Patients with chronic conditions including diabetes experienced challenges during the period of lockdown especially patients in developing countries with pronounced barriers in accessing healthcare services and medical supplies .
To achieve tight control, monitoring of blood sugar all over the day in children with type 1 diabetes is mandatory; meanwhile, those with fluctuating blood sugar or intermittent hypoglycemia, blood glucose should be checked at least four times a day with additional check in case of signs or symptoms of occurring hypoglycemia .
It is obvious from the current study that about 51% of the patients monitored their blood glucose less frequent during the lockdown period with 60% of patients monitoring less than three times daily. The defect in SMBG could be related to shortage of supply or lack of insurance as most supplies are covered by insurance. This negative impact of lockdown was also reported in a similar study in Middle East where a higher percentage of families (43%) had to ration or cut down the use of glucose test strips which led to more frequent hypo-/hyperglycemic excursions in glucose levels in most of their children .
When the lockdown was eased early in July, most patients were able to check their HbA1C, and there was an overall significant increase in mean HbA1C. Although being non-significant, HbA1C improved in toddlers and preschoolers; however, school children and adolescents had significant worsening. This is similar to previous studies which showed that the pandemic and lockdown negatively impacted the metabolic control of type 1 diabetes among children and adolescents [11,12,13]. However, data from the current study, regarding impact of lockdown on glycemic control, was in contrast to data explored by previous studies showing no worsening or even improvement of glycemic control during the period of lockdown [5,6,7]. Differences in study population as well as differences in standards of care together with differences in availability of medical supply could provide insight and possible explanation for such observed difference.
In concordance with a study conducted among an Indian cohort, a country with limited resources as ours, poor dietary habits and lack of physical exercise are noticeable causes of the poor glycemic control during the period of lockdown .
Limited outdoor activities, with increased desire for frequent snacking especially with online learning, had made it noticeable that dietary habits and control were becoming worse among almost all age groups; however, those with newly diagnosed diabetes or duration less than a year were the best in regard to maintaining diet control in comparison to those with longer duration. We speculated that parents or caregivers of patients, whose disease duration is less than a year, took over diabetes control all over the day, which may partially explain the relative improvement in dietary habits. Similarly, Shah et al. highlighted the importance of family support in maintaining a steady daily routine .
The pandemic impacted the practice and the standard of care offered to patients with type 1 diabetes and the implementation of telemedicine service, which became a crucial tool in managing patients [15, 16].
With the onset of lockdown, our diabetes team started to launch a telemedicine service. Synchronous simple service was used by sharing logbooks and patients’ inquiries through social media applications (WhatsApp and Facebook) and phone calls. Around 97% of the patients and their families were successfully able to communicate with their medical team, and almost 70% were more or less satisfied. Similar data from a Jordanian study showed the efficacy of simple basic ways of telemedicine service in managing type 1 diabetes through sharing data from logbooks and adjusting insulin regimens .
This survey explored the worries associated with COVID-19 among the studied cohort and showed that the pandemic was associated with different worries among patients with diabetes. Almost half was afraid from hospital admission and contacting infection, and about 29% was feeling more susceptible to infection. Beside the previous worries, the majority was afraid of shortage of medical supplies.
Joensen and colleagues showed that their studied cohort was most frequently worried about COVID-19, 56% was worried of being severely affected due to diabetes, 28% was afraid of being unable to manage diabetes if infected with COVID-19, and 24% was worried from lack of medical supplies . In this context, different resources and diabetes fact sheets were developed aiming to support and manage patients’ worries and concerns about COVID-19 [18,19,20].
The current study evaluated the levels of perceived stress among patients and/or caregivers during the challenging period of lockdown. Sixty percent perceived moderate stress, and 40% perceived severe stress. This was shown in a similar study where more than half of the studied cohort reported moderate stress .
Several studies evaluated perceived stress among patients with diabetes and correlated it with patients’ glycemic control. Diabetes treatment, management and perception of complications anticipated by poorly controlled patients significantly impact patients' perception of stress [21, 22]. A significant positive correction was noticed between PSS-10 and pre-lockdown Hb A1C. Similar finding was reported by Agarwal et al., where they observed higher PSS-10 scores among adolescent patients with poor glycemic control. They attributed such observation to the fact that the pandemic could possibly augment pre-existing health-related stress .
Similar to the findings reported by Agarwal et al. , we observed a significantly positive correlation between level of perceived stress and patients’ glycemic control, as reflected by Hb A1C level assessed after ease of lockdown. Stress is known to negatively impact outcome of disease, and this could be related to non-adherence to medication and disruption of healthy lifestyle as well .
The pandemic affected all aspects of life with special impact on patients with type 1 diabetes. The main limitation of the current study is relatively small sample size representing data from a single center. The absence of data assessing the history of COVID-19 infection in patients/caregivers as well as contact with suspected or confirmed cases is another limitation of the current study. Additionally, the disadvantages associated with the nature of online survey with its potential have limited the ability to access certain portals.