The Effect of Lockdown and Physical Activity on Glycemic Control in Italian Children and Young Patients With Type 1 Diabetes.

Aims: The purpose of the study was to evaluate the impact of the lockdown established by the Italian government to limit the spread of Coronavirus disease (COVID-19) on glycemic control in a large sample of patients with type 1 diabetes (T1D) based on age, type of insulin therapy, number of telemedicine visits and physical activity. Material and Methods: We retrospectively evaluated glycemic control in young T1D patients using the DexcomG6® system before the Italian lockdown (February 10-23, 2020-Time 0) and during lockdown (April 17-30, 2020-Time 1). Data on age, type of insulin therapy, number of telemedicine visits and physical activity of 202 patients with T1D and a median age of 18.2 years (range: 6-39) were collected. Results: Data showed a significant improvement of TIR from 54.58% at T0 to 59.09% at T1 (p ≤0.0001). Glycemic control improved significantly in patients ≥14 years old, showing the best outcome in the "university students and young adults" group (55.40% at T0 and 61.37% at T1, p ≤0.001). All patients reduced physical activity during lockdown; in the 56 patients of "intense physical activity" group both at T0 and T1 TIR increased from ±56.91 to 64.11% (p ≤0.0001). Conclusions: Overall, the lockdown led to an unexpected improvement in glycemic control of young patients with T1D. A healthier and stressless lifestyle changes in association with the maintenance of physical activity resulted in a significant age-proportional improvement in glycemic control.

Diabetes and susceptibility to infections: Implication for COVID-19.

A number of mechanisms have been proposed to explain the well-established link between diabetic status and an increased susceptibility to infection. Notably, diabetes has been shown to be one of the strongest factors influencing healthcare outcome in COVID-19 infections. Though it has long been noted that lymphocytes upregulate insulin receptors following immune activation, until recently, this observation has received little attention. Here, we point out key findings implicating dysregulated insulin signalling in immune cells as a possible contributing factor in the immune pathology associated with diabetes. Mechanistically, insulin, by activating the PI3K/Akt/mTOR pathway, regulates various aspects of both myeloid cells and lymphocytes, such as cell survival, metabolic reprogramming and the polarization and differentiation of immune cells. PI3K signalling is also supressed by immune checkpoint proteins, suggesting that insulin signalling may antagonize peripheral tolerance. Remarkably, it has also recently been shown that, following insulin binding, the insulin receptor translocates to the nucleus where it plays a key role in regulating the transcription of various immune-related genes, including pathways involved in viral infections. Taken together, these observations suggest that dysregulated insulin signalling may directly contribute to a defective immune response during COVID-19 infections.

Cohort profile: National Diabetes Audit for England and Wales.

The National Diabetes Audit (NDA) collates and analyses data on the quality and variation in clinical care and outcomes for people with diabetes. It also provides opportunities to assess trends, determinants, and outcomes of diabetes to help guide clinical and public health priorities. COHORT: Between 1 January 2003 and 31 March 2020, a total of 5,280,885 people diagnosed with diabetes were included in at least one NDA data collection. To this date, median follow-up was 12 and 8 years for people with type 1 diabetes and type 2 diabetes respectively. Comparisons with the 2019/20 Quality and Outcomes Framework show it included 98% of adults in England and Wales with diagnosed type 1 and type 2 diabetes. Data include demographic characteristics (age, sex, ethnicity, age at diagnosis, deprivation), risk factors (HbA1c , blood pressure, cholesterol, body mass index, smoking status) diabetic and cardiovascular complications and deaths. SECONDARY ANALYSIS: Secondary analyses have included comparisons of HbA1c and blood pressure measurements in cohorts with similar characteristics to the Epidemiology of Diabetes Interventions and Complications study and the UK Prospective Diabetes Study; COVID-19 related mortality in people with type 1 and type 2 diabetes and incidence of type 2 diabetes following admission to intensive care units. FUTURE PLANS: Commissioned NDA reports will continue to inform service development in England and Wales. The same data, with or without linkages to other external datasets, are also a rich resource for clinically orientated research.

Impact of lockdown for COVID-19 pandemic in Indian children and youth with type 1 diabetes from different socio-economic classes.

