key: cord-0992396-p6u1mmgr
authors: khare, Jaideep; jindal, Sushil
title: Observational study on Effect of Lock Down due to COVID 19 on glycemic control in patients with Diabetes: Experience from Central India
date: 2020-08-20
journal: Diabetes Metab Syndr
DOI: 10.1016/j.dsx.2020.08.012
sha: ecba0fc4595e78df6315ca15b0f75c1d10c6202a
doc_id: 992396
cord_uid: p6u1mmgr

BACKGROUND AND AIMS: Diabetes is a chronic metabolic condition characterized with hyperglycemia and associated with several complications. Glycemic control is important factor in preventing the complications associated with diabetes. Pillars for good glycemic control are good life style modification with proper medication under medical guidance. The aim of this study was to study the effect of lock down on glycemic control in diabetic patients and possible factor responsible for this. MATERIAL AND METHODS: – Out of 407 only 143 diabetic patients who attended the our endocrine OPD in last 3 months who had good glycemic control in past without any chronic complication and willing to participate were included in study. They were advised for the self-monitoring of blood glucose for identifying the glycemic control and with questionnaire designed possible factor was identified during the lockdown period. RESULTS: – The patients were aged between 18 and 65 years with mean age of 54.68 years and male to female ratio was 91:52.56 (39.16%) patients reported worsening of hyperglycemia and requiring addition of medications for control of blood glucose and 3 (2.09%) patients reported hypoglycemic events and medications were stepped down. Psychological stress was most common factor worsening of hyperglycemia followed by change in diet and exercise.

Overall Glycemic control got deranged in diabetic patients during the lockdown period.

Lifestyle changes and psychological stress identified as possible factors responsible for derangement of glycemic control.

Background and Aims-Diabetes is a chronic metabolic condition characterized with hyperglycemia and associated with several complications. Glycemic control is important factor in preventing the complications associated with diabetes. Pillars for good glycemic control are good life style modification with proper medication under medical guidance. The aim of this study was to study the effect of lock down on glycemic control in diabetic patients and possible factor responsible for this.

Material and methods -Out of 407 only 143 diabetic patients who attended the our endocrine OPD in last 3 months who had good glycemic control in past without any chronic complication and willing to participate were included in study. They were advised for the self-monitoring of blood glucose for identifying the glycemic control and with questionnaire designed possible factor was identified during the lockdown period. People with diabetes and other co-morbid conditions like asthma, heart failure, raised serum creatinine and elderly people above the age of 65 years may be at higher risk. The Indian

Council of Medical Research-India Diabetes (ICMR-INDIAB) study estimates that approximately 62 million people in India have diabetes. [2, 3] A recent survey by World health organization estimated that India have 72.96 million cases of diabetes in adult population. [4] Diabetes is a chronic metabolic condition characterized with hyperglycemia and associated with metabolic complications. It is not uncommon endocrine disorder and prevalence in India ranges from 10.9 -14.2 % in urban area and 3.0-7.8% in rural area. [2, 3] Good glycemic control is important factor in preventing the complications associated with diabetes. Adaption of good life style modification which includes balanced diet, exercise, proper sleep & psychological wellbeing with proper medication under medical guidance are the pillars for good glycemic control. All these pillars may be shaken in the lock down period. Hence aim of our study was to study the effect of lock down on glycemic control in diabetic patients and possible factor responsible for this. [3, 5, 6] J o u r n a l P r e -p r o o f

This was the observational cohort study performed at our Endocrine department. Patients who met the above criteria were included and advised for SMBG ( self-monitoring of blood glucose) for minimum 2 readings which included Fasting Blood Glucose ( FBG) and

Post Prandial Blood Glucose (PPBG) which is two hours after taking breakfast to maximum as many patient wanted or as and when required if patient had any symptom suggesting of change in blood sugars. Patients were reminded through automated messaging services and minimum 5 days readings were recorded and patients were asked to report the blood sugars charting regularly through telemedicine which was regularly used earlier too through mobile applications. Then with paired T -test, statistical analysis was done and blood sugars during lock down and pre-lock down were compared.

Though Ideal targets for glycemic control are based on age and associated co-morbid condition but for our study the FBG (before breakfast blood glucose) below 140mg/dl and any other blood glucose below 180mg/dl and above 70 mg/dl were considered for good glycemic control, Stepping up of medications was done if FBS was persistently higher than J o u r n a l P r e -p r o o f 140mg/dl and any other blood sugars more than 180mg/dl. And even a single episode of hypoglycemia was entertained with stepping down of medications.

Questionnaire was self-designed as described in Table 7 to identify the possible cause for loss of glycemic control by patient's subjective response.

The patients were aged between 18 to 65 years with mean age of 54.68 years and male to female ratio was 91:52. Mean fasting and post prandial blood glucose before lock down in our patients was 115.9 mg/dl and 124.9 mg/dl respectively. The summary of baseline characteristics is described in Thus, both fasting and post prandial blood glucose in lock down period were higher than prior to lock down but statistically significant difference was seen with post prandial blood glucose only as described in table 5.

