COVID and diabetes, colliding in a public health train wreck

After an insect bite on his back became infected, David Donner, a retired truck driver in rural Alabama, waited six hours in a packed emergency room with his wife, before coronavirus vaccines were widely available. A few days later, they both began experiencing the telltale symptoms of COVID-19.

Debra Donner quickly recovered but David Donner, 66, landed in the intensive care unit. “The virus barely slowed her down, but I ended up surrounded by nurses in hazmat suits,” he said. His halting recovery has left him dependent on a wheelchair. “I walk 20 feet and I’m huffing and puffing like I ran 20 miles.”

The Donners see little mystery in why they fared so differently: David Donner has diabetes, a chronic disease that hobbles the body’s ability to regulate blood sugar and inexorably wreaks havoc on circulation, kidney function and other vital organs.

After older people and nursing home residents, perhaps no group has been harder hit by the pandemic than people with diabetes. Recent studies suggest that 30-40% of all coronavirus deaths in the United States have occurred among people with diabetes, a sobering figure that has been subsumed by other grim data from a public health disaster that is on track to claim 1 million American lives sometime this month.

People with diabetes are especially vulnerable to severe illness from COVID, partly because diabetes impairs the immune system but also because those with the disease often struggle with high blood pressure, obesity and other underlying medical conditions that can seriously worsen a coronavirus infection.

“It’s hard to overstate just how devastating the pandemic has been for Americans with diabetes,” said Dr Giuseppina Imperatore, who oversees diabetes prevention and treatment at the Centres for Disease Control and Prevention.

Diabetes patients hospitalized with COVID spend more time in the ICU, are more likely to be intubated and are less likely to survive, according to several studies, one of which found that 20% of hospitalized coronavirus patients with diabetes died within a month of admission. Though researchers are still trying to understand the dynamics between the two diseases, most agree on one thing: Uncontrolled diabetes impairs the immune system and decreases a patient’s ability to withstand a coronavirus infection.

Diabetes is a pernicious disease that is at once ubiquitous and invisible, partly because most people with the condition do not appear outwardly ill. It affects 34 million Americans, or 13% of all adults, but draws less funding and public attention than other major killers like cancer, Alzheimer’s and heart disease.

Even as the pandemic’s hold on political leaders and the public begins to fade, researchers, clinicians and other experts in the field are hoping the disproportionate suffering and death among people with diabetes will bring renewed attention to the disease, which annually claims 100,000 lives and soaks up 1 in 4 health care dollars spent.

Betty Angeles, a community health worker who helps Spanish speakers navigate how to treat their diabetes, in Santa Barbara, Calif, March 24, 2022. The New York Times

“Millions of Americans were already struggling with diabetes, and then COVID came along and cut a huge swath of suffering and misery that has been largely overlooked by the public and policymakers,” said Dr David Kerr, the director of research and innovation at Sansum Diabetes Research Institute in California. “Diabetes is a wicked problem and COVID has just shone a bright light on this crisis.”

Like the pandemic, which has had an outsize toll on communities of color, the burden of diabetes falls more heavily on Latino and Black Americans, highlighting systemic failures in health care delivery that have also made the coronavirus far deadlier for the poor, said Nadia Islam, a medical sociologist at NYU Langone Health. “It’s not that diabetes itself makes COVID inherently worse but rather uncontrolled diabetes, which is really a proxy for other markers of disadvantage,” she said.

Compounding the concerns, some studies suggest that a coronavirus infection can heighten the risk of developing type 2 diabetes, a disease that is largely preventable through a healthy diet and exercise. Type 1, by contrast, is a genetic disorder that tends to emerge early in life and is sometimes referred to as juvenile diabetes. More than 90% of all diabetes cases in the United States are type 2.

One study published last month found that patients who recovered from COVID were 40% more likely to be diagnosed with type 2 diabetes within 12 months compared with the uninfected, though researchers have yet to determine a connection between the two conditions.

Over the past two years, doctors have also reported a sharp rise in young people being diagnosed with type 2 diabetes, an increase that many believe is tied to the drastic spike in childhood obesity during the pandemic. “We’ve seen kids coming in so sick and dehydrated that they sometimes require ICU care,” said Dr Daniel Hsia, a diabetes specialist at the Pennington Medical Research Center at Louisiana State University.

About 1.5 million Americans are diagnosed with diabetes each year, according to the CDC, and roughly 96 million, about 1 in 3 adults, are at high risk for developing the disease.

Although the number of new diagnoses has begun to decline, the overall number of Americans with diabetes has doubled in the past two decades, an increase that mirrors the alarming rise of obesity, which affects more than 42% of adults.

