When the Covid-19 pandemic struck, reports indicated that people with diabetes were especially vulnerable to infection and increased mortality. There were also concerns that Covid-19 infection could cause diabetes (Hartmann-Boyce et al, 2021).
Although we have learnt a great deal more as Covid-19 has become endemic, there is much we do not yet know. There is still insufficient data to conclude whether diabetes predisposes people to Covid-19 infection (Hartmann-Boyce et al, 2021).
“Access to routine diabetes care was severely reduced at the height of the pandemic”
However, we know some people with diabetes are at greater risk of becoming very unwell than others. Research involving 264,390 people with type 1 diabetes and 2,874,020 people with type 2 diabetes was carried out by Holman et al (2020). For both types, a greater risk of Covid-19-related death was associated with a history of cardiovascular disease, renal impairment, stroke and/or heart failure; male sex; older age; non-White ethnicity; and socioeconomic deprivation.
Initially, there were concerns that glucose-lowering therapies used to treat type 2 diabetes associated with increased Covid-19-related mortality. More recent studies indicate that people taking metformin, the drug most commonly prescribed to treat type 2 diabetes, have lower mortality rates and are less likely to require ventilation and supplementary oxygen (Jang et al, 2024).
It is thought that Covid-19 infection has a diabetogenic effect and can cause new-onset diabetes. There may be a number of processes involved in this, including: people having undiagnosed diabetes when they develop severe Covid-19; diabetes developing as a stress response following severe illness; steroid-induced hyperglycaemia developing as a result of severe illness; and beta-cell changes secondary to Covid-19 infection (Khunti et al, 2022).
Additionally, the Covid-19 pandemic may have led to people’s diabetes worsening. Access to routine diabetes care was severely reduced at the height of the pandemic; this led to people not being diagnosed in a timely way. Routine follow-ups were not carried out, and people were not able to access medication and advice to manage their diabetes.
During lockdowns, many people worked from home; people often became less active, ate a poor diet and gained weight (Fitero et al, 2022). This all affected the ability of people with diabetes to manage their condition well.
As the NHS moves from the emergency mode of the pandemic into recovery mode, it is important to prioritise the care of people with diabetes. They should have eight health checks or care processes carried out annually; these are checks of HbA1c, blood pressure, cholesterol, serum creatinine, urine albumin, foot surveillance, body max index and smoking status (Khunti et al, 2022).
People who have not been reviewed since the pandemic are at greater risk of ill health. Those at greatest risk are people with poor pre-pandemic risk-factor control, obesity, microvascular complications (especially chronic kidney disease), cardiovascular disease and multiple comorbidities (Fitero et al, 2022).
These people should be reviewed as soon as practically possible. People with diabetes who were severely affected by Covid-19 infection and required hospital admission are at risk of increased ill health and should be carefully monitored. In some areas, follow-up is undertaken by acute hospitals; in other areas by primary care, often remotely.
We must be careful not to further disadvantage the most vulnerable of people – those who are older, from ethnic minorities or from a socially deprived background – as some people from these groups may not be able to access or use technology.
Covid-19 immunisation reduces the risk of people with diabetes becoming severely unwell and requiring hospital admission. This risk is lower in people who have had three vaccinations than one or two (Heald et al, 2023). We must also promote health and wellbeing across the UK population.
Linda Nazarko is consultant nurse, physical health, West London NHS Trust. The views expressed here are those of the author, not of West London NHS Trust.
References
Fitero A et al (2022) Comorbidities, associated diseases, and risk assessment in COVID-19 – a systematic review. International Journal of Clinical Practice; 1571826.
Hartmann-Boyce J et al (2021) Risks of and from SARS-CoV-2 infection and COVID-19 in people with diabetes: a systematic review of reviews. Diabetes Care; 44: 12, 2790-2811.
Heald AH (2023) COVID-19 vaccination and diabetes mellitus: how much has it made a difference to outcomes following confirmed COVID-19 infection? Diabetes Therapy; 14: 1, 193-204.
Holman N et al (2020) Risk factors for COVID-19-related mortality in people with type 1 and type 2 diabetes in England: a population-based cohort study. The Lancet Diabetes & Endocrinology; 8: 10, 823-833.
Jang HN (2024) Impact of antidiabetic drugs on clinical outcomes of COVID-19: a nationwide population-based study. Endocrinology and Metabolism; 1857.
Khunti K et al (2022) Diabetes and the COVID-19 pandemic. Diabetologia; 66: 2, 255-266.