key: cord-0778394-two8nvdb
authors: Ramalho, Diogo; Rouxinol-Dias, Ana; Tavares, Patrícia; Correia, Sara; Almeida, Lúcia; Alves, Helena; Rocha, Gustavo; Oliveira, Maria João
title: Control glucémico en tiempos de pandemia por COVID-19: ¿una catástrofe o un signo de esperanza para la persona con Diabetes Mellitus tipo 1?
date: 2022-01-31
journal: Endocrinol Diabetes Nutr
DOI: 10.1016/j.endinu.2021.10.015
sha: 2dd2d6c33eab2f6253fb5b2fe4992dd30899bca4
doc_id: 778394
cord_uid: two8nvdb

Introduction: In a person with type 1 diabetes, any change concerning daily routine may lead to changes in glycaemic control. This study aimed to evaluate the impact of work and lockdown on glycaemic control in adults with type 1 diabetes. Material and methods: A retrospective cohort was stratified into three activity groups (g1-students/telework/laid-off; g2-unemployed/retired; g3-work without lockdown). Continuous and categorical variations (reductions ≥0.4%) in glycated haemoglobin were obtained in 2020 (t3: December/2019-March/2020; t4:April/2020-July/2020) and in homologous periods of 2019. Intragroup comparisons between years and intergroups in the same year were made. Regression models were developed to predict the variation of glycated haemoglobin in 2020. Results: 241 participants were included, with a significant reduction between t4 and t3 (vs. t2 and t1) in g1 (p<0.001) and g2 (p=0.025) and in 2020 in g1 (vs. g2, p<0.001; vs. g3, p<0.001). Only g1 presented superiority in the reduction ≥0.4% in glycated haemoglobin in 2020 (vs. 2019, p<0.001; vs. g2, p<0.001; vs. g3, p<0.001). The insulin regimens were comparable and the development of hypoglycaemia was found to be superimposed between t3 and t4, except for g1, which was higher at t3 (p=0.029). G1 correlated with continuous reductions (vs. g2, p=0.001; vs. g3, p<0.001) and ≥0.4% in glycated haemoglobin in 2020 (vs. g2, OR 3.6, p<0.001; vs. g3, OR 12.7, p<0.001), regardless of the age and duration of type 1 diabetes. Conclusions: A more optimised and stable glycaemic control was targeted for participants who transitioned from face-to-face work to total lockdown. Introducción: En una persona con diabetes tipo 1, cualquier cambio en la rutina diaria puede provocar cambios en el control glucémico. Este estudio tuvo como objetivo evaluar el impacto del trabajo y el confinamiento en el control glucémico en adultos con diabetes tipo 1. Material y métodos: Se estratificó una cohorte retrospectiva en tres grupos de actividad (g1-estudiantes/teletrabajo/despido; g2-desempleados/jubilados; g3-trabajo sin encierro). Se obtuvieron variaciones continuas y categóricas (reducciones ≥0,4%) en la hemoglobina glucosilada en 2020 (t3: diciembre/2019-marzo/2020; t4:abril/2020-julio/2020) y en períodos homólogos de 2019. Se desarrollaron modelos de regresión para predecir la variación de la hemoglobina glucosilada en 2020. Resultados: Se incluyeron 241 participantes, con una reducción significativa entre t4 y t3 (vs. t2 y t1) en g1 (p<0,001) y g2 (p=0,025) y en 2020 en g1 (vs. g2, p<0,001; vs. g3, p<0,001). Solo g1 demostró superioridad en la reducción ≥0,4% de la hemoglobina glucosilada en 2020 (vs. 2019, p <0,001; vs. g2, p<0,001; vs. g3, p<0,001). Los regímenes de terapia con insulina fueron comparables y se encontró que el desarrollo de hipoglucemia estaba superpuesto entre t3 y t4, excepto para g1, que fue mayor en t3 (p=0,029). G1 se correlacionó con reducciones continuas (vs. g2, p=0,001; vs. g3, p<0,001) y ≥0,4% en la hemoglobina glucosilada en 2020 (vs. g2, OR 3,6, p<0,001; vs. g3, OR 12,7, p<0,001), independientemente de la edad y la duración de la diabetes tipo 1. Conclusiones: Se apuntó un control glucémico más optimizado a los participantes que pasaron del trabajo presencial al confinamiento total.

