key: cord-0740620-n89hhq41 authors: Quirke‐McFarlane, Sophia; Hodgkinson, Anna; Weinman, John; Meiyalagan, Narthana; Prince, Alexis C; Chamley, Mark; Stevenson, Jennifer M title: The effects of COVID‐19 on self‐management behaviours and service experiences in type 2 diabetes mellitus date: 2021-10-04 journal: Practical Diabetes DOI: 10.1002/pdi.2356 sha: 9bef924552c1ec3edc30a94b28c181d62630e7e5 doc_id: 740620 cord_uid: n89hhq41 This study explored the impact of COVID‐19 on adults with type 2 diabetes mellitus (T2DM) self‐management behaviours and service experiences within an ethnically diverse UK sample. A cross‐sectional survey design was employed. An 18‐item survey was administered to suitable patients attending the Lambeth Diabetes Intermediate Care Team (South East London, UK) via text message (n=993) or post (n=62). A total of 150 participants completed the survey, which revealed that 30% had changed their diabetes medication taking behaviour since the start of the COVID‐19 pandemic for a number of reasons. Negative changes in physical activity levels and dietary behaviours were also reported. Of those who received a telephone consultation, high satisfaction levels were reported but a clear preference for face‐to‐face consultations was still present. Our findings suggest that the COVID‐19 pandemic is having a negative impact on individuals with T2DM physical activity levels and dietary behaviours. Additionally, the findings indicate that although telephone consultations were highly accepted, many would prefer to receive a face‐to‐face consultation in future. Copyright © 2021 John Wiley & Sons. On 11 March 2020, the World Health Organization declared COVID-19 a global pandemic. 1 Among UK COVID-19 patients admitted to hospitals, diabetes is one of the most common comorbidities. 2, 3 Individuals with diabetes are more susceptible to experience severe symptoms and complications from COVID-19 compared to individuals without diabetes, including mortality. 4, 5 Given the evidence, consistent and effective engagement in diabetes medication taking and self-management behaviours are crucial to prevent negative consequences. However, crosssectional survey studies have reported inconsistent findings; the COVID-19 pandemic has caused both positive and negative changes in diabetes medication taking 6 and/or self-management behaviours related to glycaemic control, [7] [8] [9] [10] [11] physical activity, [6] [7] [8] [9] [10] [12] [13] [14] alcohol consumption, 10, 14, 15 and/or dietary behaviours. 6, [8] [9] [10] [12] [13] [14] [15] [16] To adapt to COVID-19 restrictions, national and international health care systems have switched from face-toface consultations to remote consultations. Fisher et al. 6 found that of US individuals with type 2 diabetes mellitus (T2DM) who switched to telephone or video consultations during the pandemic, 44.0% reported lower satisfaction, 42.2% reported equal satisfaction, while 12.9% reported higher satisfaction, compared to faceto-face consultations. This study aimed to explore the effects of COVID-19 on adults with T2DM self-management behaviours and service experiences and expectations, within an ethnically diverse UK sample. Specific objectives included determining: • The extent to which the COVID-19 pandemic impacted upon diabetes medication taking behaviour. • The extent to which the COVID-19 pandemic impacted upon diabetes self-management behaviours. A cross-sectional survey design was employed. A text message containing the survey weblink (JISC online surveys) was sent to all suitable people (n=993) attending the Lambeth Diabetes Intermediate Care Team (South East London, UK) who had a mobile phone number recorded; for those without (n=62), a postal survey was sent out. Suitable candidates included individuals with T2DM who had been seen by the service in the previous year. The online version of the survey was available for completion from 14 July to 19 August 2020, while the postal version was available for completion from 3-17 August 2020. The survey comprised of 18 questions (Appendix 1, available online at https://wchh.onlinelibrary.wiley. com). Six questions were clinical and sociodemographic; 12 questions explored topics relating to changes in diabetes medication taking and self-management behaviours since the beginning of the COVID-19 pandemic, as well as service experiences and expectations. The survey took approximately 5 minutes to complete. SPSS (version 26.0 for Windows) was used to analyse the data. Descriptive statistics were used to report the findings. Chi-square tests of independence were used to compare differences between groups, where appropriate. A total of 150 participants completed the survey; 131 completed the online version, while 19 completed the postal version. As no demographic or clinical differences were detected between the two groups, the results presented throughout are of the entire sample (n=150 Table 1 and Figure 1 . Thirty percent of respondents (n=45) revealed that they had changed their diabetes medication taking behaviour since the start of the COVID-19 pandemic. How and the reasons why are presented in Table 2 . Blood glucose levels. Although 46.7% (n=70) reported