World Diabetes Day in the Age of COVID-19: An Urgent Wake-up Call

The heightened threat of COVID-19 for diabetics makes this year’s World Diabetes Day more important than ever.

By Thomas Roades and Erin Gregor

This year’s World Diabetes Day comes at a time when people living with diabetes are under threat more than ever before. Diabetics are at especially high risk for COVID-19, a risk that is exacerbated even further by difficulties accessing care and maintaining their health and wellbeing during the pandemic. As with so many other diseases, COVID-19 has exposed the massive burden of disease caused by diabetes, and tragic inequities and shortfalls in how we care for diabetic patients.

Public health officials have consistently cited diabetes as one of the top comorbidities that can make individuals more susceptible to serious symptoms of COVID-19. The Centers for Disease Control and Prevention (CDC) warns that people with diabetes, in particular Type 2 diabetes, “are at increased risk of severe illness” from the virus. The American Diabetes Association (ADA) concurs, stating that “people with diabetes are more likely to have serious complications from COVID-19.”

Digging into the data on COVID-19 hospitalization and mortality rates can offer a more precise view of just how heightened the risks are for those living with diabetes during this pandemic. A whole-population study from the U.K. in August offers some shocking findings. The study, which observed over 61 million people in the U.K., found that people with diabetes made up one-third of all COVID-19 deaths in the country. For context, less than 10% of all U.K. residents have diabetes, meaning the diabetic population is at disproportionately high risk of COVID-19 mortality relative to people without diabetes.

According to that study’s findings, a person with Type 1 diabetes is more than five times more likely to die of COVID-19 than someone without diabetes, and for Type 2 diabetes, the increased risk is nearly ten times. The World Health Organization (WHO) recently found that about one in five COVID-19 deaths in Africa have been in people with diabetes. And the CDC’s data shows the disparity in mortality rate may be even more pronounced in younger people: about half of Americans under 65 who have died of COVID-19 had diabetes.

More CDC data from the summer of this year on underlying conditions among COVID-19 patients showed diabetes to be among the most prevalent (and, notably, most of the common underlying conditions were other noncommunicable diseases, or NCDs).

The CDC was only able to collect information on underlying medical status (specifically, the presence or absence of any underlying conditions) for about 20% of the patients in the sample. But among those reporting their underlying medical status, just over 30% had diabetes, while 32% had cardiovascular disease and 17% had chronic lung disease.

While data on the interactions between diabetes and COVID-19 in low- and middle-income countries (LMICs) is much sparser, these same trends likely hold true worldwide. In fact, there’s reason to believe diabetes is an even more prevalent and dangerous comorbidity for the pandemic in those countries. As we at HFI noted in our previous blog, undiagnosed diabetes is rampant, especially in LMICs with limited capacity for testing, and uncontrolled diabetes is heavily concentrated in the world’s poorest regions.

There are a variety of factors leading to this deadly combination of COVID-19 and diabetes. The most straightforward ones are the well-documented medical effects of diabetes. Diabetes causes inflammation, can interfere with immune system response, and increases the risks of coagulation and hyperglycemia in the blood — all of which can be exacerbated by COVID-19.

Other contributing factors to COVID-19 mortality in diabetics may be more likely to be overlooked. For example, it’s quite well established that diabetes is more common among those of lower socioeconomic status (SES), and even among people who do have diabetes, those with lower SES are less likely to be diagnosed and properly treated.

Lower-income people, who are already more likely to have diabetes, are also less able to limit their exposure to the virus. They’re more likely to work essential jobs that must be done in person, live in more crowded or multigenerational households, or live in denser population centers where contact with strangers is more difficult to avoid.

People of lower SES who have diabetes are also likely facing greater difficulties in managing their condition due to COVID-19. One endocrinologist at Joslin Diabetes Center in Boston told Stat News the pandemic “makes it harder for people to meet their fitness goal, which is such a critical element of…metabolic health.” Being locked down at home limits one’s options for physical activity, and could also limit access to a healthy, diabetic-friendly diet.

And even continuing to get scheduled care from a care provider has become more difficult due to the pandemic. Per a WHO report this summer, about half of countries in the world have experienced partial or complete disruption of services for diabetes and its complications. Telemedicine has alleviated some of that burden but can be difficult for those without reliable internet access or the necessary devices, and some complications require in-person care.

The challenges in the continuation of care can be even worse for diabetics who do contract the virus. For patients with both diabetes and COVID-19 in a hospital setting, it’s risky for care providers to do finger-prick blood tests regularly. Continuous glucose monitors are used when available, but there’s a limited supply of those devices. The FDA has suggested that diabetic patients hospitalized for COVID-19 bring their own home glucose monitors and read out the results to limit exposure for healthcare workers and preserve scarce resources.

In light of these challenges, and the patchwork of temporary solutions being used to respond to them, it’s no wonder that COVID-19 mortality rates for those with diabetes are so staggeringly high compared to the non-diabetic population. Like many other NCDs, diabetes has long comprised a large proportion of the global burden of disease while receiving just a small fraction of global health spending. This is especially true in LMICs, where the disease is even more widespread and deadly, and where health systems capacity to treat it is even more limited. COVID-19 has been devastating for those living with diabetes, and this should be a wake-up call for the global health community. Today, on World Diabetes Day, we should all be focused on how to better care for those living with diabetes — both during this pandemic and beyond it.