J o u r n a l P r e -p r o o f Control glucémico en tiempos de pandemia por COVID-19: ¿una catástrofe o un signo de esperanza para la persona con Diabetes Mellitus tipo 1? RESUMEN Introducción: En una persona con diabetes tipo 1, cualquier cambio en la rutina diaria puede provocar cambios en el control glucémico. Este estudio tuvo como objetivo evaluar el impacto del trabajo y el confinamiento en el control glucémico en adultos con diabetes tipo 1.

Se estratificó una cohorte retrospectiva en tres grupos de actividad (g1-estudiantes/teletrabajo/despido; g2-desempleados/jubilados; g3trabajo sin encierro). Se obtuvieron variaciones continuas y categóricas (reducciones ≥0,4%) en la hemoglobina glucosilada en 2020 (t3:diciembre/2019marzo/2020; t4:abril/2020-julio/2020) y en períodos homólogos de 2019. Se desarrollaron modelos de regresión para predecir la variación de la hemoglobina glucosilada en 2020.

Resultados: Se incluyeron 241 participantes, con una reducción significativa entre t4 y t3 (vs. t2 y t1) en g1 (p<0,001) y g2 (p=0,025) y en 2020 en g1 (vs. g2, p<0,001; vs. g3, p<0,001). Solo g1 demostró superioridad en la reducción ≥0,4% de la hemoglobina glucosilada en 2020 (vs. 2019, p <0,001; vs. g2, p<0,001; vs. g3, p<0,001). Los regímenes de terapia con insulina fueron comparables y se encontró que el desarrollo de hipoglucemia estaba superpuesto entre t3 y t4, excepto para g1, que fue mayor en t3 (p=0,029). G1 se correlacionó con reducciones continuas (vs. g2, p=0,001; vs. g3, p<0,001) y ≥0,4% en la hemoglobina glucosilada en 2020 (vs. g2, OR 3,6, p<0,001; vs. g3, OR 12,7, p<0,001), independientemente de la edad y la duración de la diabetes tipo 1. During this period, only essential activities were maintained in person, namely in the health area, the remaining population being encouraged to work in a lay-off or teleworking regimen. Additionally, face-to-face contact with patients was essentially limited to the provision of emergency care, while outpatient consultations were postponed or performed remotely. 7 It is well-known that glycaemic control in people with Type 1 Diabetes Mellitus (T1DM) or the management of any chronic disease is sensitive to any change in the daily routine, namely concerning diet, physical exercise and compliance with pharmacological therapy, as well as, and with relevance, work activity, emotional stress and social life. 8, 9 Achieving and maintaining the glycaemic target is and will always be a challenge, but its importance increases in times of pandemic, with the restriction of face-to-face access to scheduled consultations. 10 We aimed to assess the impact of work activity (WA) and lockdown on glycaemic control in adults with T1DM.

We carried out a population-based retrospective cohort, including adults with T1DM diagnosed at least two years prior, followed by an endocrinology consultation at Centro Hospitalar de Vila Nova de Gaia / Espinho, between We divided the sample into three distinct groups, taking into account the WA in force at the time of the state of emergency and its implication in the type of lockdown: g1 (students, teleworking or lay-off regimen), g2 (unemployed or retired) and g3 (WA without possibility of total lockdown).

We obtained continuous HbA1c values in four different periods, each with a 3month interval: in the period immediately prior to the SE decree (t3:

December/2019-March/2020); during the SE until approximately two months after its end (t4: April/2020-July/2020) and in the same periods of the previous year In addition, we performed a subanalysis of HbA1c reductions considered clinically relevant (ΔHbA1c ≥0.4%), in accordance with international recommendations for continuous glucose monitoring systems. 11 Bearing this in mind, we adopted a chisquare test with peer-to-peer analysis (g1 vs. g2; g2 vs. g3; g1 vs. g3) in 2019 and 2020, and the McNemar test for intra-group differences in the periods of 2020, compared to similar periods in 2019.

Hypoglycaemia was defined as having at least one episode of blood sugar level below 70 mg/dl during the aforementioned periods.

We used the McNemar and chi-square tests, respectively, in intragroup (between t3 and t4) and intergroup (in t3 and t4) analysis of hypoglycaemia influence that could skew the differences obtained in glycaemic control. In the same way, we J o u r n a l P r e -p r o o f compared insulin therapy regimens (multiple daily injections and insulin pump) between groups in the presence of t4, using the chi-square test.

