'Hidden Toll' of Pandemic a Major Deficiency in Diabetes Care

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People with either type of diabetes experienced significant deficiencies in routine care, financial problems, and psychosocial issues during the COVID-19 pandemic, indicate new data from the real-world iNPHORM study.

"To date, most diabetes-related COVID-19 studies in the US have focused exclusively on the epidemiology of hospitalized cases and failed to consider the nature and extent of the pandemic on community-based diabetes management. iNPHORM is one of the first studies in the world to quantify this impact," Alexandria Ratzki-Leewing, a PhD candidate at Western University, London, Ontario, Canada, told Medscape Medical News. She presented the results September 29 at the virtual European Association for the Study of Diabetes (EASD) 2021 Annual Meeting.

The pandemic was found to cause substantial deficiencies in routine diabetes care with only few significant differences observed by diabetes type. "The results of this study will be instructive for handling diabetes management both during the current public health emergency and in future...Our findings help us to understand the hidden toll the COVID-19 pandemic has taken on those with chronic diseases like diabetes," she noted in an EASD statement.

The Underserved With Diabetes Suffered the Most in the Pandemic

Launched in February 2020 and conducted monthly, the 12-month iNPHORM survey is a project of Sanofi Canada looking at aspects of hypoglycemia.

The new "snapshot" data were gathered from the online survey taken in January 2021, which involved 772 people with type 1 or type 2 diabetes treated with insulin or an insulin secretagogue. Participants reported numerous financial, medical, and psychosocial challenges.

Asked to comment, endocrinologist Irl B. Hirsch, MD, of the University of Washington, Seattle, told Medscape Medical News: "What's important about this report is that it studied the 'pan-insecurities' of a generalized cohort of Americans with diabetes. This population included a more complete socioeconomic population than what I see in my clinic or in some published studies."

Hirsch noted that the lucky few who had access to diabetes technologies such as continuous glucose monitoring during the pandemic didn't seem to suffer deficits in care, and even reported improvement in some cases.

But such technology "likely wasn't available to those with major deficiencies in diabetes care characterized in this report. My conclusion is like so many aspects of the pandemic: the underserved with diabetes had the greatest negative impact on their diabetes care."

Also asked to comment, Amar Puttanna, MBChB, consultant in diabetes at the University Hospital Birmingham, UK, noted that although the UK doesn't have the same problem of drug affordability as the United States, it still has disparities in care among deprived populations.

"Deprivation is a factor in different areas within the healthcare system, in affluent versus nonaffluent areas, [and] will have an impact on COVID-19 outcomes in people with diabetes...What needs to be done is to understand it a bit more with a view towards reducing that inequality," he said.

"Pan-insecurities": Obtaining Food, Medications, Daily Life Disruptions

Of the 772 participants, 18.9% had type 1 diabetes and the rest had type 2 diabetes. The overall group was a mean age of 52 years, had a diabetes duration of 14 years (as of January 21, 2021), 51% were female, and 9.3% had been diagnosed with COVID-19 between March 2020 and January 21, 2021. In 22.8% of the overall group, the most recent A1c was above 8.1%.

Asked which situations were more difficult during the pandemic, 23.4% said affording basic living expenses such as rent, 17.4% said affording diabetes medications, and 16.2% said affording glucose testing supplies. Another 22.2% said having trouble retrieving diabetes medications from the pharmacy, and 18.8% said keeping enough food in their home to avoid hypoglycemia.

Difficulty remembering to perform various aspects of care during the pandemic were also common, including taking diabetes medications (11.6%), testing glucose (12.5%), and consulting with care providers (25.2%).

All of the aforementioned problems were reported in similar proportions by those with type 1 and type 2 diabetes.

However, there were differences between the two types in rationing: 15.8% of those with type 1 diabetes versus 10.7% with type 2 diabetes reported restricting diabetes medications to preserve supply. And there was a significant difference in those who said they rationed diabetes medications to avoid hypoglycemia: 17.1% for those with type 1 diabetes versus just 9.1% for type 2 diabetes (P = .005).

Among psychosocial and lifestyle issues, 36.9% had difficulty staying as physically active as usual, and 16.0% had difficulty "maintaining social support to help manage hypoglycemia." The difference between type 1 and type 2 diabetes in "feeling in control" of hypoglecemia (15.8% vs 10.4%) was also significant.

Ratzki-Leewing told Medscape Medical News: "These results draw awareness to the manifold and pressing care gaps caused by the pandemic. In so doing, we hope to provide a roadmap for necessary remedial action that ensures undisrupted diabetes management, both in the acute phase of the pandemic and well after vaccines are distributed. A proactive, holistic approach will be required to get patients back on track."

An earlier version of the cross-sectional data from April 2020 was published online September 2 in BMJ Open. The investigators plan to publish the full dataset from the monthly surveys going back to the beginning of the pandemic and to examine effects by subgroups and the impact of community COVID-19 infection.

The iNPHORM study is funded by Sanofi Global. Ratzki-Leewing has reported receiving grants from and/or is a consultant for Sanofi Global, Sanofi Canada, Novo Nordisk Global, and Eli Lilly Canada. Hirsch has reported receiving research funding from Medtronic Diabetes, Insulet, and Beta Bionics and has received consulting fees from Abbott Diabetes Care, Bigfoot, Roche, and GWave. Puttanna has reported receiving honoraria and/or speaker fees from Sanofi, Novo Nordisk, Eli Lilly, AstraZeneca, Menarini, and Napp.

EASD 2021 Annual Meeting. Abstract 694. Presented September 29, 2021.

Miriam E. Tucker is a freelance journalist based in the Washington, DC, area. She is a regular contributor to Medscape, with other work appearing in The Washington Post, NPR's Shots blog, and Diabetes Forecast magazine. She is on Twitter: @MiriamETucker.

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