Global expert on flourishing with diabetes and international inspirational speaker. Living with type 1 diabetes 48 years.
By Riva Greenberg
COVID-19 has led to an abundance, and unprecedented acceleration, of medical professionals and organizations sharing medical insights and learnings. I have had the honor of being invited into one such illustrious group under the leadership of Professor Itamar Raz, diabetologist and former head of Israel’s national diabetes health policies and Guang Ning, Head of Shanghai Clinical Center for Endocrine and Metabolic Disease, China.
My role is one of a thinking partner having worked in diabetes for 17 years advocating for a more humanistic, and less mechanistic, relationship between practitioner and patient, and having lived with type 1 (T1D) diabetes 48-plus years. Also, I will be sharing updates from the group and, at times, my and patients’ point of view. I am in a privileged position: I get to be a dancer on the dance floor, as the metaphor goes, and also observe the room from the balcony.
Writing Faster Recommendations and Guidelines
The Raz/Ning team consists of more than a dozen MDs, researchers, scientists, heads of universities, and hospital departments with long and heralded careers. They are calling into frequent video calls from China, Thailand, Hong Kong, India, Italy, Spain, Belgium, Japan, Australia, Israel, Germany, the U.S., U.K., and Canada sharing their knowledge, observations, experiences, findings, literature reviews and lessons learned. Through ongoing emails, they digest a barrage of information and brainstorm prevention and treatment guidelines that they can safely, and quickly, recommend to health professionals and the public.
Currently most pressing amid the discussion is:
How do we identify those with diabetes most at risk for COVID-19 and lessen their vulnerability?
What can we safely recommend now that anyone with diabetes can do to lower their risk of getting the virus?
How do we reshape diabetes prevention, care, and treatment in a way that makes people with diabetes (PWD) more metabolically healthy and less vulnerable to a disease like COVID-19?
Early findings over these last few months show that people with poorly managed diabetes and obesity are being hospitalized three to four times the rate of people without diabetes and obesity, and once hospitalized they experience more severe outcomes, including death. A recent UK study finds people with type 1 diabetes may be at even higher risk for poor outcomes than people with type 2 diabetes, if hospitalized, due to longer-term vascular damage.
Diabetes and/or its associated comorbidities - cardiovascular disease, hypertension, kidney, lung and liver disease, and obesity, have left millions vulnerable to COVID-19. Obesity has been associated with higher ICU admissions, and just looking at the United States, according to a recent study conducted by researchers at the University of North Carolina at Chapel Hill’s Gillings School of Global Public Health, only 12% of Americans are metabolically healthy.
While COVID-19, is for most of us, the first pandemic that has touched us in such a personal way, diabetes, pre-diabetes, and obesity are three pandemics we have lived with for decades that the world has all but ignored.
Paradigm Shift for Diabetes Prevention, Treatment, and Care
As government leaders work to “flatten the coronavirus curve” the group’s longer-term mandate is to flatten the “diabetes and obesity curve.” Most epidemiologists agree a Coronavirus type of pandemic will happen again. And as Professor Raz told me quite openly, “We cannot afford to get caught with our pants down again. If we do not address our failure in diabetes and rising obesity, including childhood obesity, when the next pandemic comes the death rate will be astronomical.”
So the team is also reimagining a new model for diabetes prevention, care, and treatment. Early thinking involves medical education that teaches all health professionals about diabetes, better-informed patients, greater collaboration and communication between health professionals and people with diabetes, attention to emotional support, and using telemedicine for more frequent contact and greater support. More to come on this.
List of Early Recommendations
Baseline prevention is for people with diabetes to be metabolically and nutritionally healthy and of normal weight.
PWDs should adhere to their therapeutic regimen and seek assistance from their health care professionals to improve glycemic control.
People with diabetes should improve their metabolic control preemptively so that their risk of complications will be lower. To do so, maintain a healthy balanced diet. Including antioxidants like vitamin C or zinc may be of benefit as well as supplements that improve immunity like Vitamin D and Selenium. Adhere to an individually tailored physical activity regimen. Outdoor activity, when possible, should be included for PWDs at a low risk of severe disease. Stop smoking.
Those infected with the coronavirus should monitor their glucose levels closely, strive for achieving glucose levels as close to normal as safely possible, and contact their healthcare professionals to consider medication changes as individually mandated.