that their blood glucose levels were about the same, 33.3% (n=50) reported they were higher than usual, 14.0% (n=21) reported they were lower than usual, while 5.3% (n=8) reported this was not applicable to them. Physical activity and alcohol consumption. Reported changes in physical activity and alcohol consumption are presented in Table 3 . Reported changes in dietary behaviours are presented in Figure 2 . The majority of respondents (73.3%, n=110) had received a telephone consultation with the Lambeth Diabetes Intermediate Care Team since the beginning of the COVID-19 pandemic. Reported levels of satisfaction are presented in Figure 3 . Additionally, preferred consultation media in future are presented in Figure 4 . Chisquare statistics revealed there were no differences between the survey groups (i.e. online vs postal) in preference for future consultation media: telephone (χ 2 (5)=6.499, p=0.261); video (χ 2 (5)=6.294, p=0.279); and face-to-face (χ 2 (5)=4.275, p=0.450). This study explored the effects of COVID-19 on self-management behaviours and service experiences within an The majority of respondents (70.0%, n=105) reported that they had not changed their diabetes medication taking behaviour since the start of the pandemic. Fisher et al. 6 reported similar findings: 51.4-83.2% of their participants with T2DM reported no changes in medication taking. However, it should be noted that 30.0% of our respondents (n=45) revealed that they had changed their diabetes medication taking behaviour and, of these, around 40% had either stopped their medication or were taking less. Reasons for these changes ranged from health care professional advice through to routine change. Together, these findings highlight the need to monitor and support medication adherence during the COVID-19 pandemic. Although nearly half the sample reported that their blood glucose levels were about the same during the pandemic, one-third reported they were higher than usual, while a smaller number reported lower levels. These findings are consistent with other studies. 7, 9, 11 For example, Barone et al. 7 discovered that 59.4% of their participants experienced an increase, a decrease or a higher variability in glucose levels during the pandemic. The reported changes in blood glucose levels in the current study may be related to changes in physical activity and/or dietary behaviours. Over half of respondents reported that their physical activity levels were lower than usual during the pandemic. This is unsurprising given that, at the time of data collection, gym and pool facilities were still closed, and government-imposed restrictions on outdoor activities were newly relaxed. This finding is consistent with other research. 6, 7, 9 For example, Fisher et al. 6 found that 57.2% of their participants with T2DM reported that they were exercising less than before the pandemic. These findings are a cause for concern as regular physical activity offers health benefits and is a fundamental element of managing T2DM. 17, 18 Just over 40.0% of respondents reported lower alcohol consumption levels during the pandemic; this contrasts with similar studies, which have reported an increase in alcohol consumption among individuals with T2DM. 10, 14, 15 Additionally, research has reported an increase in alcohol consumption among the general UK Table 3 . Reported changes in physical activity and alcohol consumption population. 19, 20 However, Alcohol Change UK 20 also found that one in three individuals were drinking less during lockdown, a finding similar to ours. Potential reasons for this reduction in alcohol consumption may be intrinsically motivated (e.g. prioritising one's health) and/or extrinsically determined (e.g. the closure of pubs). Our findings also suggest that the COVID-19 pandemic had some impact upon dietary behaviours of people with T2DM, which is consistent with existing research. 6, 9, 10, [13] [14] [15] [16] For example, Ruiz-Roso et al. 16 found an increase in sugary food and snack consumption among individuals with T2DM during the COVID-19 lockdown. These findings are not surprising as excessive consumption of unhealthy foods has been linked with stressful situations and emotions such as boredom. 21 The majority of respondents (73.3%, n=110) had received a telephone consultation with the local Community Diabetes Team since the beginning of the pandemic. Reported satisfaction levels were high (51.8% [n=57] strongly agreed, 36.4% [n=40] agreed). In contrast, Fisher et al. 6 found that 44% of people with diabetes in the US who switched to telephone or video consultations during the pandemic reported lower satisfaction. Nevertheless, the majority of our respondents expressed a preference for face-to-face consultations in the future. Our study has made a novel contribution to the limited research evidence base on the impact of COVID-19 on T2DM self-management behaviours and service experiences in the UK. However, there are study limitations. First, given the design, we are unable to conclude causality and the results may be subject to self-report bias. Second, as this survey had a modest sample size from a single diabetes community service, the results may not