There was both good news and bad news last week when a team of Scottish doctors published their research on the impact of the COVID-19 lockdowns on glycemic control in patients with Type 1 diabetes.
The good news: the researchers found “a small but significant improvement” in glycemic control, as measured by metrics such as time-in-range and estimated HbA1c.
The bad news: blood sugar control improvement, or the lack thereof, was highly correlated with socioeconomic status. Patients in the lowest socioeconomic brackets were significantly more likely to see their control deteriorate.
The study, in the journal Diabetic Medicine, utilized glucose data from over 500 patients of diabetes clinics in Edinburgh, Scotland. All of these patients used the FreeStyle Libre flash glucose monitoring system, and had previously elected to share their data with their doctors.
As a whole, the patients showed modest but statistically significant improvements across the board. Average glucose, standard deviation, and time-in-range all improved. There were also increases in the rate of hypoglycemic events, but the authors called these “negligible and unlikely to be clinically relevant.”
The overall finding of improved glycemic control more or less echoes an earlier, much smaller study from Italy. This analysis found that patients with T1D that had stopped working (and stayed at home) during the lockdown experienced dramatically improved glycemic control—lower average blood glucose, improved standard deviation and improved time-in-range. Those that continued to work out of the house, by contrast, exhibited no change in their blood glucose numbers. The authors speculated that these results showed that “slowing down routine daily activities can have beneficial effects on T1D management, at least in the short term.”
It was anybody’s guess as to how the strict lockdowns in response to the COVID-19 pandemic might have affected glucose management in patients with Type 1 diabetes. On the one hand, the pandemic meant stress, financial difficulty, the closure of gyms and exercise centers, and a widely-reported rise in comfort food. On the other hand, with more people staying at home than ever, many patients must have enjoyed a newfound opportunity to establish consistent healthy routines. It should be unsurprising that the Italian study found a significant difference in those that stayed at home, and those that could not.
Unfortunately, the Scottish study strongly suggests the lockdowns were yet another force exacerbating the socioeconomic gap in diabetes outcomes. The authors suggested that “deprivation may be disproportionately associated with poorer diet and reduced exercise during lockdown, as well as increased stress from childcare commitments and uncertainty around employment and income.” The study is ultimately just one more small piece contributing to the broad picture we have that the most deprived members of our society have been disproportionately victimized by the pandemic—both by the virus itself and the economic devastation it has wrought.
The authors cautioned that these results, which are derived from committed users of the FreeStyle Libre glucose monitoring system, cannot be generalized. In reality, they may understate the extent of the results gap between different socioeconomic strata: “Even greater challenges may exist for those not currently using modern glucose monitoring technologies and remote data?sharing.”
It would therefore be right to fear that the outcome gap in America may be even more stark. Scotland has a robust nationalized healthcare system, but in the United States, loss of income and unemployment have forced some patients to ration their insulin, an extraordinarily dangerous practice.