Managing Type 1 Diabetes among Saudi adults on insulin pump therapy during the COVID-19 lockdown
Sultan F. Magliah Hawazen A. Zarif Alaa Althubaiti Mahmoud F. Sabban
The coronavirus disease 2019 (COVID-19) pandemic has affected people’s lives including patients with type 1 diabetes mellitus (T1DM). We aimed to investigate the impact of the COVID-19 lockdown on psychological status, self-management behaviors, ...
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PubMed Central (PMC)
4. Discussion

This study explored the impact of the COVID-19 lockdown on different aspects of the lives of T1DM patients using insulin pump therapy in Saudi Arabia. T1DM is a demanding chronic endocrine disorder that influences the patient’s physical, psychological, and social wellbeing; moreover, individuals with T1DM have higher rates of depression and anxiety compared with those without T1DM [14,15]. During the COVID-19 lockdown, these rates are expected to increase because of fear of contracting the disease and social isolation causing the separation of families and loved ones.

We evaluated the psychological status of participants based on depression and anxiety symptoms using the PHQ-9 and GAD-7 scales. Our patients had varying degrees of depression and anxiety during the COVID-19 lockdown. Over 50% had mild to severe depression, and over 40% had mild to severe anxiety, despite only 9.2% reporting a history of mental disorder diagnosis. In addition, those who had a mental disorder diagnosis were more likely to have moderate to severe depression and anxiety symptoms. In Italy, a study including 48 adults with T1DM on flash glucose monitoring (18.7% insulin pump users) reported that half the participants were at risk of mild psychological distress during the lockdown, as measured by the General Health Questionnaire-12 [16]. In contrast, a Saudi study including 394 patients with type 2 diabetes reported that the COVID-19 lockdown had minimal impact on psychological health as measured by the Kessler Psychological Distress Scale [17]. Finally, a study involving 1160 Saudi adults from the general population reported that 28.3%, 24%, and 22.3% of the participants experienced moderate to severe depressive, anxiety, and stress symptoms, respectively, as assessed by the Depression, Anxiety, and Stress Scale at the beginning of the pandemic [18].

Although the psychological distress rates found in our study seem similar to those of the Saudi general population, it is still unclear whether the mental status of the participants was negatively affected by the lockdown because of the lack of baseline psychological assessment. Moreover, the survey was distributed after the end of the lockdown, which may have relieved some stress due to the impression that the COVID-19 outbreak was under control. Nevertheless, we emphasize the importance of incorporating psychological evaluation and support in the routine care of T1DM patients during times of increased stress.

Physical activity improves cardiorespiratory health and insulin sensitivity, while healthy eating behaviors improve glycemic control, and limit weight gain and hypoglycemia in patients with T1DM [19,20]. An Italian study including 55 adults with diabetes (nearly 50% on insulin pump therapy) reported that glycemic control was not significantly affected during the first 14 days of lockdown. The authors hypothesized that improved self-management behaviors occurred through better eating habits and increased free time to manage diabetes [21]. Moreover, a small study involving 13 participants with T1DM on the Medtronic MiniMed™ 670G insulin pump noted additional glycemic control improvements in adolescents who maintained physical activity during the lockdown [22]. Stay-at-home orders were expected to increase sedentary behaviors and unhealthy eating habits. Accordingly, in our study, many participants reported a decrease in physical activity and ability to follow a healthy diet, and an increase in weight and hyperglycemia symptoms during the lockdown. However, some participants reported an increase in physical activity, improved diet compliance, weight loss, and decrease in hyperglycemia symptoms during the same period.

Adherence to insulin pump behaviors is essential for optimal glucose control. Behaviors such as carbohydrate counting, use of bolus wizard, and frequency of blood sugar measurements are associated with better glycemic control [23,24]. In this study, the level of adherence to insulin pump behaviors was largely not adversely affected compared with pre-lockdown behaviors ( ). Additionally, the majority of glucometer users reported increased adherence to self-monitoring of blood glucose 4 or more times daily. In contrast, a cross-sectional telephone-based study in India that interviewed 30 young adults with T1DM using multiple daily injections found that one third of the participants self-monitored blood glucose less frequently during the lockdown because of financial issues or limited accessibility to glucometers. They also reported that most participants had a decrease in physical activity and an increase in glucose level readings during the same period, despite their routine diet remaining unchanged [25]. The positive changes observed in our study may be attributed to increased spare time to manage diabetes and a personal desire to stay active and healthy. In addition, the local media raised awareness about the importance of maintaining adequate glucose control to reduce the severity of COVID-19 infection in patients with diabetes [26], which may have motivated our patients to adapt a healthier lifestyle and better self-management behaviors.

