远程医疗或自我管理行为干预, 全因住院和糖尿病相关住院分别减少了11%和17%, 从而降低了费用。呼吁“立即进行一场数字革命来面对这场危机”, 在COVID‐19面前似乎是非常恰当的。

现在有很好的证据支持将控制血糖和高血压作为远程医疗的目标, 并概述了合理的战略。可以鼓励在有限空间内锻炼和健康饮食的方法。患者应该尽量保持他们以前的用餐时间安排, 并应该坚持他们的药物治疗方案。可以进行有关药物和胰岛素剂量调整的教育, 使患者能够自我管理糖尿病和高血压, 并重视自我监测血糖和血压水平, 以及与医疗保健人员持续沟通。值得重视的是, 当糖尿病和高血压得到良好控制时, 有理由相信COVID‐19患者的预后会改善。在发展中国家, 考虑到财政影响, 应该为贫困和服务不足的人群开出低成本的疗法和简单的治疗方案。并努力与患者重新联系, 给予适当的预防和管理建议。

在我们的临床实践中, 我们已经开始了这样的努力, 并已经看到了好处。我们鼓励所有的读者也遵循这样的方法。