Have a sustainable supply of medicines and equipment.
Educate health teams in the hospital on the critical impact of high glucose when people with diabetes are ill, and help teams work collaboratively.
Address emotional and mental health recommendations.
Re-imagine diabetes caretaking from the perspective of a systems view, including public health measures and policies, improved social justice legislation, community, wellness, and mental health resources.
Recommendations for What People with Diabetes Can Do Now
1. The best prevention against COVID-19, outside of the general recommendation of social distancing and washing your hands, is to keep oneself nutritionally and metabolically healthy.
What does that mean? Eat a healthy balanced diet, including antioxidants like vitamin C, found in fruits and leafy greens, supplements like zinc, selenium, and Vitamin D. You can get a day’s worth of selenium from eating just two Brazil nuts. *Some evidence shows Vitamin D reduces the risk of COVID-19 infections and deaths and may help manage cytokine storms. Do some form of exercise, if possible aerobic to bring up your heart rate and anaerobic to build muscle. These “lifestyle” changes can help bring down chronic inflammation and weight, and lower the risk for comorbidities - heart disease, hypertension, obesity, liver, and lung disease - all of which are risk factors for COVID-19.
* At this time, the evidence of Vitamin D and other supplements’ use for prevention, and as treatment, is inconclusive and group members have varying opinions on their efficacy. However as they may be beneficial, they are included in the recommendation. The group agrees, however, that healthy eating, including a tailored nutritional program if necessary, and healthy lifestyle behaviors are paramount.
2. Keep blood sugar levels in range as much as possible
Those not infected with the virus should follow their management plan and monitor their glucose levels closely. Those infected with the coronavirus should strive for glucose levels as close to normal as safely possible and contact their healthcare professionals if medication changes, or any assistance, is needed. Why? While it appears people with well-managed diabetes (both type 1 and type 2) are not necessarily at greater risk of getting the coronavirus, early evidence shows hyperglycemia (high blood sugar) may make one more vulnerable to COVID-19 and cause more severe outcomes.
COVID-19 and Hyperglycemia
There is an association between high glucose and the coronavirus - 4 theories were postulated
Hyperglycemia increases susceptibility for getting COVID-19. If so, normalizing blood glucose is the optimal treatment.
Hyperglycemia is associated with other conditions like inflammation and insulin resistance, which could be the actual risk factors. If so, high blood glucose itself is not the problem.
Hyperglycemia is not a risk factor for COVID-19 but a marker of the condition. If so, it is an unrelated adverse outcome.
Hyperglycemia is associated with diabetic comorbidities which themselves are associated with adverse COVID-19 outcomes. If so, the comorbidities are more causal than high blood glucose.
COVID-19 and Cardiovascular (CV) Disease
COVID-19 has been shown to lead to multiple alterations in the cardiovascular system including a direct effect on the cardiac muscle and endothelial cells and a tendency to form micro-thrombi that adversely affect all organs and leads to a possible heart attack. Further, due to fear of going to the hospital and possible coronavirus infection, CV morbidity and mortality have increased as people with signs of acute CV events have stayed home.
COVID-19 and Inflammation and Obesity
Inflammation worsens immune responses and obesity worsens the outcome of hospitalized patients, mainly in the ICU. Several reports indicate morbid and visceral obesity, when inflammation is high, cause cytokine storms mainly from the intra-abdominal fat cells. Patients with diabetes and severe COVID-19 exhibit severe inflammatory response. They are more likely to be put on a ventilator in the ICU. If patients are in poor metabolic health, they lack the stamina to maximally benefit from the ventilator.
Ideas That Can be Enacted Now
1. Collaboration across specialties
Health teams in hospitals need to be quickly educated on the critical impact of high glucose when people with diabetes are ill and teams of specialists should work more collaboratively. Doctor Del Prato shared he was not asked for a single consultation at his hospital in Italy while attending COVID-19 patients with diabetes regarding a high glucose value or glucose management.
2. Do not take a historical perspective of diabetes and coronavirus
The team agreed as they continue to work together to not rely on how diabetes and infectious diseases have interacted before but to look at COVID-19 as a new and novel entity. Too much is still too unclear and potential new insights could be overlooked.
