COVID-19 and Type 2 Diabetes: Shedding light on an often-neglected approach to saving lives during the pandemicPublished: Monday, August 10, 2020
Are you living up to your healthiest potential? This might be the key to surviving the pandemic.
It is no secret that those with the highest risk of hospitalization, intubation, and death from COVID-19 are those with chronic conditions such as type 2 diabetes mellitus, chronic lung disease, and cardiovascular disease. Complied data from the Center for Disease Control’s weekly morbidity report shows that of all individuals with diabetes who contracted the coronavirus Disease of 2019 (COVID-19), 55 percent were hospitalized, 20 percent were hospitalized and admitted to the intensive care unit, and only 45 percent did not need hospitalization. This comes in stark contrast to individuals without any chronic conditions, of whom only 10 percent were hospitalized, 2 percent were hospitalized and admitted to the ICU, and 90 percent were not hospitalized1. In other countries that were hit hard by the pandemic, diabetes was the second most common comorbidity (30 percent) after hypertension (67 percent) in those who died from COVID-19. Indeed, this pattern has been well recognized across Europe, Asia, the US, and Latin America2. In short, diabetes on its own is a large predictor of whether or not an individual will require hospitalization, suffer from complications, or die if infected with COVID-19.
I recently had a heart wrenching telemedicine interaction during my Family Medicine rotation with a COVID-negative patient – let’s call her Gloria – who, despite social distancing and self-quarantining, is now at a greater risk of complications and death from COVID-19 than she ever was before the pandemic. The main reason? Exacerbation of her diabetes.
Gloria is a woman in her late 60’s on Medicare with a history of type 2 diabetes, obesity, and hypertension. Before the pandemic, she had recently been diagnosed with diabetes and was being seen at the Robert B. Green Family Health Clinic in downtown San Antonio. Despite her late diagnosis, and having not seen a doctor for many years, Gloria was on her way to controlling her blood sugars and losing weight. She had begun going out for walks in the evenings with her best friend, eating a healthier diet that cut down carbs, and she would attend church every Sunday. From a primary care standpoint, social support and interactions are crucial for maintaining a healthy lifestyle and keeping up with medications. In essence, she had all the basic necessities to get her to a healthier place in her life.
But then the pandemic happened.
The first thing Gloria lost was the social support she received from her church, as services transitioned to Facebook live events with virtually no interactions with fellow congregants. Her in-person clinic visits became telemedicine phone calls. Rumors went around that there were COVID-positive residents living in her apartment complex, making her fearful to leave the apartment and interact with neighbors. On top of that, increasing numbers of homeless individuals began to congregate outside of her complex, making her feel unsafe to go out for her daily walks. She became isolated, and in many ways confused. Her diabetes regiment included pills, insulin, and a new injectable medicine called liraglutide that was prescribed to her during the pandemic. As Gloria and I were chatting, she told me that she never figured out how to administer her new medicine, and so she never took it. She also disclosed that the boredom from staying at home all day had made her “cheat.” She explained that she was not eating as healthy, as she was partaking in more desserts and bread than before the pandemic. On top of that, she proudly told me that she was eating her fruits and vegetables, while emphasizing that she really enjoyed her daily glasses of pineapple, grape, and apple juice (we’ll touch on this last part later).
In summary, the pandemic directly caused Gloria to lose access to her social support and her ability to go out for her daily walks. She lost access to the friendly in-person resources at the family health clinic that had been helping her keep track of her medicines and counseling her on healthy dietary habits. Managing her diabetes over the phone became too confusing – and understandably so – because it meant that she had to keep track of half a dozen pills, plus two different types of daily injections that had schedules of their own. Being told about changes in her medications over the phone, getting new ones prescribed over the phone, and misinterpreting nutritional advice prevented her from receiving the full benefits from her medical care. Specifically, Gloria succumbed to the all-too-common misconception that fruit juices are healthy. The reality is that sugar content from fruit juices is no different than that of soft drinks, and should be avoided entirely in people with diabetes or pre-diabetes.
It is hard to point to a single event, but Gloria’s diabetes got much worse over the past several months. Her most recent hemoglobin A1c, a blood sugar measure that takes into account the total amount of blood sugar present in the body over the course of two to three months, was at 10.7 percent, up from 8.2 percent before the pandemic, and well above her goal of getting to a level less than 8.0 percent. To put it in perspective, a normal A1c level is less than 6.0 percent, a pre-diabetes level is between 6.0 percent and 6.4 percent, and a diabetes level is 6.5 percent or greater. At Gloria’s current level, she is at a very high risk of kidney damage, nerve damage, and eye damage. But more importantly, she is at a very high risk of complications, disability, and death from COVID-19, more so than if her diabetes were under control.
