Diabetes & COVID-19: Frequently Asked Questions Answered by Dr Sunil Kumar Kota

The novel Corona virus (COVID-19) has affected several countries across globe leading to its declaration as a pandemic by WHO (World Health Organization) on 12^th March 2020. It is transmitted predominantly by respiratory droplets or aerosols. COVID-19 is usually a mild disease and around 98% of\ people affected survive. The majority of cases (>80%) are mild (showing only minimal flu-like symptoms) and people can recover at home. Some cases (around 15%) are severe and very few (around 5%) can result in critical illness due to pneumonia, ARDS (Acute respiratory distress syndrome), septic shock and kidney failure or even death. This is more common in people who have other health problems, particularly in the elderly and young children, those with Diabetes, Hypertension, cardiovascular disease, chronic lung disease (asthma, chronic bronchitis), chronic liver & kidney disease and those who receive chronic immunosuppressant therapies like steroids.

Here are some of the frequently asked questions about issues pertinent to Diabetes & COVID-19 and answered by Dr Sunil Kumar Kota, MD (Med), DNB (Endo) and  Consultant Endocrinologist, DIABETES & ENDOCARE Clinic, Berhampur.

1. How Diabetes & COVID-19 affect each other?

Ans- Diabetes is associated with reduced immunity leading to higher occurrence of infections. Diabetics with poor blood glucose control, especially the elderly and those with additional comorbidities like hypertension, cardiac & renal problems, and chronic lung problems are prone for increased chances of severe and critical COVID-19 infection. Additionally there is increased hospitalization, complications and death.

Similarly COVID-19 infection leads to increased blood glucose levels and variability throughout the day. This can give rise to both hyperglycemia (increased blood sugar levels) and hypoglycaemia (low blood sugar levels).

2. What sort of diet & lifestyle changes do diabetics need to follow in the wake of COVID-19?

Ans- The dietary changes should aim at reduction in extreme fluctuations in blood glucose levels. Therefore avoidance of simple sugars (like sweet dishes, candy, soda, sweetened beverages, honey, and fruit juices) and reliance on complex carbohydrates (rice, potato, grains, pasta etc) is the way to go. Have a meal to fill your stomachs with reduced carbohydrates with more intake of curries, salads and daal. Adequate intake of protein and diet rich in vitamins & minerals (green leafy vegetables, whole fruits) is the need of hour. Do not take half cooked or uncooked nonvegetarian items. Exercise has been shown to improve immunity, though it might be prudent to be careful and avoid crowded places like gymnasia or swimming pools. Daily 30 minutes of aerobic exercise (brisk walk) and 10 minutes of anaerobic exercise 3 days a week are recommended. Those with knee problems should indulge in upper body exercises. Daily 7 hours of uninterrupted sleep and indulgence in yoga would be proper stress busters. Avoid alcohol & smoking.

3. What precautions should be taken by Diabetics to avoid COVID-19 infection?

Ans- Wash your hands thoroughly and regularly for 20 seconds with soap and water or use an alcohol-based solution (minimum 60%), especially before eating and after being in public.

• When sneezing or coughing, cover the nose and mouth with a handkerchief or tissue or with the crook of the elbow. Throw the tissue immediately into a closed bin and wash your hands afterwards.
• Avoid touching your eyes, nose or mouth
• Regularly clean commonly used surfaces and devices you touch or handle like table, phone, laptop.
• Don’t share food, tools, glasses and towels.
• Dont spit in public
• Use online transactions and sanitise the delivered goods (newspaper, water bottle, milk packet, vegetable etc) before using them
• Avoid close contact with those who are ill. If someone is visibly ill, coughing or sneezing, keep away.
• Wash your clothes daily.
• Avoid non-essential use of public transport, varying your travel times to avoid rush hour, when possible. Work from home, wherever possible.
• Avoid large gatherings, and gatherings in smaller public spaces such as pubs, cinemas, restaurants, theatres, bars or clubs.
• Avoid gatherings with friends and family. Keep in touch using remote technology instead, such as phone, internet, and social media.

• If you have a fever, cough and difficulty breathing, seek medical care early and share previous travel history with your health-care provider

• Use telephone or online services to contact your GP practice or other essential services.

• If you have a scheduled visit with your health-care provider, contact them via phone/or portal first to see what other options you may have (many clinics have increased their use of telemedicine) as visiting a clinic can increase your risk of being exposed to the virus. Follow the advice of your health-care provider
• Avoid unprotected contact with wildlife and farm animals.
• Check national travel advice before planning or taking trips

4. What to do if a diabetic patient is defined as a contact and instructed to stay at home?

Ans- A Diabetic patient is defined contact in the context of COVID-19 when

• The patient lives in the same household as a COVID-19 case;
• The patient had direct physical contact with a COVID-19 case or his/her infectious secretions without recommended personal protective equipment (PPE) or with a possible breach of PPE
• The patient was in a closed environment or had face to face contact with a COVID-19 case at a distance of within 1 metre including air travel;

The epidemiological link may have occurred within a 14‐day period before the onset of illness in the case under consideration. The incubation period (time between onset of infection and occurrence of first symptom) for COVID-19 is 14 days with majority of them developing symptoms within 5-7 days.