OBJECTIVES: In March 2020, lockdown was imposed in India to combat spread of Coronavirus, which was extended till 31st May. Implementation of lockdown and limited outdoor activities resulted in changes in routines of children with diabetes. The aim of this study was to assess the impact of lockdown on glycemic control, weight and body mass index (BMI) patterns of children with type 1 diabetes (T1DM) from different socio-economic (SE) classes. METHODS: This observational study included 77 children and youth (5-20 years) with T1DM having disease duration of ≥6 months. Demographic data and investigations were recorded at two time points (post lockdown when the children came for follow up, pre lockdown data from medical records). RESULTS: Glycemic control improved (pre lockdown HbA1C 79.4±19.2 vs. post lockdown Hba1C 74.5±16.9 mmol/mol, p<0.05) and there was weight gain post lockdown (pre lockdown weight z-score -0.4±0.8 vs. post lockdown weight z-score -0.2±0.8, p<0.05) without any significant change in BMI and insulin requirements. Improved glycemic was seen in the lower SE group control post lockdown (p<0.05), whereas in higher SE group, it remained unchanged. Children whose parents were at home during lockdown showed an improved glycemic control (p<0.05) as compared to children whose parents continued to work during lockdown (p>0.01). CONCLUSIONS: During coronavirus lockdown, glycemic control was adequately maintained in children with T1DM, highlighting importance of stronger family support system leading to more steady daily routine.

The impact of the COVID-19 pandemic on people with diabetes and diabetes services: A pan-European survey of diabetes specialist nurses undertaken by the Foundation of European Nurses in Diabetes survey consortium.

AIM: To describe diabetes nurses' perspectives on the impact of the COVID-19 pandemic on people with diabetes and diabetes services across Europe. METHODS: An online survey developed using a rapid Delphi method. The survey was translated into 17 different languages and disseminated electronically in 27 countries via national diabetes nurse networks. RESULTS: Survey responses from 1829 diabetes nurses were included in the analysis. The responses indicated that 28% (n = 504) and 48% (n = 873) of diabetes nurses felt the COVID-19 pandemic had impacted 'a lot' on the physical and psychological risks of people with diabetes, respectively. The following clinical problems were identified as having increased 'a lot': anxiety 82% (n = 1486); diabetes distress 65% (n = 1189); depression 49% (n = 893); acute hyperglycaemia 39% (n = 710) and foot complications 18% (n = 323). Forty-seven percent (n = 771) of respondents identified that the level of care provided to people with diabetes had declined either extremely or quite severely. Self-management support, diabetes education and psychological support were rated by diabetes nurse respondents as having declined extremely or quite severely during the COVID-19 pandemic by 31% (n = 499), 63% (n = 1,027) and 34% (n = 551), respectively. CONCLUSION: The findings show that diabetes nurses across Europe have seen significant increases in both physical and psychological problems in their patient populations during COVID-19. The data also show that clinical diabetes services have been significantly disrupted. As the COVID-19 situation continues, we need to adapt care systems with some urgency to minimise the impact of the pandemic on the diabetes population.

Knowledge, attitudes and practices towards COVID-19 among young adults with Type 1 Diabetes Mellitus amid the nationwide lockdown in India: A cross-sectional survey.

AIMS: To assess knowledge, attitude, and practices (KAP) of young adults with type 1 diabetes mellitus (T1DM) towards COVID-19 amid nationwide lockdown in India. METHODS: We conducted a cross-sectional web-based survey among young adults with T1DM (aged 18-30 years) in the North, Central, South, and West zones of India. It consisted of fifteen, five and eight questions pertaining to knowledge, attitude, and practices towards COVID-19, respectively. Certain questions relevant to T1DM were also incorporated. RESULTS: After exclusion, 212 participants were included (mean age = 25.1 ± 4.3 years; M:F = 10:11). The overall correct rate of the knowledge questionnaire was 83% (mean total knowledge score = 12.4 ± 1.9). Most (74%) had an average knowledge score (mean ± 1SD). Higher educational status, urban residence, and being married were associated with better knowledge scores; however, only urban residence was found to be statistically significant on multinomial logistic regression. Most (88%) felt that being a patient of T1DM, they were at higher risk of getting infected with COVID-19. At the same time, 98% were confident about self-protection. Fifty-one percent of respondents had left home amid lockdown mostly to procure insulin/injection needles/syringes/glucometer strips from the pharmacy. However, all were maintaining proper hand hygiene and majority were following routine dietary advice (95%) and administering prescribed insulin doses (99%). Seventy-two participants (34%) had experienced one or more episodes of hypoglycemia since the commencement of lockdown. CONCLUSIONS: Young adults with T1DM have average knowledge, positive attitude, and healthy preventive practices towards COVID-19. Awareness campaigns targeted towards rural communities and providing doorstep delivery of insulin/needles/syringes may be more rewarding.

