According to the Centers for Disease Control and Prevention (CDC), certain underlying medical conditions, like diabetes, put adults at increased risk of severe illness if they become infected with the coronavirus.1 In honor of National Diabetes Month, we checked in with Dr. Martin J. Abrahamson, a member of our Clinical Advisory Board and renowned expert in diabetes management. Dr. Abrahamson offers some insight into COVID-19 and chronic conditions, and how health plans and employers can support their populations during this time.
What we know about certain medical conditions and COVID-19.
As new data emerges, the CDC has been updating its list of medical conditions that raise the risk of becoming severely ill with COVID-19. The list includes cancer, heart disease, obesity, kidney disease, type 2 diabetes, chronic obstructive pulmonary disease (COPD), and sickle cell disease. Pregnancy and smoking are also now considered risk factors.
Given that about 40% of the U.S. adult population is considered obese, 34 million adults have diabetes, and just under 50% suffer from heart disease, it’s definitely cause for concern.2
It’s important to note, though, that having a particular condition doesn’t make one more susceptible to catching COVID-19, it just means that the effects of the illness are more pronounced—including hospitalization, intensive care unit (ICU) admission, intubation, or even death.
What we know about diabetes and COVID-19.
In general, people with diabetes who contract COVID-19 are at higher risk for developing a more severe or complicated infection and may not do as well in an ICU setting. This is because elevated glucose levels impair white cell function and the ability to fight infections. The risk for severe infection further increases if the patient has other chronic conditions, like obesity, hypertension, cardiovascular disease and kidney disease. In general, we know that younger people with diabetes who get COVID-19 generally do better than older people.
It’s interesting to note that people with well-controlled diabetes and no “comorbid conditions” (more than one condition present at the same time) have much the same risk of developing more severe infection as those without diabetes. However, if a patient’s diabetes isn’t under control, risk increases, just as with any other viral illness. This is because elevated glucose levels impair white cell function and the ability to fight infections.
What people with diabetes can do to maintain good overall health.
It’s important for people with diabetes to keep their condition under control. When asked, Dr. Abrahamson recommends the following:
What is the best diet?
There really is no “best” diet for people with diabetes. In general, people with diabetes should aim to reduce their carbohydrate intake, as this has been shown to have the best impact on glucose levels. Carbohydrates high in dietary fiber are encouraged and sugary carbohydrates discouraged. There should always be adequate protein in the diet, especially if you are working to lose weight. The type of protein should preferably be lean protein—protein that does not contain too much saturated fat. Fish and chicken are preferred to red meat. The fats that should be eaten are preferably mono- and polyunsaturated fats rather than saturated fats.
For some people, low carbohydrate or low carbohydrate diets may be very helpful and may help improve glucose control where other dietary interventions have not succeeded. Increased consumption of fruit lowers the risk for developing type 2 diabetes, whereas consumption of fruit juices increases the risk for developing type 2 diabetes. Eating at least 2 servings of dairy-rich products (milk, cheese, yogurt) has been shown to reduce the risk for development of diabetes, hypertension and other factors that increase the risk for the development of heart disease.
How much, and what type of exercise is best?
Exercise has a multitude of health benefits that are particularly relevant to people with diabetes. These include improvement in blood glucose control, weight maintenance, and a significant reduction in cardiovascular mortality. Long term exercise lowers levels of total and “bad” LDL cholesterol and triglycerides and also increases the HDL (good cholesterol).
Both resistance training and aerobic exercise are recommended for optimal glucose control. Studies have shown that both aerobic and resistance training alone improve glucose control in people with type 2 diabetes, but the improvements are greatest when individuals combine both aerobic and resistance exercises.
Aerobic exercise is generally recommended for at least 30 minutes per day for five days a week, but there really is no upper limit to how much aerobic exercise one should do. High-intensity interval training has been shown to be beneficial and can sometimes be an option for people who have limited time for exercise. Resistance training should be done at least twice a week.
