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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 4  |  Issue : 4  |  Page : 197-201

The impact of lockdown and changes in clinical practice on glycemic control during the COVID-19 pandemic: Analysis of data from the National Diabetes Center, Doha, Qatar


Department of Endocrinology, Hamad Medical Corporation, Doha, Qatar

Date of Submission21-Oct-2021
Date of Decision31-Oct-2021
Date of Acceptance01-Nov-2021
Date of Web Publication30-Dec-2021

Correspondence Address:
Dr. Zeinab Dabbous
Department of Endocrinology, Hamad Medical Corporation, P O Box 3050, Doha
Qatar
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdep.jdep_49_21

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  Abstract 


Introduction: The coronavirus disease-2019 (COVID-19) pandemic was associated with international obligations that modified lifestyles and clinical practice. These changes are worrisome for patients with diabetes, as disruption from a routine can have devastating effects on glucose control. This retrospective study aims to assess the impact of lockdown and the efficacy of the instituted changes in patient management on blood sugar control. Methods: Patients with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) who received management through telemedicine at the National Diabetes Center over a lockdown period of 3 months were included. The blood investigations that were done for them as part of standard care were reviewed. Results: A total of 509 patients were included. HbA1c slightly decreased in 49.5% of the patients after the lockdown (P = 0.42). Patients who were not hypertensive experienced a significant reduction in HbA1c (adjusted odds ratios [ORa]: 0.59, 95% confidence interval [CI]: 0.39–0.91, P = 0.018) during the lockdown. A significant association between body mass index (BMI) and lower HbA1c level postlockdown was also determined (ORa: 0.95, (95% CI: 0.92–0.98, P = 0.001). A significant HbA1c reduction was only noted in the BMI group of normal weight (mean: 0.46 ± 0.3, P = 0.03). Conclusion: The imposed lockdown due to COVID-19 did not adversely impact the HbA1c level and glycemic control in T1DM and T2DM patients. Inversely, HbA1c improvements were determined in patients with normal weight and blood pressure after the lockdown period.

Keywords: Coronavirus disease-2019, diabetes, HbA1c, lockdown, telemedicine


How to cite this article:
Alowainati B, Dabbous Z, Salameh O, Hamad MK, Al Hail L, Abuheliqa W, AL-Janahi I, Jayyousi A, Zirie M. The impact of lockdown and changes in clinical practice on glycemic control during the COVID-19 pandemic: Analysis of data from the National Diabetes Center, Doha, Qatar. J Diabetes Endocr Pract 2021;4:197-201

How to cite this URL:
Alowainati B, Dabbous Z, Salameh O, Hamad MK, Al Hail L, Abuheliqa W, AL-Janahi I, Jayyousi A, Zirie M. The impact of lockdown and changes in clinical practice on glycemic control during the COVID-19 pandemic: Analysis of data from the National Diabetes Center, Doha, Qatar. J Diabetes Endocr Pract [serial online] 2021 [cited 2022 Jun 28];4:197-201. Available from: https://www.jdeponline.com/text.asp?2021/4/4/197/334344




  Introduction Top


The coronavirus disease-2019 (COVID-19) was declared by the World Health Organization as a pandemic on March 11, 2020.[1] It is associated with significant mortality rates that can reach up to 12.8%.[2] Comorbid patients with diabetes mellitus (DM), obesity, cardiovascular diseases, and hypertension are at a greater risk of complications and deaths.[3] Uncontrolled DM alters the immune system function and may be associated with a more severe presentation of the COVID-19 and poorer clinical outcomes.[4],[5] Patients with diabetes have preexisting micro and macrovascular complications and reportedly have a higher progressive acute respiratory distress syndrome rate among hospitalized patients with COVID-19.[6]

