Ever since coronavirus disease 2019 (COVID-19) first emerged in China, lockdowns have been implemented in numerous countries as an attempt to reduce the spread of disease. Lockdowns resulted in significant changes to daily life, from decreased physical activity, dietary changes, alterations in psychological and emotional states, and appetite dysregulation in individuals. During lockdown, vulnerable populations, such as patients with diabetes mellitus (DM), encountered restrictions in healthcare access that resulted in substandard care for patients. Moreover, routine monitoring of metabolic control parameters, including glycaemic and lipid control, decreased significantly, resulting in an overall worsening of the assessment of patients with diabetes.
In an attempt to tackle the limitations on face-to-face meetings, several solutions using advanced technology were proposed as monitoring alternatives for maintaining good glycaemic control. Before the COVID-19 pandemic, technological solutions for continuous glucose monitoring (CGM) and telemedicine were used to a limited extent. CGM usage was associated with improved clinical outcomes of overall care. With social restrictions due to COVID-19, CGM is a critical tool for remote glucose monitoring in patients with diabetes. Therefore, the benefits of CGM in monitoring diabetes during the COVID-19 pandemic needs to be further evaluated.
With this systematic review and meta-analysis, this study aims to provide an overview of the correlation between lockdowns and metabolic control. At first this study found 166 articles however after being screened, 45 articles were selected for full-text evaluation. Of those, 21 studies with a total of 3,992 participants met the eligibility criteria and were included in this study. All studies included were observational studies and consisted of 13 cohort studies, five case-control studies, and three cross-sectional studies. Most studies were conducted in Italy, with others conducted in Spain, France, Greece, the Netherlands, Israel, Saudi Arabia, Turkey, and India.
Among patients with T1DM showed improvements during lockdown, both from time-in-range (TIR) parameter and time-above-range (TAR) is which is the glycemic control parameter in CGM. While FBG among patients with T2DM deteriorated. Total cholesterol and LDL-C were improved, but triglyceride worsened. The majority of the studies reported that diet, physical activity, and stress management played a primary role in affecting the control of metabolic parameters. However, other factors were found to have an equal effect on worsening control. Social factors including emotional instability, socioeconomic vulnerability, uncertainty in employment status, and difficulty in accessing healthcare and medication aggravated the deterioration of metabolic parameters. In contrast, all arrangements of telemedicine, whether in the form of tele-assistance or use of automated glucose monitoring systems were found to improve the control of diabetic parameters.
Excessive consumption of high carbohydrate foods, including several types of fruit and vegetables, is a well-known cause of increased triglyceride and blood glucose levels in patients with diabetes. A reduction in physical activity during lockdown may have further contributed to an increase in triglyceride and blood glucose. Several risk factors such as gender, younger age, higher body mass index, and previous higher average glucose levels also played a role in the metabolic control of DM patients. Nevertheless, poor dietary practices and physical inactivity were still the main contributors to adverse outcomes in the control of diabetes. In addition to dietary factors, physical activity, and stress management, adherence to medication was essential in maintaining satisfactory glycaemic control during lockdown.
Individuals who lacked exercise and neglected healthy habits during lockdown were at higher risk of having poor glycaemic control. Socioeconomic issues and psychological burdens during lockdown had also worsened glycaemic control parameters. This deterioration was evident even among patients with T1DM who previously had appropriate metabolic control.
Regarding lipid profile findings, a previous observational study observed that a high carbohydrate diet increases fasting triglycerides and is associated with higher mortality rates. Triglycerides are closely related to non-esterified fatty acids and could have hazardous effects on glucose homeostasis due to lipotoxicity. Serum triglycerides could also independently represent a risk factor for cardiovascular and kidney diseases.
In summary, the implementation of lockdowns to limit the spread of COVID-19 resulted in lifestyle modifications for many people worldwide. A sedentary lifestyle, unhealthy dietary intake, and poor stress management could be a factor in the poor management of diabetes. However, the application of CGM for some people had a positive effect on diabetic management, such as improving medication adherence. Lockdowns did not have a negative effect on metabolic parameters in patients with diabetes, especially in those individuals who were able to maintain healthy daily habits. A nutritionally balanced diet, regular physical activity, and proper stress management, alongside the use of GCM as a remote diabetic monitoring strategy are recommended for good control of metabolic parameters in patients with diabetes who were unable to access in-person consultations with physicians during lockdown.
Author: Hermina Novida, dr., Sp.PD.