The prevalence of Type 2 Diabetes Mellitus in the United States currently stands at 10.1 percent, with Native Americans, Hispanic Americans, and African Americans having greater prevalence rates than the national average at 14.7 percent, 12.5 percent, and 11.7 percent respectively3. Indeed, a combination ofpoverty, genetic predispositions, and poor social determinants of health are putting individuals in these communities at a compounded risk of morbidity and mortality from COVID-19, including Gloria.
Like many communities across the country, San Antonio’s Robert B. Green Family Health Clinic is fortunate to have a program of Promotores de Salud (community health-care promoters) comprised of lay healthcare workers from the community who ensure that patients seen at the clinic are being followed-up appropriately and are keeping up with their healthcare goals4. This is an invaluable resource that helps tackle the root of the problems facing people like Gloria. Thankfully, we were able to place an order to dispatch a promotora to Gloria’s home in order to ensure she is getting the healthcare she needs.
Now, more than ever, we need to expand our public health efforts to encourage healthy habits such as exercise, healthy eating and drinking (cutting out sugary beverages in particular), proper follow-up with healthcare providers, and proper use and compliance with medications. Involving community members as with the Promotores program is a step in the right direction, but it is not enough. We need both a top-down and bottom-up approach that empowers individuals to take responsibility for their own personal health and wellbeing as much as possible.
The vast majority of public health campaigning has focused on social distancing, self-quarantining, and wearing masks. While these efforts are rightfully aimed at mitigating the spread of COVID-19, little is being done in promoting personal health to survive the disease if one does become infected. Many in the medical community believe that a greater emphasis should be placed on outreach to promote self-care measures in people with chronic diseases including healthy diets, proper physical activity, mental health awareness, and more5. Especially since such a non-trivial percentage of people in the US – specifically in minority communities and impoverished communities – currently live with chronic diseases. This is especially true for individuals with diseases known to complicate the COVID disease process.
So, what can we as students, staff, residents, fellows, and faculty do about it?
As members of the San Antonio community, we can do a lot to help our friends and neighbors with chronic diseases focus on maintaining control over them. By being healthcare ambassadors in our communities, we can do our part to mitigate morbidity and mortality from COVID-19 in high-risk communities. Let’s keep our neighbors and our loved ones safe. Let’s continue to mask, let’s continue to social distance, but let’s also encourage each other to engage in healthy choices; including making sure that those with chronic diseases like diabetes have an optimized health plan and social support.
Unfortunately, as of writing this, I have not been able to follow-up with Gloria to see how she is doing. But, I hope that her story in the context of the greater public health obstacles we are facing can shed a light on an often-neglected issue that can help save lives. We must help our neighbors obtain the healthcare they need before it’s too late. For so many in the Hispanic community in San Antonio and South Texas, in the Native American communities in New Mexico, in the African American communities in the South and Northeast, poor white communities in Appalachia, and many other vulnerable communities, the virus has already taken a devastating toll.
About the Author
Eithan Kotkowski is a South Texas Medical Science Training Program candidate and recent Ph.D. graduate from the Radiological Sciences’ Neuroscience Imaging Track. His Ph.D. project entailed identifying neurocognitive biomarkers for insulin resistance and type 2 diabetes in the Mexican-American population of the greater San Antonio area. Read the article “A Neural Signature of Metabolic Syndrome.” He is currently completing his final year of his M.D. degree at UT Health’s Long School of Medicine.
1 Chow, N., Fleming-Dutra, K., Gierke, R., Hall, A., Hughes, M., Pilishvili, T., et al. (n.d.). Preliminary Estimates of the Prevalence of Selected Underlying Health Conditions Among Patients with Coronavirus Disease 2019 — United States, February 12–March 28, 2020. MMWR. Morbidity and Mortality Weekly Report, 69.
2 Caballero, A. E., Ceriello, A., Misra, A., McDonnell, M. E., Hassanein, M., Ji, L., Mbanya, J. C., Fonseca, V. A. COVID-19 in people living with diabetes: An international consensus, June 29, 2020. Journal of Diabetes and Its Complications. https://doi.org/10.1016/j.jdiacomp.2020.107671
3 “Statistics About Diabetes.” Statistics About Diabetes | ADA, 2020, www.diabetes.org/resources/statistics/statistics-about-diabetes
4 Albin, Jaclyn, and Ling Chu. “6 Ways to Improve Wellness during the Pandemic: COVID: UT Southwestern Medical Center.” COVID | UT Southwestern Medical Center, 29 Apr. 2020, utswmed.org/medblog/6-ways-improve-wellness-during-pandemic/
5 Alvino, Virginia. “Promotoras De Salud Could Help Close The Health Gap For Latinos.” Texas Public Radio, 2 Oct. 2015, www.tpr.org/post/promotoras-de-salud-could-help-close-health-gap-latinos.