The pandemic was associated with international obligations that modified lifestyles and forced many countries to enact lockdowns to stop contagion.[7] Patients faced new challenges of self-isolation such as an increasingly sedentary lifestyle, stress, and changes in eating habits.[8] These challenges are particularly worrisome for people with diabetes, as disruption of their routine can devastate glycemic control. There is enough evidence to emphasize the importance of glucose control in preventing complications stemming from uncontrolled diabetes.[9] Despite the belief that the lockdown may worsen glycemic control in patients with DM, there are anecdotal data around this association. One study from Italy evaluated the effect of lockdown on the glycemic control of patients with type 2 diabetes mellitus (T2DM) concluded that there is no significant difference in fasting blood glucose and glycated hemoglobin (HbA1c) before and after lockdown.[10] Nevertheless, another study by Biancalana et al. found that lockdown increased HbA1c by at least 0.3% and worsened T2DM control in around one-fourth of the patients.[11]

The prevalence of DM in Qatar is 17%, contributing to 7% of the total disease burden and 10% of the mortality in Qatar.[12] The first case of COVID-19 was declared in Qatar on February 29, 2020, a 36-year-old Qatari male returning to Doha.[13] The national governmental and health-care systems responded quickly to this unprecedented situation. Hamad Medical Corporation (HMC), the main governmental hospital, changed the outpatient practice to telemedicine and started several portals to support patients during a total lockdown instituted by the government starting March 10, 2020. Telemedicine is associated with favorable psychosocial outcomes among young diabetic patients.[14] Patients with diabetes are seen in primary health care centers around the country and Hamad General Hospital, National Diabetes Center (NDC) as a tertiary center.

During the lockdown, the practice in NDC shifted to telemedicine. The patient appointments were conducted over the phone. The phone consult comprised a comprehensive patient interview, including medications review and the latest laboratory investigations and management. The laboratory was open for patients to come to conduct the necessary investigations. As for medications, the pharmacy delivered the patients' medications to their homes in 24 h. Patients who had to be seen in person were instructed to come to the clinic. The diabetes hotline run by diabetes educators continued to work from 7 am to 10 pm supporting the patients in all their inquiries regarding their diabetes. Educational videos, including insulin injection tutorials, were prepared and sent to patients.

This study is a retrospective assessment of patients with diabetes managed at the NDC in HMC, Doha, Qatar. We aimed to assess the impact of lockdown and the efficacy of the instituted changes in patient management on blood sugar control by analyzing the changes in HbA1c before and after the lockdown.


  Methods Top


Study design

A retrospective chart review was conducted at HMC, Doha, Qatar. The medical records of patients managed through telemedicine at the NDC over 3 months (March 10, 2020, to June 10, 2020) were reviewed for possible inclusion in this study.

Study population

Patients with type 1 diabetes mellitus (T1DM) and T2DM who received treatment during the previously mentioned period and who had a documented HbA1c measurement at most 3 months before and at least 3 months after the lockdown initiation were included. The exclusion criteria were (1) patients who had a history of COVID-19 infection or major surgical intervention within 6 months from their enrollment; (2) patients with clinical conditions such as active malignancy, active cardiovascular disease, and end-stage renal disease; and (3) pregnant women. Patients who did not have a documented HbA1c measurement were also excluded from the study.

Procedures and data collection

Patients received standard treatment according to their clinical condition by seven senior endocrinologists. The blood investigations that were done for them as part of standard care were reviewed. HbA1c was measured by an autoanalyzer (Hitachi 747 autoanalyzer; Tokyo, Japan).

Demographic and clinical data included body mass index (BMI), duration and type of diabetes, diabetic medications, comorbidities, and the results of the HbA1c analysis performed on patients before and after the lockdown. Changes in HbA1c were explored in three patient groups divided into three BMI modalities: normal weight (≤24.9 kg/m2), overweight (25–29.9 kg/m2), and obese (≥30 kg/m2).[15]

Statistical analysis

Statistical analysis was done using IBM Statistical Package for the Social Sciences IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp. Continuous variables were expressed by their mean and standard deviation. Categorical variables were expressed by their frequencies and percentage. The normal distribution of variables was tested using histogram and Shapiro–Wilk test. A multivariable analysis was conducted using binary logistic regression with Enter method to determine predictors associated with HbA1c changes after the lockdown. The results were reported as adjusted odds ratios (ORa) and 95% confidence intervals (CIs). In the three BMI modalities, a univariate analysis for the dependent variable HbA1c utilized paired sample t-test. All P < 0.05 were considered to be statistically significant.