Going forward - Changing the system
There are unsettling similarities between COVID-19 and diabetes; both are pandemics, both are silent killers and both are due to changes in the ecosystem and human behavior. Both are collapsing countries’ healthcare systems and economies. And both are potentially preventable and treatable.
It will take a systems approach to curb diabetes and obesity. New public health measures and policies, improved social justice legislation, and more community, wellness, and mental health resources to support people changing their actions. How to translate the onslaught of scientific findings into creating this new system and behavior change is the next question. And it can’t be ignored any longer.
Current Open Questions
How many people exhibiting hyperglycemia at hospital admission is new-onset diabetes?
What does the reported observation that people with T1D in lockdown have had relatively unchanged glycemic control tell or suggest to us?
Has early telemedicine been successful? How does it work when acute conditions arise? How will it be integrated into future care?
Further analysis of the impact of Vitamin D supplementation
How should systems reorganize so that they can manage the next crisis more promptly and efficiently?
My view/Patient’s Pulse
After wearing a CGM (continuous glucose monitor) for more than six years, it has dramatically eased my blood glucose management. I do not wear an insulin pump. Having blood glucose data available every five minutes, and knowing whether my blood sugar is stable, going up or down, I can often avoid hypo and hyperglycemia. Based on my experience, and knowing in the U.S. that hospitals are allowing the use of CGMs during the pandemic, I would make the following recommendations:
Allow patients in the hospital who already use a CGM, if able, to continue to monitor their own glucose and make dosing decisions.
Bring the use of CGMs into hospitals and train health professionals on them. Having patients use a CGM cuts down on health professionals’ time spent with infected patients.
Many people with diabetes, in general, are afraid to go into the hospital. Many health professionals lack diabetes management knowledge. (Something the group proposes should change.) I have told my husband on numerous occasions, long before the pandemic, “Should I ever be in the hospital and unable to manage my diabetes, you must advocate for me.” Accordingly, people with diabetes hearing they are more at risk for COVID-19 have chosen not to leave their homes as their best protection.
Team Participants List
Sin Gon Kim - Associate Professor of Endocrinology and Metabolism for the Internal Medicine Department of the Korea University College of Medicine, South Korea
Philip Home - Emeritus Professor, Translational and Clinical Research Institute, Newcastle University, U.K.
Guang Ning - Head of Shanghai Clinical Center for Endocrine and Metabolic Disease, China
Juliana Chan, Director, Hong Kong Institute of Diabetes and Obesity Faculty of Medicine, The Chinese University of Hong Kong
Stefano Del Prato - Professor of Endocrinology and Metabolism at the School of Medicine, University of Pisa and Chief of the Section of Diabetes, University Hospital of Pisa, Italy
Banshi Saboo, Consultant Diabetologist: Diabetes Care & Hormone Clinic
Visiting Diabetologist: Jivraj Mehta Hospital and Thaker Sy Hospital, India
Boonsong Ongphiphadhanakul, Professor of Medicine at the Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand.
Zachary Bloomgarden - Clinical Professor, Medicine, Endocrinology, Diabetes and Bone Disease, Mt. Sinai, U.S.
Eberhard Standl - Professor of Medicine, specializing in endocrinology and angiology, at the Munich Diabetes Research Group, Germany
Ronit Endevelt - Director of the nutrition department of the health ministry and lecturer at the University of Haifa, Israel
Luc VanGaal, Professor of Medicine, Department of Endocrinology, Diabetology and Metabolism, Antwerp University Hospital, Belgium
Ralph A. DeFronzo, Professor of Medicine and Chief of the Diabetes Division at the University of Texas Health Science Center and the Deputy Director of the Texas Diabetes Institute, San Antonio, Texas, US
Dror Diker - Head of Internal Medicine Department and Obesity clinic, Hashsron Hospital-Rabin Medical Centre, affiliated with Tel Aviv University
Avivit Cahn - Diabetes Unit - Hadassah Hebrew University Hospital, Jerusalem
Antonio Ceriello - Professor and Head of Diabetes Department at IRCCS MultiMedica, Milan, Italy
Paolo Pozzilli, Professor of Endocrinology and Metabolism, University Campus Bio-Medico, Rome, Italy