The COVID-19 pandemic affects not only people’s physical health – but definitely also their mental health. Different daily lives with much uncertainty has created insecurity and stress in most households. However, this insecurity can especially affect the people identified as being at high risk of severe illness if infected with COVID-19 such as older people, people with lung disease, people with overweight and people with diabetes. A new study highlights the daily life and concerns of people with diabetes. Especially women and people with type 1 diabetes experience concerns, but the concerns do not only have negative effects.
The human brain loves predictability. Our brains run on autopilot 85–90% of the time because we do what we usually do. But during the COVID-19 pandemic, very little has remained as it usually is. This makes many people uncertain and anxious. Further, the people who are informed that they are especially vulnerable because they have a higher risk of becoming severely ill with COVID-19 may experience stress. Researchers have now investigated potential COVID-19-specific worries and what characterizes people with high levels of worries in one of the defined high-risk groups for COVID-19: people with diabetes.
“People with diabetes were quickly identified as a group that could be more severely affected by COVID-19. Unfortunately, the information from the Danish Health Authority varied in the initial phase of the pandemic, which may have contributed to additional concerns for many people with diabetes. It has been difficult for them to assess the degree to which they have high risk of becoming severely ill if infected with COVID-19. In addition, the changes to their daily lives during lockdown and, for example, working from home have also led to concerns about how these changes would affect the management of their diabetes on a daily basis. We hope that our study can raise more awareness of what concerns people at higher risk may have and, for example, make healthcare professionals even more aware of talking to people with diabetes about how the situation might affect their diabetes and quality of life,” explains first author Lene Eide Joensen, Senior Researcher and Team Leader, Psychosocial Health and Support, Diabetes Management Research Group, Steno Diabetes Center Copenhagen.
Women more worried than men despite higher mortality among men
The new study was initiated immediately after Denmark initiated its lockdown on 11 March 2020 in connection with an increase in the number of people who were infected with COVID-19. Already when the pandemic started, people with diabetes were advised that they generally had a higher risk of becoming severely ill if they were infected with COVID-19.
“The lockdown in Denmark made people with diabetes – like most others – isolate and their daily lives changed. We wanted to explore how this affected their mental health: for example, the experience of loneliness, stress from diabetes and specific concerns about COVID-19. We did this by distributing an online questionnaire to 2430 adult members of two user panels – one at Steno Diabetes Center Copenhagen and one at the Danish Diabetes Association – asking about COVID-19 specific worries, the extent to which they felt isolated and alone with their diabetes and whether their health-related behaviour differed from normal,” says Lene Eide Joensen.
Almost 1400 people responded to the survey, which could be especially useful because little is known about how pandemics affect the psychosocial health of people with diabetes. Previous research has shown that self-isolation can cause stress symptoms, confusion and anger and that people with chronic illness experience greater stress, anxiety and depression during health crises. A study in China during the COVID-19 outbreak reported that a large proportion of the general population had moderate to severe symptoms of depression.
“Our study showed a high prevalence of diabetes-specific concerns related to COVID-19, and especially concerns about not being able to manage diabetes if infected with COVID-19. People with type 1 diabetes were especially concerned, which is not surprising, since managing diabetes is a large part of their daily lives. Therefore, people with type 1 diabetes are also more likely than people with type 2 diabetes to experience that the changes in daily life affect their management of diabetes,” explains Lene Eide Joensen.
The researchers had expected to find gender differences because previous studies among people with diabetes have shown that women are more often stressed and worried about their illness than men. However, such a gender difference could also be offset since men have significantly higher mortality rates from COVID-19.
“However, women are still more concerned about being overly affected due to diabetes if infected with COVID-19 and are more concerned about not being able to manage their diabetes adequately, compared to men. So it seems that, the higher mortality among men does not appear to make men with diabetes more worried,” says Lene Eide Joensen.
Reaching out to isolated people
This new article is the first of several based on the questionnaire survey. So far, the researchers have distributed not just one but four questionnaires to the participants during the COVID-19 crisis – and plan to distribute two more.
“It will be really interesting to follow the process and see how worries about COVID-19 and mental health change during the pandemic. Other studies have shown that increased stress can negatively affect the management of diabetes, but in our first study we found that the people who were more likely to have diabetes-related worries were also more aware of ensuring that they take their medicine, eat healthier and exercise more than usual,” says Lene Eide Joensen.
The questionnaire survey was supplemented by 20 qualitative interviews with people with diabetes, and both in the survey and interviews one thing was very clear – their uncertainty of being part of a high-risk group and getting unclear and varying information.
According to Lene Eide Joensen, clear communication is important when specific high-risk groups such as people with diabetes are identified. When the pandemic started, the recommendation in Denmark was that only people with “poorly controlled” diabetes had higher risk, but it was not stated what “poorly controlled” meant more precisely.
This recommendation has been changed since the first part of the survey was conducted. People with diabetes, regardless of the type, have a higher risk of severe illness with COVID-19 if their glycated haemoglobin (HbA1c) is higher than 70 mmol/mol – and especially if severe obesity, cardiovascular disease or severe kidney disease is present.
“Being precise is definitely difficult when there is no clear evidence, but our study indicates that giving specific information is important – also about what is not known – to groups identified as being at high risk,” explains Lene Eide Joensen.
However, according to Lene Eide Joensen, another important fact is that the concerns are greatest among those who experience feeling alone with their diabetes.
“It is important to be aware of supporting those who feel alone with their diabetes and therefore may be more concerned about diabetes and COVID-19. Healthcare professionals can pay extra attention to reaching out to especially vulnerable people and talk about how the COVID-19 situation affects them so that they do not feel alone with their worries. Mutual support between people with diabetes – such as peer support groups – is a useful method to share and talk about diabetes-specific worries. Peer support is always an important type of support, but it may be even more important in a crisis,” concludes Lene Eide Joensen.
“Diabetes and COVID‐19: psychosocial consequences of the COVID‐19 pandemic in people with diabetes in Denmark—what characterizes people with high levels of COVID‐19‐related worries?” has been published in Diabetic Medicine. The Novo Nordisk Foundation has awarded grants to Steno Diabetes Center Copenhagen, at which several authors are employed.