A diabetic contact should practice proper measures for infection prevention and control. Management should focus on prevention of transmission to others and monitoring for clinical deterioration, which may prompt hospitalization. There is a need to stay away from elderly people, pregnant women, children and persons with co-morbidities within the household. His/her movement within the house has to be restricted. Under no circumstances the contact can attend any social/religious gathering e.g. wedding, condolences, etc. Affected contacts should be placed in a well-ventilated single room while household members should stay in a different room or, if that is not possible, maintain a distance of at least one metre from the person affected(e.g. sleep in a separate bed) and perform hand hygiene (washing of hands with soap and water) after any type of contact with the affected person or their immediate environment. When washing hands, it is preferable to use disposable paper towels to dry them. If these are not available, clean cloth towels should be used and they should be replaced when they become wet. Avoid sharing household items e.g. dishes, drinking glasses, cups, eating utensils, towels, bedding, or other items with other people at home. To contain respiratory secretions, a medical mask should be provided to the person affected and worn as much as possible and changed every 6 hours. Individuals who cannot tolerate a medical mask should use rigorous respiratory hygiene − ie. the mouth and nose should be covered with a disposable paper tissue when coughing or sneezing. Caregivers should also wear a tightly fitted medical mask that covers their mouth and nose when in the same room as the person affected. If symptoms appear (cough /fever/ difficulty in breathing), he/she should immediately inform the nearest health centre. Masks used by patients / care givers/ close contacts during home care should be disinfected using ordinary bleach solution (5%) or sodium hypochlorite solution (1%) and then disposed of either by burning or deep burial. The floor should be regularly mopped with 0.1% bleaching water (1 gram bleaching powder in 1 liter water).

5. How should a diabetic patient be prepared in the event of infection?

Ans-

• Gather the contact information for your doctors, clinic, pharmacy and your insurance
• Write down the names and doses of your medications to share with your family & friends.
• Have enough medication for one-two weeks in case you cannot get to the pharmacy to refill your prescriptions
• Ensure you have enough device supplies as well (i.e. pump supplies, pen supplies, monitor supplies, etc.)
• Ensure all your medications have refills available, so you do not have to leave the house if you become ill
• Have extra supplies like rubbing alcohol, hand sanitizers and soap to wash your hands
• Keep simple sugars (i.e. glucose tablets) on-hand in case you need to treat low blood sugar which may occur more frequently with illness due to changes to eating patterns
• Have glucagon available in case of a significant low blood sugar (if taking insulin or medications that can cause low blood sugar)
• Have ketone strips available in case of illness (if you have type 1 diabetes ot if you are on Insulin)

• It is important to take influenza and pneumonia vaccinations. The latter may decrease chances of secondary bacterial pneumonia after respiratory viral infection.

6. What are the sick day rules for diabetics?

• Reduce carbohydrates
• Keep hydrated
• Monitor your blood glucose
• Monitor your temperature
• If you are on insulin, also monitor your ketone bodies
• Follow your healthcare team recommendations

7. Do diabetic patients require any alteration in medicines?

Ans- Anti-hyperglycemic agents that can cause volume depletion or hypoglycemia should be avoided. Dosage of oral anti-diabetic drugs may need to be reduced. Hospitalised patients with severe disease need frequent blood glucose monitoring. Oral agents especially metformin and sodium glucose cotransporter-2 inhibitors need to be stopped. Insulin is the preferred agent for control of hyperglycemia in hospitalised sick patients. Blood pressure control is an essential part of managing diabetes. In addition, certain blood pressure lowering medications [(a class of medications known as angiotensin converting enzyme inhibitors (ACE-i) or Angiotensin Receptor Blockers (ARBs)] are often recommended for people living with diabetes to protect them from kidney and heart-related complications, even in the absence of high blood pressure.  At the present time, there is no confirmed scientific link between these blood pressure medications and the risk of COVID-19 infection or its complications.  Ibuprofen, a pain killer has to be avoided. Please do NOT stop or change any of your medications without discussing with your health-care team.

8. Which diabetics should use mask & how?

Ans- Unnecessary usage of masks has been shown to instil a false sense of security leading to avoidance of hygienic practices and thereby increased chances of infection. The masks to be specifically used if

• You have symptoms (Cough, fever or difficulty in breathing)
• You are caring for a COVID-19 suspect/confirmed patient
• You are a health-worker attending to patients with respiratory symptoms
• You may use it while visiting a crowded place and a health care facility.

While wearing a mask, make sure

• Unfold the pleats of the mask; make sure that they are facing down.
• Place the mask over your nose, mouth and chin and ensure there are no gaps on either side of the mask, adjust to fit.
• Avoid touching the mask, while using it.
• Do not leave the mask hanging from the neck
• Do not touch the potentially contaminated outer surface of the mask, while removing it.
• Change the mask after six hours or as soon as they become wet.
• After removal of mask, clean your hands with soap and water or use alcohol-based hand rub disinfectant.
• Never reuse disposable masks and dispose the used masks into closed bins after disinfecting them.

Cloth masks or surgical masks can be used by public. Don’t wait for N95 masks; those should be reserved for health care professionals dealing with patients having respiratory symptoms only. Masks used by patients / care givers/ close contacts during home care should be disinfected using ordinary bleach solution (5%) or sodium hypochlorite solution (1%) and then disposed of either by burning or deep burial.

9. Which resources are useful to be updated about COVID-19?

Ans- WHO (World Health Organization), CDC-USA (Centre for Disease Control & Prevention-United States of America), Ministry of Health & Family Welfare, Govt of India and respected state Govts.

Dr Sunil Kumar Kota
MD (Med), DNB (Endo)
Consultant Endocrinologist
DIABETES & ENDOCARE Clinic, Berhampur
Email: diab.endocare@gmail.com
Ph: +917749804401