Impact of COVID-19 lockdown on glycemic control in patients with type 1 diabetes.

INTRODUCTION: The COVID-19 pandemic has forced governments to take exceptional measures to minimize its spread, imposing lockdown policies. The aim of this study was to evaluate the impact of lockdown on type 1 diabetes (T1D) glycemic control. MATERIAL AND METHODS: People with T1D using flash glucose monitoring were included. Data from the 14 days before lockdown were compared with data from the last 14 days after 8 weeks of lockdown. RESULTS: A total of 307 patients were included (age 45.8 ± 12.6 years, 50.2% male, diabetes duration 21.1 ± 12.3 years). Only one patient had COVID-19 infection. Mean glucose decreased from 166.89 ± 29.4 to 158.0 ± 29.0 mg/dL and estimated HbA1c declined from 7.4 ± 1.0 to 7.1 ± 1.0% (54 ± 10.9 vs 57 ± 10.9 mmol/mol; p < 0.001). Time in range increased from 57.8 ± 15.8 to 62.46 ± 16.1%. Time in hyperglycemia > 180 mg/dL and >250 mg/dL decreased from 37.3 ± 1.9% to 32.0 ± 17.1% and from 13.0 ± 11.3 to 10.3 ± 10.6%, respectively; (p < 0.001). Time in hypoglycaemia <70 mg/dL increased from 4.9 ± 4.0% to 5.5 ± 4.4% (p < 0.001). No differences in time <54 mg/dl, coefficient of variation (CV%) or number of scans per day were found. CONCLUSION: Despite the limitations of lockdown, glycemic control improved in patients with T1D. These results suggest that having more time for self-management may help improve glycemic control in the short term.

Impact of lockdown in COVID 19 on glycemic control in patients with type 1 Diabetes Mellitus.

BACKGROUND AND AIMS: COVID 19 is a novel pandemic affecting globally. Although no reliable data suggests that patients of well controlled Type 1 Diabetes Mellitus (T1DM) being at increased risk of becoming severely ill with SARS-CoV2, but lockdown may impact patients with T1DM requiring regular medications and follow up. Hence this study was planned to see the impact of lockdown on glycemic control in patients with T1DM. METHODS: A cross sectional study was done in T1DM patients in whom a structured questionnaire was administered on follow up within 15 days after lockdown. Data regarding hypoglycemic and hyperglycemic episodes, Diabetic ketoacidosis (DKA), insulin dose missed, regular glucose monitoring, dietary compliance, physical activity, hospitalization during the phase of lockdown was taken. Average blood glucose and HbA1C of lockdown phase was compared with the readings of prelockdown phase. RESULTS: Out of 52 patients, 36.5% had hyperglycemic and 15.3% had hypoglycemic episodes. Insulin dose was missed in 26.9%, glucose monitoring not done routinely in 36.5% and 17.4% were not diet compliant during lockdown. Average blood glucose during lockdown phase was 276.9 ± 64.7 mg/dl as compared to 212.3 ± 57.9 mg/dl during prelockdown phase. Mean HbA1c value of lockdown (10 ± 1.5%) which was much higher that of pre lockdown (8.8 ± 1.3%) and the difference was statistically significant (p < 0.05). CONCLUSION: Glycemic control of T1DM patients has worsened mainly due to non availability of insulin/glucostrips during lockdown period. There is a need for preparedness in future so that complications can be minimised.

Coronavirus lockdown effect on type 1 diabetes management οn children wearing insulin pump equipped with continuous glucose monitoring system.

AIMS: On the 10th of March, Greece imposed the closure of schools and universities and a full lockdown a few days later in order to counter the spread of the coronavirus outbreak. Our aim was to monitor the effect of the coronavirus lockdown in diabetes management in children with Type 1 Diabetes Mellitus (T1DM) wearing insulin pump equipped with continuous glucose monitoring system. METHODS: In 34 children with T1DM on Medtronic 640G insulin pump equipped with the Enlite Sensor uploaded CareLink data were categorized in 2 three-week periods before and after the 10th of March. RESULTS: Mean time in range (TIR) did not significantly differ between the two periods. However, a significantly higher Coefficient of Variation (CV) indicating an increased glucose variability in the pre-lockdown period was observed (39.52% versus 37.40%, p = 0.011). Blood glucose readings were significantly fewer during the lockdown period (7.91 versus 7.41, p = 0.001). No significant difference was recorded regarding the total daily dose of insulin and the reported carbohydrates consumed. However, the meal schedule has changed dramatically as the percentage of breakfast consumed before 10.00 a.m. has fallen from 80.67% to 41.46% (p < 0.001) during the lockdown. Correspondingly, the percentage of dinner consumption before 10.00 p.m. significantly fell during the lockdown period (60.22% versus 53.78%, p = 0.019). CONCLUSIONS: Glycemic control during the coronavirus lockdown can be adequately achieved and be comparable to the pre-lockdown period in children with type 1 diabetes mellitus wearing insulin pump equipped with sensor.