Which glucose-lowering medications do you think are best?
There really is no single answer to this question. It is very important that medical therapy and therapeutic goals be individualized for each person with diabetes. We do know that over the past 15 years, new medications have come to market that are safer to use, do not cause hypoglycemia, can cause weight loss, and have the added benefit of reducing risk for cardiovascular disease. These include drugs called GLP 1 receptor agonists and SGLT 2 inhibitors. These medications when used alone, together, or with one of the oldest medications around called metformin will not cause hypoglycemia and facilitate weight loss. They also have been shown to reduce risk for cardiovascular disease independent of their glucose-lowering effects.
For people who require insulin, there are newer insulin products called insulin analogs which are more physiologic in that their time action profiles mimic more closely the way insulin is secreted from the beta cells of the pancreas. These analogs have also been shown to reduce risk of hypoglycemia compared to the older insulin products. Unfortunately, these newer medications and insulins or more expensive than the older products or generic medications like sulfonylureas which have been used for many years in people with type 2 diabetes, but which can cause weight gain and hypoglycemia. They are however effective glucose-lowering medications and an option where cost is an issue.
Glucose monitoring—how often should a person test their blood glucose?
There is no simple answer to this. It depends on the type of diabetes you have, and, if you have type 2 diabetes, whether you are taking insulin, the type(s) of insulin, or other medications that have the potential to cause hypoglycemia (low blood sugar).
Every person with type 1 diabetes should measure glucose levels frequently. Ideally, glucose levels should be checked before each meal, before bed, before certain activities such as exercise or driving, and sometimes 2 hours after a meal. This would require testing 6-10 times a day. Continuous glucose monitoring is recommended for many people with type 1 diabetes and for those people with type 2 diabetes who require multiple injections of insulin daily. Many of the newer continuous glucose monitoring (CGM) systems do not require fingerstick testing to calibrate or standardize the CGM.
For people who have type 2 diabetes, recommendations regarding blood glucose monitoring vary, depending upon the complexity of the treatment regimen. For example, for people who manage diabetes with just diet and exercise or perhaps with a medication like metformin, the need to monitor glucose is not essential. Monitoring glucose can, however, provide feedback regarding behaviors, such as the impact of certain foods on blood glucose levels, or the effect of exercise on glucose. This can help with adherence to recommended lifestyle changes.
For people with type 2 diabetes who take multiple medications, or medications that can cause hypoglycemia like sulfonylureas or insulin, blood glucose monitoring is recommended—at least once a day, but sometimes more frequently.
What employers and health plans can do to support their diabetic population.
A study by Roche found that “full-time employees living with diabetes miss an average of 5.5 more days each year compared to others, and also can struggle with productivity as a result of common diabetes-related side effects such as fatigue.” The American Diabetes Association estimates that diabetes costs employers about $20.4 billion annually in missed work days. So, it’s in employers’ and health plans’ best interests to support employees with this condition. Here are some suggestions:
- Ensure medical benefits include access to diabetes management programs or offer support through a well-being program like WebMD ONE.
- Provide access to digital tools, like smartphone apps, to help monitor and manage blood sugar.
- If employees are working onsite, set aside a private space to monitor blood sugar and take insulin injections.
- Post-coronavirus, make sure the cafeteria offers healthy food and encourage employees to take time during and after the work day to get regular exercise.
- Hold onsite or virtual health fairs to increase awareness about diabetes and how to spot warning signs.
We all need to take precautions to reduce our risk of contracting coronavirus, but science shows this is especially important for people who are managing chronic conditions, including diabetes. For more information on how your organization can support employees or members with chronic conditions during this time, contact us email@example.com.
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- Dr. Abrahamson’s comments on keeping diabetes under control have been modified from an upcoming book that he has written with Sanjiv Chopra, MD MACP entitled “Conquering Diabetes: Prevention, Control, Remission.”