As a Professor of Endocrinology and Executive Vice Chair of the Department of Medicine at Johns Hopkins University, Sherita Hill Golden knows a thing or two about the challenges people with diabetes face in the winter months. “This is always a rough time of year,” she said, “where there are holidays and cold weather, and there are typically a lot of high-carbohydrate foods around. We spend a lot of time talking to patients about what one serving of macaroni and cheese really looks like.”

This is not in any sense a typical year, with a global pandemic still raging in most countries and across the U.S. The additional stress and changes to routine due to the COVID-19 pandemic can make positive lifestyle choices even more complicated and difficult for those with diabetes of heart disease. “When you are isolated and not seeing people and social distancing, there is a tendency to eat,” Golden noted. “The other challenge right now is exercise. For people who are teleworking, they spend a lot of time sitting in a chair. They may have exercise equipment at home, gathering dust. Now is the time to dust off that exercise bike.”

COVID-19 has compelled citizens the world over to think about health risks on a near-daily basis. For patients with comorbidities like type 2 diabetes or cardiovascular disease, even greater concerns exist. Diabetes affects over 34 million people in the U.S. while 121.5 million individuals in the U.S. have one or more cardiovascular disease.1,2 Numerous studies have indicated that people with diabetes, underlying heart disease or high blood pressure may be more vulnerable to severe COVID-19 infections, with mortality rates two to three times higher than in the general population.3

For health care providers, the situation is uniquely challenging. They must communicate the increased risks of severe complications, while not instilling so much fear in patients that they eschew the basics. Those basic management steps include maintaining glycemic control, getting enough exercise, choosing healthy foods, sticking to medication regimens and reaching out to medical professionals should an adverse event occur.

Add to the mix the devastating economic consequences of this pandemic, the inequality of access to care for certain affected groups and the overall higher diabetes and cardiovascular disease rates for historically marginalized populations, and a very complex health management task takes shape.

Maintaining balance in unbalanced times

In December 2020, Scientific American’s Custom Media division co-hosted a virtual salon event with Know Diabetes by Heart, a joint initiative of the American Diabetes Association and the American Heart Association, to explore COVID-19 considerations for high-risk populations.

As the moderator, I had the pleasure of joining Dr. Golden at the virtual roundtable, along with Drs. David Aguilar, Associate Professor of Internal Medicine at McGovern Medical School and Christopher W. Jones, Medical Director, Diabetes Care, Intermountain Healthcare. A key theme reinforced by all panelists was the need to balance honest risk-assessment with a renewed focus on the fundamentals of care in these difficult times.

“While we need to take the COVID-19 acute risk seriously for these patients,” Aguilar pointed out, “we also need to stick to the basics of chronic disease management. We cannot lose sight of those core elements such as hypertension, cholesterol, adherence to medications, blood sugar also know as blood glucose management. This is all within the context of larger issues, economic, social and psychological: job loss and other economic challenges, possibly even the loss of family members, and physical and emotional isolation.”

In addition, office visits are down in general. A recent Commonwealth Fund report shows a cumulative patient decline of 28% in U.S. endocrinology offices, 31% in primary care facilities and 40% in cardiology offices.4 These data suggest some patients are not seeking the care they need, which could lead to worsening health conditions. Telemedicine and digital technology can address some of these situations, but they are not a panacea.

The hazards of incomplete information

Among the many issues explored by the panel, information—whether too much, too little or simply incomplete—was a source of concern.

“The medical and scientific community is used to synthesizing a lot of information that comes out in peer-reviewed journals over long periods of time and putting it together into a cohesive narrative for patients,” said Christopher Jones. But in this pandemic, he said, so much information is coming out daily, and some days hourly, that patients cannot process all of it.

“Many times,” Jones said, “someone or one of their loved ones will hear snippets of a story or part of what needs to be a bigger picture, and they will run with it. This causes misinformation that then triggers a whole other level of stress and fear.”

After hearing conflicting or wrong information, a patient might tune out any health-related messages, and let empathy set in. All the panelists agreed that a good strategy for maintaining credibility is to be clear with patients on what is known, and what is still an emerging picture, without not enough data to draw conclusions. As Golden put it: “Sometimes, as professionals, we need to be able to say, with the utmost clarity, ‘we just don’t know yet.’”

Certainly, as more vaccines become available, and as infection rates go down nationally, patients everywhere will have a reason for optimism. But while there is light at the end of this tunnel, we are, most definitely, still inside the tunnel. With patience, reliable information and vigilance, we’ll continue to work together towards a healthier and smarter journey.

For the latest information, guidelines for clinicians, and other resources on how to manage diabetes and CVD, visit KnowDiabetesbyHeart.org.

References

  1. CDC, National Diabetes Statistic Report 2020. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf; 2020.
  2. American Heart Association. Cardiovascular Disease Affects Nearly Half of American Adults.  https://www.heart.org/en/news/2019/01/31/cardiovascular-diseases-affect-nearly-half-of-american-adults-statistics-show. 2019
  3. NCBI, Diabetes, infection risk and COVID-19. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7308743/; 2020.
  4. Commonwealth Fund, The Impact of the COVID-19 Pandemic on Outpatient Visits: Changing Patterns of Care in the Newest COVID-19 Hot Spots. https://www.commonwealthfund.org/publications/2020/aug/impact-covid-19-pandemic-outpatient-visits-changing-patterns-care-newest; Aug 2020.