Diabetes is an insidious disease that significantly increases the risks of premature blindness, stroke, and circulatory and neurological problems that can lead to infections requiring amputation of gangrenous toes and feet.

As with many chronic conditions, the poor and people of colour are diagnosed with diabetes at disproportionately higher rates. Black and Latino Americans are more than twice as likely to receive a diabetes diagnosis as whites, and inadequate access to medical care can make it harder for them to juggle the complex dietary, monitoring and treatment regimens that can stave off its devastating complications.

Although there is much researchers don’t understand, many believe that uncontrolled diabetes greatly amplifies the perils of a COVID diagnosis. That’s because a sedentary lifestyle, putting on extra weight or failing to keep close tabs on blood sugar levels fuel chronic inflammation inside the body, which can increase insulin resistance and weaken the immune system.

Inflammation triggers the release of cytokines, tiny proteins that regulate the body’s immune response to infection or injury. Cytokines are a critical component of the normal healing process, but for people with diabetes and underlying chronic inflammation, all those cytokines can damage healthy tissue. COVID, it turns out, can provoke an uncontrolled release of cytokines, and the resulting “cytokine storm” can wreak havoc on vital organs like the lungs, leading to dire outcomes and death.

People with type 2 diabetes tend to fare more poorly than those with type 1, in part because those with type 1 tend to be younger.

In some respects, the pandemic has already had some positive effects on diabetes care by elevating the adoption of technology that enables remote management of the disease. The ramped up embrace of telemedicine, for example, has made it possible for health care providers to spot a worrisome foot wound on a homebound patient.

Early in the pandemic, the Food and Drug Administration gave hospitals and long-term care facilities permission to distribute continuous glucose monitoring devices to coronavirus patients as a way of reducing the risks to health care workers. Clinicians have also learned the nuances of caring for hospitalized diabetics with COVID through more intensive monitoring and management of blood sugar levels.

But many advancements have been unevenly distributed. The uninsured cannot afford the latest glucose monitoring or insulin delivery devices, and in economically disadvantaged communities with low digital literacy, experts say that doctors are less likely to offer new technologies and treatments to Black and Hispanic patients, even when they are covered by insurance.

“The advances of recent years have been stunning but not everyone has access to them and that’s just tragic,” said Dr Ruth S Weinstock, a board member of the American Diabetes Association.

The soaring cost of insulin, an essential medicine for diabetes management, has also had a greater impact on the poor. A 2019 study found that 1 in 4 people with diabetes had rationed their insulin use, which can have dire health consequences. On Thursday, the House voted to cap the price of insulin at $35 a month. President Joe Biden supports the measure, which the Senate has yet to consider.

Betty Angeles, 59, sees up close the challenges of managing diabetes for the farmhands, busboys and other low-wage labourers in and around Santa Barbara, California. Angeles, a native of Peru, herself juggles three jobs: as a house cleaner, a pastry chef and a community health worker at Sansum Diabetes Research Institute, where she helps Spanish-speaking clients navigate the complexities of diabetes treatment.

“When you are uninsured and working two or three jobs it’s difficult to regularly see a doctor like you should,” said Angeles, who has managed her own diabetes for nearly three decades.

Sansum runs programs to make it easier for patients to stay healthy. That means regularly testing their blood sugar levels; encouraging clients to exercise, even if that means jogging in place for 15 minutes between jobs; and teaching them to prepare meals that favour fresh produce over bread, rice and tortillas — starchy carbohydrates that can complicate the body’s ability to regulate glucose.

Arianna Larez, who oversees the institute’s type 2 diabetes program, says Angeles and other outreach workers with community roots are the key to its success. She strongly believes the especialistas, as they are known in Spanish, deserve some credit for one encouraging data point: though many have been infected by the coronavirus, none of Sansum’s 400 clients have died of COVID.

“Building trusted relationships and creating easy-to-understand, culturally relevant information has real-world implications,” Larez said.

Experts say addressing the nation’s diabetes crisis will require more than expanding the number of community health workers: Well-funded public education campaigns are needed to drive home the importance of exercise and healthy eating, as are seismic changes to a food system geared to cheap, processed food — a heavy lift given the political might of the food and beverage industry.

But researchers say state and local governments can make a difference through programs that subsidize fresh produce for low-wage earners and zoning measures to lure supermarkets to so-called food deserts.

“Instead of telling poor people they’re lazy for not being physically active, why not make their neighbourhoods safer so they aren’t afraid to go outside and exercise?” asked Dr Sudip Bajpeyi, a researcher at the University of Texas at El Paso whose study on hospitalized COVID patients last June was among the first to highlight the outsize death toll among people with diabetes. “The only way to move the needle is to reform a system that prioritizes cures and new drugs over prevention.”

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