Overall 7 .

Lockdown being a significantly important step in order to stop and prevent the spread of COVID 19 infection was taken by government of India but it may have affected the glycemic control in diabetic patients. Good glycemic control is important have good immunity and to prevent complications related diabetes. Hence in our study we tried to identify the effect of lock down on glycemic control.

In our study we have included the patients who had good glycemic control and were on regular follow up.

In our study mean FBG was numerically higher in lock down period but was not statistically significant, while PPBG was significantly higher in lock down period as compared to J o u r n a l P r e -p r o o f previous non lock down period. Possible reason for it may be the change in amount and type of diet due to being at home with lack of exercise due to lock down which majorly affects the PPBG. Stress alters the hormonal homeostasis and lead may to hyperglycemia but as with sleep sympathetic activity reduces, effect of stress on FBG may be less as compared to PPBG. [7, 8] Secondly hypothesis for it may be that in our study we included patients who had good glycemic control with mean HBA1c of 6.7 and in such patients post prandial is major contributor for HBA1c. [9] In our study 56 (39.16%) patients experienced hyperglycemia. In our study 3 patients had episodes of hypoglycemia which included 2 male and 1 female.

First male patient noted hypoglycemic event before lunch and on enquiry cause was identified as delay in timing of lunch because all were busy doing household routine activity.

Second male patient noted hypoglycemic event at evening after doing strenuous house hold work.

Only female patient noted hypoglycemic event before dinner because of increased gap between medication taken and delayed dinner.

In our study psychological stress was identified as the most common factor for loss of good glycemic control. Similar observations were made during previous stressful situations which J o u r n a l P r e -p r o o f mimics lock down situation like earthquakes, hurricane, war. [10, 11, 12] D Dubey et al in their article described that COVID 19 itself in association with forced quarantine by nationwide lockdowns can produce acute panic, anxiety, obsessive behaviors, hoarding, paranoia, and depression, and post-traumatic stress disorder (PTSD) and several psychological disorder. [13] Similar finding was reported by Zandifar A et al in their study at Iran. [14] Other factors possibly responsible for loss of good glycemic control included unfavorable change in diet, exercise and sleep pattern with difficulty in obtaining physician guidance and medications. This was in corroboration with other study from India by Ghosh A et al which concluded that during lockdown there was increase in carbohydrate intake, decrease in exercise, decreased SMBG and widespread mental stress in patients with T2DM which resulted in exacerbation of hyperglycemia and hypertension. [15] Thus, overall glycemic control in our patients got deranged during lock-down period which is in corroboration with the study by S Ghosal et al which concluded that duration of lockdown is directly proportional to the worsening of glycemic control and diabetes-related complications. Thus, worsening of glycemic control will put additional load on already overloaded healthcare system due to complications of diabetes. Also uncontrolled glycemic control may also increase COVID19 infection rate and worsen outcome in patients with diabetes.

[16]

Our study showed that overall glycemic control got deranged during the 3-week lockdown period. Lifestyle changes, psychological stress, difficulty in getting medication and medical advice were identified as possible factors responsible for derangement of glycemic control.

Thus, multidisciplinary approach is required which is patient centric and addresses the J o u r n a l P r e -p r o o f various issues like psychological stress, diet exercise along with proper medication is required for achieving good glycemic control.

Possibility of sample Bias cannot be ruled out as patients were from one center with small sample size. The study findings were dependent on honesty of patient or attendant and reliability of glucometer used for recording the blood sugar reading. It was an unblinded study and intervention were taken if very high fluctuation in blood sugars noted. Hypoglycemia events recorded (< 70mg/dl) 2 1 3 Table 7 Prevalence of multiple causes for loss of glycemic control during lockdown due to COVID 19 based on questionnaire 

Prevalence of diabetes and prediabetes (impaired fasting glucose and/or impaired glucose tolerance) in urban and rural India: Phase I results of the Indian Council of Medical Research-India DIABetes (ICMR-INDIAB) study

Current status of management, control, complications and psychosocial aspects of patients with diabetes in India: Results from the DiabCare India

of-diabetes-in-india-11570702665713of Medical Care in Diabetes-2019, Diabetes Care

Emotional and psychological needs of people with diabetes

Sleep and autonomic nervous system

The effects of sympathetic nervous system activation and psychological stress on glucose metabolism and blood pressure in subjects with type 2 (non-insulin-dependent) diabetes mellitus

) contributions of fasting and postprandial glucose to hemoglobin a1c

Impact of a Natural Disaster on Diabetes

Impact of Psychological Stress caused by the Great East Japan Earthquake on Glycemic Control in Patients with Diabetes

The Gulf War and diabetes mellitus

Psychosocial impact of COVID-19

Observational study on Effect of Lock Down due to COVID 19 on glycemic control in patients with Diabetes: Experience from Central India

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