  Results Top


Study population

A total of 2302 medical records were reviewed, among which 509 patients satisfied the inclusion criteria and were considered for analysis. Patients' mean age and BMI were 55.8 ± 13.4 years and 31.7 ± 6.96 kg/m2, respectively. Most patients had T2DM 493 (96.6%), and the mean diabetes duration was 13.7 ± 7.9 years. Two hundred and ninety-nine (58.7%) were females and 329 (64.6%) were Qatari patients. [Table 1] represents the characteristics of the study population.
Table 1: Characteristics of the study population

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Changes in Hba1c

The mean HbA1c was 7.91 ± 1.7% and 7.86 ± 1.7% before and after the lockdown, respectively. HbA1c slightly decreased in almost half of the patients (N = 252, 49.5%) after the lockdown. The mean change was −0.05 ± 1.5 (P = 0.42). The changes in HbA1c before and after the lockdown are represented in [Figure 1].
Figure 1: HbA1c levels before and after lockdown

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Determinants of Hba1c changes

In the multivariable analysis, patients' BMI and hypertension status significantly affected the HbA1c outcome. Patients who were not hypertensive were more likely to experience a reduction in HbA1c (ORa: 0.59, 95% CI: 0.39–0.91, P = 0.018) during the lockdown. As for the BMI effect, the ORa was 0.95 (95% CI: 0.92–0.98, P = 0.001). Accordingly, the changes in HbA1c were explored in the three BMI categories (normal, overweight, and obese). A significant reduction was only noted in the BMI group of normal weight (mean: 0.46 ± 0.3, P = 0.03). [Table 2] and [Table 3] present the multivariate analysis exploring variables associated with decreased HbA1c levels following lockdown and the univariate analysis of changes in HbA1c levels before and after lockdown concerning BMI categories, respectively.
Table 2: Binary logistic regression analysis exploring variables associated with decreased hemoglobin A1c levels following lockdown

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Table 3: Changes in hemoglobin A1c levels before and after lockdown concerning body mass index categories

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  Discussion Top


The lockdown obligations to counteract the spread of the COVID-19 pandemic have caused glycemic management and routine follow-ups with diabetic patients to be disrupted. Consequently, the increased sedentary lifestyle due to inadequate dietary adherence and physical inactivity may have been associated with uncontrolled blood sugar in patients with DM. The lockdown alters blood sugar control and the psychological well-being of patients with diabetes.[16],[17],[18] Telemedicine was widely used to monitor patients remotely as the lockdown enforced different interactive patterns with patients.[19]

To the best of our knowledge, this is the first study evaluating the HbA1c levels objectively before and after the lockdown period to determine the impact on glycemic control in T1DM and T2DM patients in Qatar. Moreover, the study assessed the anthropometrics that predict HbA1c changes after the lockdown period. We found that HbA1c levels changed during the lockdown, as indicated by the after-lockdown measurements. Patients with normal body weight as indicated by their BMI and normotensive patients had significantly better blood glucose control after the lockdown period.

The HbA1c measurements after the lockdown revealed a good glycemic control during the lockdown period, as demonstrated by a temporary reduction in the levels after the lockdown. Nevertheless, the overall decrease in HbA1c levels was statistically insignificant to indicate a favorable clinical outcome after the lockdown period. Our results are consistent with other findings that showed no adverse impact of lockdown on glycemic control among T2DM patients in Turkey.[20]

Our study did not include an assessment of lifestyle and dietary changes during the lockdown, but we hypothesize that patients were eating more and exercising less due to home confinement. A questionnaire assessing the effect of lockdown on patients with type 1 diabetes in Italy showed a reduction in physical activity, high food intake, and more frequent snacking.[21] Another research concluded that lockdown had a negative influence on eating habits and physical activity. Increased intake of carbohydrates and poor compliance to dietary recommendations were observed in addition to stress and reduced physical activity.[22]