Coronavirus disease (Covid-19): How does the exercise practice in active people with type 1 diabetes change? A preliminary survey.

AIMS: Coronavirus disease (Covid-19) could lead persons with pre-existing medical conditions to severe respiratory infections. The Italian Government introduced quarantine to limit viral transmission. This measure could lead people with type 1 diabetes (PWT1D) to disrupt daily care routine including PA practice with difficulties in glycemia management. This study aims to explore PA level in PWT1D before and during quarantine and to describe variation in glycemia values. METHODS: An online survey investigating medical factors and the perceived and PA level in pre-established period before and after the introduction of quarantine was developed. Comparison between pre and post quarantine was assessed by Wilcoxon Signed Ranks test for continuous variables. RESULTS: A total of 154 subjects satisfied the eligibility criteria (54.5% males, 44.8 ± 12.5 years). We found a decrease of PA level (Godin Scale Score 25 ± 1.7vs38.6 ± 1.7 points), steps number and minutes of exercise (respectively 12.606 ± 5026vs4.760 ± 3.145 and 66±4 vs 38±3) and an increase of glycemia values (142.1 ± 25.4 mg/dLvs150.8 ± 29.4 mg/dL). CONCLUSIONS: PWT1D reported a decrease in exercise and worst glycemia. Although PWT1D tried to remain active, their PA level was inadequate to prevent glycemia rising. The difficult to maintain a glycemic control could expose patients to diabetes complications and to an higher risk to counteract infections.

School and pre-school children with type 1 diabetes during Covid-19 quarantine: The synergic effect of parental care and technology.

INTRODUCTION: Management of Type 1 Diabetes (T1D) poses numerous challenges, especially for young children and their families. Parental care positively influencesthe outcomesofchildren with T1D, while there are often criticisms in school environment. The COVID-19 pandemic has forced children and parents to spend many hours at home and diabetes care has returned mainly in the hands of parents. AIM OF THE STUDY: To evaluate the effectiveness of exclusive return to parental care in pre-school and school children with T1D treated with Tandem Basal IQ system during the COVID-19 pandemic. PATIENTS AND METHODS: 22 children (M:F = 14:8) with T1D have been evaluated. We compared insulin and CGM data (TIR, TBR and TAR) of two periods: PRE-COV and IN-COV, in which children have transitioned from normal school attendance to the exclusive care of their parents. RESULTS: During the IN-COV period a significantly (p < 0.001) higher median value of TIR (66,41%) was observed as compared to PRE-COV period (61,45%). Patients also showed a statistically significant difference (p < 0.002) between the IN-COV period and the PRE-COV period as concerning the TAR metric: respectively 29,86 ± 10,6% vs 34,73 ± 12,8%. The difference between the bolus insulin doses was statistically significant (PRE-COV 5,3 IU/day, IN-COV 7,9 IU/day - p < 0.05). CONCLUSION: Our observational real-life study confirms the positive effect of parental care in T1D very young children and demonstrates that during the COVID-19 pandemic it was possible to obtain a good glycometabolic compensation despite the significant change in lifestyle.

Practical recommendations for the management of diabetes in patients with COVID-19.

Diabetes is one of the most important comorbidities linked to the severity of all three known human pathogenic coronavirus infections, including severe acute respiratory syndrome coronavirus 2. Patients with diabetes have an increased risk of severe complications including Adult Respiratory Distress Syndrome and multi-organ failure. Depending on the global region, 20-50% of patients in the coronavirus disease 2019 (COVID-19) pandemic had diabetes. Given the importance of the link between COVID-19 and diabetes, we have formed an international panel of experts in the field of diabetes and endocrinology to provide some guidance and practical recommendations for the management of diabetes during the pandemic. We aim to briefly provide insight into potential mechanistic links between the novel coronavirus infection and diabetes, present practical management recommendations, and elaborate on the differential needs of several patient groups.