Esteemed Experts Design New Guidelines for Diabetes Prevention and Treatment During COVID-19 and Beyond

By Riva Greenberg

Riva Greenberg reports the findings and recommendations of an international group of diabetes experts that is working to understand the pandemic's impact on people with diabetes, strengthen prevention, and improve how diabetes care is delivered long-term

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 in 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 people with diabetes and healthcare professionals, and having lived with type 1 diabetes for more than 48 years. I will be sharing updates from the group and, at times, my and others’ 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 less well-managed diabetes and obesity are being hospitalized at 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 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 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 (meaning that they meet recommended levels for blood glucose, triglycerides, HDL cholesterol, blood pressure, and waist circumference, without the need for medications).

While COVID-19 is, for most of us, the first pandemic that has touched us in such a personal way, diabetes, prediabetes, 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 that 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, greater collaboration and communication between health professionals and people with diabetes, attention to emotional needs, 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.

• People with diabetes should adhere to their therapy regimen and seek assistance from their health care professionals to improve glycemic management.

• People with diabetes should proactively improve their metabolic management so that their risk of complications will be lower. To do so, maintain a healthy and balanced diet. Antioxidants like vitamin C or zinc may also be beneficial, as well as supplements that improve immunity like Vitamin D and Selenium. Adhere to an individually tailored physical activity routine. Outdoor activity, when possible, should be included for people at a low risk of severe disease. Stop smoking.

• Those infected with the coronavirus should monitor their glucose levels closely, strive to achieve glucose as stable and in range 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 effects 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, do aerobic exercise to bring up your heart rate and anaerobic exercise to build muscle. These “lifestyle” changes can help bring down chronic inflammation and weight, and lower the risk for health complications – heart disease, hypertension, obesity, liver, kidney, and lung disease – all of which are risk factors for severe COVID-19 infection.

* 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 diabetes management plan and monitor their glucose levels closely. Those infected with the coronavirus should strive for glucose levels as close to their typical levels as safely possible. They should contact their healthcare professionals if medication changes, or assistance, is needed.  Why? While it appears that people with carefully managed diabetes (both type 1 and type 2) are not necessarily at greater risk of getting the coronavirus, early evidence shows that hyperglycemia (high blood sugar) may make someone more vulnerable to COVID-19 infection and cause more severe outcomes.

COVID-19 and Hyperglycemia

There is an association between high glucose levels and the coronavirus – four theories have been suggested:

1. Hyperglycemia increases susceptibility for getting COVID-19. If so, stabilizing in-range blood glucose is the optimal treatment.

2. Hyperglycemia is associated with other conditions like inflammation and insulin resistance, which could be the actual risk factors. If so, high blood glucose itself may not the problem.

3. Hyperglycemia is not a risk factor for COVID-19 but a marker of the condition. If so, it may be an unrelated adverse outcome.

4. Hyperglycemia is associated with diabetes-related health complications which themselves are associated with adverse COVID-19 outcomes. If so, the comorbidities are more causal than high blood glucose.

COVID-19 and Cardiovascular Disease (CVD)

COVID-19 has been shown to lead to changes in the cardiovascular (heart) system including a direct effect on the cardiac muscle and endothelial cells and a tendency to form micro-thrombi (clots in small blood vessels) that challenge all organs and lead to a possible heart attack. Further, the fear of going to the hospital due to possible coronavirus infection means that CVD morbidity and mortality have increased as people with signs of acute heart 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 that morbid and visceral obesity, when inflammation is high, cause cytokine storms mainly from the intra-abdominal fat cells. People with diabetes and severe COVID-19 exhibit a heightened inflammatory immune response; they are more likely to be put on a ventilator in the ICU. If someone’s metabolic health is low, they lack the stamina to fully 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. Dr. Del Prato shared he was not asked for a single consultation about a high glucose value or glucose management while attending COVID-19 patients with diabetes at his hospital in Italy.

2. Do not take a historical perspective of diabetes and coronavirus

In their ongoing work, the team agreed 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 a result of 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 are needed 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 Questions

• How many people exhibiting hyperglycemia at hospital admission is new-onset diabetes?

• What does the reported observation that people with type 1 diabetes 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?

• What is the health effect of Vitamin D supplementation?

• How should systems reorganize so that they can manage the next crisis more promptly and efficiently?

My View

Wearing a continuous glucose monitor (CGM) for more than six years 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 going down – I can often avoid hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar). Based on my experience, and knowing that in the US hospitals are allowing the use of CGM during the pandemic, I would make the following recommendations:

• Allow people with diabetes in the hospital who already use a CGM, if able, to continue to monitor their own glucose and make insulin dosing decisions.

• Bring the use of CGM into hospitals and train health professionals on them. Having people use a CGM cuts down on the time health professionals must spend with people who may be infected.

Many people with diabetes, in general, are afraid to go into the hospital. Many health professionals lack diabetes management knowledge (which is 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, after hearing that they are more at risk for severe COVID-19 infection and health complications, many people with diabetes have chosen not to leave their homes as their best protection.

About Riva

Riva is a global expert on flourishing with diabetes and an international inspirational speaker. She has lived with type 1 diabetes for 48 years.

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