We developed linear regression and multivariate logistic regression models to forecast ΔHbA1c in 2020 (ΔHbA1c [2020] and ΔHbA1c reductions ≥0.4%, respectively), considering variables with statistical significance, after univariate analysis. We studied the interactions between the independent variables in the event of a bias in the relationship with the dependent variable (HbA1c variation in 2020).

We presented continuous variables as medians (interquartile ranges [IQR] = (p25; p75)). We considered a p-value of <0.05 to be statistically significant. We analysed statistical data using the Statistical Package for the Social Sciences (SPSS®) version 26. (Table 1) .

There was a statistically significant reduction between t4 and t3 (vs. t2 and t1) in 

The development of hypoglycaemia was shown to be comparable in the intragroup analysis at t3 and t4, with the exception of g1, in which there was a predominance of the aforementioned episodes at t3 (t3 vs. t4: 25.1% vs. 18.0%, The different insulin therapy regimens did not influence the glycaemic profile during the period of the SE (Figure 3 .2).

The regression models developed included variables with demonstrated statistical significance in the intergroup (age, T1DM length) and intragroup (hypoglycaemia with statistical difference obtained in g1) analysis. The sole difference between models 1 and 2 occurs in the WA groups compared (g1 vs. g2; g1 vs. g3, respectively).

WA in g1 was independently related to ΔHbA1c ≥0.4% reductions in 2020, a chance of approximately 12.7 and 3.6 times higher, compared to g2 and g3 (both: p <0.001), respectively, whereas g2 demonstrated a non-significant chance of 3.5 times (vs. g3, p = 0.05) ( Table 2 ).

In turn, g1 remained independently associated with the continuous reduction of glycated haemoglobin in 2020, both considering g3 (p <0.001) and g2 (p = 0.001) as a reference (Table 3) . None of the remaining independent variables showed statistical significance.

In the study of interactions between those mentioned in relation to the dependent variable, no independent variable strengthened or weakened the relationship between the type of WA and the variation of glycated haemoglobin in 2020 (* type 

The present study suggests the opposite of what would be expected -a deterioration of glycaemic control due to difficulties in accessing health services, increased levels of anxiety and reduced physical activity. 10, 12, 13 We showed a more optimised and stable glycaemic control of clinical relevance in people with T1DM who went from higher activity levels to total lockdown with non-face-toface work, to the detriment of participants who did not have previous WA (unemployed or retired) or who maintained in-person activities during the period of the SE, with direct and independent influence of the type of WA. In turn, the improvement in glycaemic control tended to favour the group of individuals who did not have previous WA, compared to the group that did not completely confine, with a statistically significant difference in the proportion of clinically relevant HbA1c differential (ΔHbA1c ≥0.4%).

The fact that this study is of retrospective nature, in a single centre, may represent a limitation to the generalisation of the results obtained. In addition, the relatively small number of participants in each group may limit the power of the study to find significant differences, particularly with regard to ∆HbA1c [2020], as a continuous variable, between g2 and g3. Finally, we reported no information on therapeutic non-compliance, T1DM education degrees, changes in insulin doses, severity and timing of hypoglycaemic episodes, and lifestyles. Previous studies have shown similar results and conclusions in children and adolescents, due to their greater ability of parental control in the management of the disease, 14-17 and in adults, [18] [19] [20] [21] [22] owing to the slowing down of routine activities, with more time J o u r n a l P r e -p r o o f dedicated to prepare their own meals and the concern with the development of serious complications of COVID-19.

However, these studies aimed to assess the influence of lockdown on an individual with T1DM, using systems of continuous glucose monitoring, but without mention of stratification by WA. For this reason, as far as we are concerned, this is one of the first studies that aimed to assess the influence of WA on glycaemic control during the period of the SE.

In challenging times, this can be a starting point in an attempt to encourage the adoption of measures taken during the period of total lockdown and adapt them to a future in-person routine, namely in the reinforcement of healthy lifestyles (programmed meals, made by oneself at home, in a healthier way, and the reduction of food consumption in restaurants and similar ones), with the essential help of telemedicine and continuous and flash glucose monitoring systems in the optimisation of time to dedicate to self-management of the disease, which was possible during lockdown, but which is often hampered by the demands of modern times. Hence, there is an urgent need to involve employers in this complex and central process for the avoidance of acute and chronic complications of T1DM, which is the main determinant of the disease's morbidity and mortality.

We demonstrated a more optimised and stable glycaemic control in participants who moved from face-to-face WA to total lockdown, highlighting the relevance of individual availability for self-management of T1DM. 

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