be generalisable and may be subject to selection bias. Thus, future research should consider collecting data from multiple diabetes services. Third, we recognise that the low participation uptake rate (i.e. 14.2%) further limits the generalisability of the findings. The low participation uptake rate may be explained by a multitude of factors, such as fears that survey responses would affect usual care; a fear which may have already been heightened due to the pandemic. To prevent this limitation, future research should gauge interest in study participation from eligible participants prior to study initiation. Our findings suggest that the COVID-19 pandemic has had a negative impact on physical activity levels and dietary behaviours in individuals with T2DM. Additionally, although telephone consultations are highly accepted, many would prefer to receive a face-to-face consultation in future. These findings suggest the need for national and international health care systems to continually improve peoples' experiences of remote consultations via regular service evaluation. • Self-management behaviours of patients living with type 2 diabetes mellitus, including medication taking behaviours, physical activity, alcohol consumption and dietary behaviours, have changed since the start of the COVID-19 pandemic • Physical activity and dietary behaviours were negatively affected, alcohol consumption levels were lower than usual, while blood glucose levels remained the same for the majority. Increased medication use, under health care practitioner advice was common • Continued access to health care practitioners during the COVID-19 pandemic is important to ensure the appropriate management of long-term conditions such as type 2 diabetes mellitus. While telephone consultations were acceptable, face-to-face consultations were preferred. Health care services should evaluate and review their consultation delivery method to comply with current restrictions while meeting patient preferences, where possible World Health Organization. WHO Director-General's opening remarks at the media briefing on COVID-19 -11 Type 2 diabetes and COVID-19 -related mortality in the critical care setting: A national cohort study in England Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study Associations of type 1 and type 2 diabetes with COVID-19-related mortality in England: a whole-population study OpenSAFELY: factors associated with COVID-19 death in 17 million patients The early impact of the COVID-19 pandemic on adults with type 1 or type 2 diabetes: A national cohort study The impact of COVID-19 on people with diabetes in Brazil Coping with diabetes during the COVID-19 lockdown in India: Results of an online pilot survey The effect of COVID-19 lockdown on glycemic control in patients with type 2 diabetes mellitus in Turkey Effect in self-care behavior and difficulties in coping with diabetes during the COVID-19 pandemic Impact of lockdown in COVID 19 on glycemic control in patients with type 1 diabetes mellitus The nutritional and health effects of the COVID-19 pandemic on patients with diabetes mellitus Diabetes and COVID-19: psychosocial consequences of the COVID-19 pandemic in people with diabetes in Denmark -what characterizes people with high levels of COVID-19-related worries Perceived risk, behavior changes and health-related outcomes during COVID-19 pandemic: Findings among adults with and without diabetes in China Behavioral changes in patients with diabetes during the COVID-19 pandemic COVID-19 lockdown and changes of the dietary pattern and physical activity habits in a cohort of patients with type 2 diabetes mellitus Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association: joint position statement The long-term effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: a 20-year follow-up study Characterising the patterns of and factors associated with increased alcohol consumption since COVID-19 in a UK sample Research: drinking in the UK during lockdown and beyond Eaten up by boredom: Consuming food to escape awareness of the bored self Please tick all that apply and if possible list their names)*** Diabetes self-management questions Q7 If you self-monitor your blood sugar levels, in general how have they changed during the COVID-19 pandemic?* Q8 Has the way you take your diabetes medication changed since the start of the COVID-19 pandemic? Q9 Please indicate how the way you take your diabetes medications has changed since the start of the COVID-19 pandemic. (Please tick all that apply and if possible list their names Q10 Please tell us why you have changed the way you take your diabetes medication. (Tick all that apply and if possible list the names of the medication We would like to thank the 150 individuals with T2DM who took the time and shared their self-management and service experiences during the COVID-19 pandemic with us. We would also like to thank Rachael O'Reilly and Nancy Carranza from the administrative team of the Lambeth Diabetes Intermediate Care Team for their support on this project, and King's Undergraduate Research Fellowship Scheme for supporting study administrative costs. There are no conflicts of interest declared.