What are the real risks of Covid-19 and diabetes, and what should we do?

By the Integrated Diabetes Services Clinical Staff

It is hard to avoid the low level of anxiety that has become part of our new “normal”. But for people with diabetes, the media reminders about risk factors and Covid-19 can be extra anxiety-inducing. Seeing “Diabetes” listed as a “high risk group” and seeing the numbers can strike terror into our hearts. So what does this risk mean? And what can we do?

If I have diabetes, am I at higher risk of catching Covid?

No – there is nothing about having diabetes that makes us more likely to catch Covid. The same avoidance, distancing and hygiene practices that protect everyone else also protect people with diabetes. We are not innately “immuno-compromised” and more susceptible to catching a viral disease spread than the general population. The immune-compromised state does increase, however, with poor glycemic control. Elevated glucose levels are the risk factor, not simply “having diabetes.”

Why are people with diabetes listed as high risk?

People with diabetes are more likely to become severely ill for a longer duration than people without diabetes. However, we are at lower risk than those with other chronic medical conditions. Statistics from the Centers for Disease Control (CDC) show that 42% of people with diabetes who acquire coronavirus do not require hospitalization, 32% require non-ICU (intensive care unit) hospitalization, and 19% require ICU admission.  That compares to 84%, 7%, and 2% of people without any chronic health conditions.

According to a report on 44,672 confirmed cases of the disease from the Chinese Center for Disease Control and Prevention in February, the overall case-fatality rate (CFR) at that stage was 2.3% (1,023 deaths of the 44,672 confirmed cases). The data indicated that the CFR was elevated among COVID-19 patients with preexisting comorbid conditions, specifically, cardiovascular disease (CFR, 10.5%), diabetes (7.3%), chronic respiratory disease (6.3%), hypertension (6%), and cancer (5.6%). However, these statistics do not differentiate between people who have type 1 or type 2 diabetes and their level of glucose control, whether they had more than one condition (such as diabetes AND renal impairment or diabetes AND hypertension), and were not adjusted for age. We know that older persons are at higher risk for severe illness and are also at higher risk for type 2 diabetes, so there would be an anticipated correlation between diabetes and CFR.

Therefore, people with diabetes may be at higher risk because they get lumped into one massive group that includes people who tend to be older and have many other health problems. Endocrinologists have reported not seeing a higher than normal infection rate among their patients, and that those with good glycemic control have not shown any increase in rates or severity of disease.

If Diabetes is only a “potential” high-risk group why does the media not say so?

The media is responsible for informing everyone, particularly those at the highest risk. Their approach errs on the side of caution, simply because many people would not practice sound prevention unless required to do so. The media must state the most extreme risk profile because otherwise many people would not consider themselves at risk at all. For example, if the media said “persons with poorly controlled diabetes are at an increased risk,” many people with poor control would not identify as such since poor control is not well-defined. They may consider themselves in good or satisfactory control simply because they are prescribed medication for it. Ironically, people with good (or even exemplary) diabetes management are the ones who might consider themselves in “poor” control due to occasional blood sugar excursions and wind up worrying needlessly.

In general it comes down to this: with good diabetes management, our risk is not higher than that of the general public. However, if we get sick, diabetes management becomes more difficult to maintain. When blood sugars are elevated, we have more inflammation, poor circulation, and the extra glucose is “feeding the enemy” in the case of bacterial and viral infections. When blood sugars are elevated, we also have a reduction in the immune system’s ability to identify and fight infection.

What should a person with diabetes do to prevent COVID 19?

Preventive measures including abiding by recommended guidelines (frequent handwashing, social distancing, use of facemasks in social settings) as well as maintaining glucose control within your target range as often as possible.

Here are some other recommendations:

  1. Rest – in times of stress such as these, sleep quality is often poor, so make sure to maintain sleep quality and quantity. This will help to keep your immune system performing properly.
  1. Eat well but avoid stress eating – grocery stores can be lean these days, but often the fresh produce sections are full! In times of stress we tend to reach for processed and high-fat, high-carb foods. Maintaining a healthy diet boosts the immune system and helps with glycemic control. The “Covid 15” (similar to the freshman 15), as it is being dubbed, will also impact your insulin needs. This is not the time to play fast and loose with food. It is time to eat for our health rather than for our feelings.
  1. Stay active – try to set up a daily physical activity schedule for your new “normal.” Resist the urge to just sit in front of the TV or computer all day. Getting physical activity daily keeps our blood flowing and maintains heart health. It also helps to boost immune function and stave off depression and binge-eating. The added insulin sensitivity provided by exercise can make a big difference with your glucose control. From online exercise programs and apps like GlucoseZone that provide at-home exercise options on demand, there are plenty of opportunities to get moving – even in a single room.

Make ample use of home exercise equipment, or venture outside for a walk, jog, hike or bike ride. Just don’t forget to maintain a 6-foot personal distance from others.

What if I get COVID 19?

Should symptoms of an illness (including COVID 19) arise, tight glucose control is even more important. This is key to reducing the longevity and severity of the illness.

An effective sick day management plan includes:

  1. Persistent blood glucose monitoring, including frequent fingersticks or use of a continuous glucose monitor. Don’t forget that CGMs such as Medtronic Guardian and Dexcom G5 are impacted by acetaminophen use (you may see artificially elevated readings for several hours). If you use a CGM that is affected by acetaminophen, use fingerstick readings instead or check into switching to a CGM that is not affected.
  1. Routine Ketone monitoring. Infections tend to cause the production of ketones regardless of blood sugar levels, so monitor at least every 3 hours. An illness/infection that produces large ketones or rising ketones despite treatment can indicate an infection of increasing severity. NEVER skip insulin on a sick day, even if you are not eating as much as usual.

If you are making ketones and your glucose is elevated, drink lots of water (see below) and increase your basal insulin (via pump or injected long-acting insulin) and bolus extra to cover the elevated readings. Failure to address ketones quickly can lead to diabetic ketoacidosis (DKA). Symptoms of DKA include lethargy, slurred speech, fruity breath, shortness of breath, irritability, and nausea/vomiting. DKA usually requires treatment at a hospital or trauma center. Left untreated, DKA often leads to death.

  1. EXTRA Hydration – 8 ounces (1 cup) per waking hour for adults, 4 ounces per waking hour for children. Hydration allows for adequate insulin absorption, CGM accuracy and proper kidney function.
  1. When treating a fever, reach for acetaminophen, not ibuprofen – check with your provider if you have a history of liver disease or have been advised to limit acetaminophen (Tylenol) use. Due to the renal impacts of severe Covid infections, researchers have recommended avoiding Ibuprofen as a fever and pain reducer at this time, unless directed by a physician. Persons with kidney failure, chronic kidney disease, renal insufficiency or other renal/kidney related diagnoses should take additional precautions to avoid contact with other persons or locations that could spread Covid. This could mean having someone grocery shop and deliver needed items to you rather than going out, and working from home whenever possible.
  1. Reach out to the physician who treats your diabetes if you are diagnosed with coronavirus. If you are on medications that can impact kidney function, such as metformin, SGLT2 inhibitors, blood thinners, NSAIDs, prophylactic antibiotics, antifungals or antiviral medications, discuss the safety of these medications and whether alternate treatments are necessary. Do NOT stop medications without contacting your prescriber first!

To see and hear a first-hand account of what it is like dealing with a relatively mild case of coronavirus, here is a video posted by one of our clients