The continuous spread of the virus required the implementation of telemedicine services to replace in-person routine appointments, impacting the maintenance of optimal diabetes care. Scientific evidence supports the use of telemedicine for patients with diabetes; moreover, patients were able to easily contact their health care providers from their home, decreasing hospital visits and, consequently, the risk of contracting the virus [27]. In the first two weeks of lockdown, the specialized clinic temporarily closed and appointments were rescheduled for the next available slots. In the following weeks, physicians attended routine phone call appointments as scheduled for most cases, although a few patients missed the physician’s call. During the phone call, the patient and physician discussed several aspects, including reviewing the patient’s insulin pump parameters and glucose level charts through self-monitoring of blood glucose logbooks and flash or continuous glucose monitoring reports that were shared with the physician via e-mail or social media platforms. Additionally, they discussed the patient’s eating, sleeping, and physical activity patterns during the lockdown. When necessary, insulin pump settings were adjusted to fit these patterns with the intent of reaching target glycemic control while minimizing the risk of hypoglycemia. Most patients were satisfied with the phone call appointment and found it beneficial.

In addition to routine appointments, all patients had direct access to diabetic educators and were encouraged to seek assistance for problems or inquiries during the lockdown. Upon the patient’s request, a physician or diabetic educator administered virtual education sessions regarding insulin pump or sensor use, adjustment of insulin dosages, and/or other self-management behaviors using the technology that best fit the patient’s personal needs. Most of those who received virtual education considered their experience beneficial. Similarly, a large multinational cross-sectional survey study including 7477 patients with T1DM (56% insulin pump users) reported that most of those who had remote appointments during the COVID-19 outbreak found it helpful and planned on using this mode of healthcare in the future [28].

Access to medical supplies was another challenge during the lockdown. In a cross-sectional Indian study including 52 young patients with T1DM using multiple daily injections, lack of insulin and glucostrips was associated with impaired glycemic control during the first 15 days of lockdown, which was presumably attributable to inadequate stock of supplies and limited transportation [29]. As expected, around 66% of participants experienced difficulty obtaining insulin pump resources. Specifically, those using flash or continuous glucose monitoring were more affected than glucometer users because sensor supplies were likely to be depleted sooner. Participants also frequently reported difficulty obtaining infusion sets, insulin reservoirs, and insulin. Movement restrictions and fear of getting infected when leaving the house contributed to this situation. Despite these difficulties, most patients were adequately stocked on supplies before the lockdown, and very few had to frequently use multiple daily injections for blood sugar control due to lack of supplies. The fact that insulin pump supplies are regularly provided free of charge to patients in our specialized clinic may have contributed to this.

Our findings should be interpreted carefully because of the study limitations, such as the small sample size and susceptibility to recall bias [30]. Nonetheless, our study had an excellent response rate, because many patients were interested in sharing their experience during the lockdown. To the best of our knowledge, our study was the first to explore the impact of the COVID-19 lockdown on the adherence to insulin pump behaviors and the availability of supplies in patients with T1DM on insulin pump therapy. Furthermore, conducting the study immediately after the end of the lockdown helped illustrate the overall personal lockdown experience of the participants, including thoughts, feelings, and behaviors.

In conclusion, Saudi adults with T1DM on insulin pump therapy routinely followed up in a specialized insulin pump clinic at King Abdulaziz Medical City-Jeddah showed varying levels of depression and anxiety during the COVID-19 lockdown. Although a few patients were able to increase their adherence to a healthy diet and physical exercise during this period, many patients reported a decrease in healthy diet and physical exercise behaviors. Adherence to insulin pump behaviors was largely not adversely affected. Those who received routine diabetes care through phone visits or virtual education sessions found it beneficial, and many patients had difficulty obtaining insulin pump supplies. We emphasize the role of healthcare workers in promoting self-management behaviors and improving the psychological wellbeing of patients with T1DM using insulin pump therapy. Telemedicine is a useful alternative to in-person routine appointments, but strategies to ensure that patients have access to adequate resources during a lockdown must be developed.