The bodyweight of patients appears to be an essential predictor of better glycemic control during the lockdown period. Our results determined a significant association between BMI and a reduced postlockdown HbA1c level. Therefore, as described previously, we classified the baseline BMI into three modalities to include normal, overweight, and obese patients. We found a significant reduction in the mean HbA1c among patients with normal body weight (BMI ≤24.9 kg/m2). This may hypothesize that patients with diabetes with normal body weight are more adherent to dietary and physical activity recommendations. This finding does not appear to be confounded by a possible younger age of this BMI category as the multivariable analysis showed no significant association between age and HbA1c reduction after the lockdown (ORa: 0.998; 95% CI [0.981–1.015]; P = 0.832). Overweight and obese patients may have further gained weight during the lockdown period. Other research revealed an average weight gain of 1.51 kg and a significant increase in the mean BMI by 0.58 kg/m2 among obese patients after a 1-month lockdown period.[23]

We found that normotensive patients had significantly lower HbA1c levels following the lockdown. DM and hypertension share common risk factors, including dyslipidemia and obesity.[24] Although we did not find a significant association between hyperlipidemia and postlockdown HbA1c levels, patients with normal weight and desired BMI are assumed to have a healthier lifestyle associated with favorable outcomes of chronic diseases.[25]

As determined by continuous or flash glucose monitoring, a significant improvement in glycemic control was reported by Aragona et al. during and after a lockdown period in Italy.[26] However, the study did not compare HbA1c levels to determine the overall pre- and postlockdown blood glucose control and whether the daily glycemic improvement was only temporal, especially that there was a significant increase in the body weight and total daily dose of insulin. Another study compared glucose control between T1DM patients who continued working and those who stayed at home during the lockdown. The study found that glucose control did not improve among patients who continued working. Nevertheless, the results are inconclusive because these patients had a better baseline blood glucose profile than those who remained at home.[27] Our study did not give additional attention to patients with T1DM in continuous or flash glucose monitoring.

Our study has several strengths. It is the first study to evaluate the pattern of blood glucose control among T1DM and T2DM patients from all over Qatar. It included a large sample size from the national population, including Qatari and nonQatari patients. The study's retrospective design is not associated with any possible recall bias as the outcome measures were objectively determined from the patients' medical records. The results can enforce counseling on dietary and exercise habits during any future social or clinical obligations. The pandemic globally continues with the spread of worrisome variants despite the escalated pace of vaccination.[28]

The study has some limitations, such as possible selection bias. All data were retrieved solely from the NDC at HMC, leading several portals to support the patients at home adequately. Furthermore, we did not assess the lifestyle changes, including diet and activity modifications, during the lockdown period. Similarly, the changes in BMI were not evaluated across the lockdown period. Determining these changes would have provided better insight to explain the HbA1c variations during and after the lockdown. Furthermore, this research did not include children and teenagers, and therefore, the results cannot be generalized for T1DM patients.


  Conclusion Top


Due to access to adequate health-care resources and support in an unprecedented pandemic, the imposed lockdown due to COVID-19 did not adversely impact the HbA1c level and glycemic control in T1DM and T2DM patients. Inversely, HbA1c improvements were noted in patients with normal weight and blood pressure after the lockdown period. Remote clinical support to patients through telemedicine appears to play a vital role in this regard. Other patients' anthropometrics, including age, diabetes duration, lipid profile, and the type of diabetes management, do not appear to predict glycemic control changes across the lockdown period. Future work will include children and teenagers and evaluate lifestyle changes to determine the impact of lockdown obligations among this population.

Authors' contribution

All named authors have contributed substantially to the published work. They all confirm that they fulfill the ICMLE authorship criteria and have approved the final version of the article.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Compliance with ethical principles

The institutional review board at Hamad Medical Corporation: approved the study. (protocol No MRC-01-20-870). As a retrospective chart review study, the consent for inclusion was waived.



 
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