Elsevier

Primary Care Diabetes

Volume 16, Issue 5, October 2022, Pages 644-649
Primary Care Diabetes

The impact of a prolonged lockdown and utilization of diabetes telemedicine on cardiometabolic health in people with diabetes during the COVID-19 outbreak in Saudi Arabia

https://doi.org/10.1016/j.pcd.2022.06.002Get rights and content

Highlights

  • COVID-19 lockdown interrupted the healthcare access for many people with diabetes (PWD).

  • In the Middle East, most PWD live in areas where telemedicine is not well-established.

  • The cardiometabolic health of these individuals may have been negatively impacted as a result.

  • Utilizing a simplified telemedicine clinic may mitigate this risk during lockdown.

  • Attending “virtual” visits during lockdown improved the cardiometabolic health of PWD.

Abstract

Objective

To mitigate the spread of COVID-19, Saudi Arabia implemented a nationwide lockdown that lasted for approximately five months. Due to the limited availability of telemedicine in Saudi Arabia, many people with diabetes (PWD) lost access to diabetes care services during the lockdown period. Here, we examined the impact of lockdown on cardiometabolic health in PWD and how this may have differed between those who utilized diabetes telemedicine during lockdown versus those who did not.

Methods

Hemoglobin A1C (A1C), body weight, lipid, and other cardiometabolic parameters were retrospectively reviewed in 384 PWD who attended routine clinic visits in the pre-lockdown (September 2019 to March 2020) and post-lockdown (Aug to Dec 2020) periods. Changes in cardiometabolic parameters from pre- to post-lockdown were compared across 3 groups according to the type of visit that they had during lockdown (April to July 2020): “no visit” (n = 215), “in-person” visit (n = 44), or “virtual” visit (n = 125). The virtual visits in our institution followed a simplified protocol that utilized technological tools readily available to most PWD and clinicians.

Results

PWD who attended “virtual” visits during lockdown were the youngest and most likely to have type 1 diabetes; followed by those who attended “in-person” visits and those who had “no visit”. A significant reduction in A1C from pre- to post-lockdown periods was noted in PWD who attended a “virtual visit” (9.02 to 8.27%, respectively, p < 0.01) and those who attended an “in-person” visit (9.18 to 8.43%, respectively, p < 0.05) but not in those who had “no visit” (8.75 to 8.57%, p > 0.05). No significant changes were noted in serum glucose, blood pressure, or lipid parameters during the lockdown in any of the groups.

Conclusion

Simplified telemedicine visits, including real-time audio calls, were as effective as in-person visits in improving glycemic control in PWD during the lockdown period in a country where telemedicine infrastructure was not well-established. Older adults and those with type 2 diabetes were less likely to utilize telemedicine; suggesting a potential risk of digital divide that warrants greater attention in the future.

Introduction

The novel coronavirus disease 2019 (COVID-19) was first identified in Wuhan, China in December 2019 as a cluster of cases of pneumonia [1]. A few months later, the World Health Organization (WHO) announced Covid-19 as a global pandemic; and many countries started to implement precautionary measures to mitigate the spread of the virus [2]. Saudi Arabia was one of the first countries to strictly enforce a national lockdown order early on, in March 2020. Other precautionary measures including closures of schools and non-essential businesses, bans of social and religious gatherings, and cancellation of routine (non-urgent) in-person clinic visits and elective surgeries were also implemented early on in Saudi Arabia. The national lockdown implemented in Saudi Arabia was one of the most strict and longest lockdown orders in the world, lasting from March 23rd to August 22nd, 2020. Recent studies have suggested a possible negative impact of lockdown on health behaviors in people with diabetes (PWD) including an increase in caloric intake and a decrease in exercise and frequency of blood glucose monitoring during lockdown[3]. Whether these changes in health behaviors had a negative impact on cardiometabolic health of PWD remains unclear.

Several studies have examined the impact of the COVID-19 pandemic on patients' glycemic control and cardiometabolic health in PWD and found conflicting results [4], [5]. It is possible that the impact of lockdown on cardiometabolic health in PWD may have differed based on several patient-related factors including the socioeconomic status, level of education, and physical and mental health of those individuals ; as well as healthcare-related factors including the interruption of healthcare services, limited accessibility to medications and diabetes supply, and unavailability of telemedicine during lockdown [6]. Data linking socioeconomic deprivation (e.g. lower educational level, unstable housing, lower income, unemployment, and job insecurity) to worse diabetes-related outcomes have long been reported [7]. The COVID-19 pandemic appears to have highlighted, and in many times, exacerbated this effect. Moreover, in parts of the world where telemedicine infrastructure did not exist or was not well-established prior to the pandemic, such as in Saudi Arabia, many PWD found themselves without access to healthcare services during the lockdown [8]. In many instances, this has resulted in interruption of access to diabetes medications, devices, and supplies; which put PWD at a risk of deterioration of glycemic control, blood pressure, and other parameters of cardiometabolic health.

The high penetration of broadband coverage and smartphone use in most countries, including Saudi Arabia, provided an opportunity to many diabetes centers to rapidly implement simplified telemedicine clinics that could serve the purpose of restoring communication with PWD during the lockdown period. The simplified diabetes telemedicine clinic at King Saud University in Riyadh, Saudi Arabia, is an example of such clinics; and a detailed description of the clinic’s protocol as well as the satisfaction reports of patients and healthcare professionals who utilized the clinic have been previously reported [9]. In this study, we examined the effect of attending our simplified diabetes telemedicine clinic during the lockdown period on the cardiometabolic health of PWD in Saudi Arabia; and compared the changes in blood pressure, body weight, serum glucose, hemoglobin A1C (A1C), lipid panel, and albumin-creatinine ration (ACR) from pre- to post-lockdown in PWD who attended the telemedicine clinic versus those who had a “traditional” in-person clinic visit versus those who had no clinic visit at all during the lockdown period.

Section snippets

Study design and participants

The electronic health records (EHR) of 384 patients with diabetes who attended at least 2 routine visits (pre- and post-lockdown) in the Adult Endocrine & Diabetes Clinics at King Saud University Medical City in Riyadh, Saudi Arabia between September 2019 and December 2020 were retrospectively reviewed. The study included adults (14 years old and older) with any type of diabetes. According to the policy of our institution, children with diabetes (i.e. younger than 14 years old) are typically

Participant characteristics

While the overall average age of our study participants was 45.6 ± 20.2 years old, those who attended a “virtual” visit during lockdown were significantly younger than those who had “no” visit (39 versus 50 years old, respectively, p < 0.01). Although those who attended an “in-person” visit during lockdown were slightly older than those who attended a “virtual” visit (43 versus 39 years old, respectively, p = 0.31), the “in-person” visit group was still significantly younger than the group who

Discussion

The COVID-19 outbreak has interrupted access to diabetes care and negatively impacted the physical and mental health of PWD in an unprecedented way, particularly in parts of the world where PWD lost communication with their HCPs due to lack of well-established telemedicine [6], [10]. In this study, we demonstrated a comparable effectiveness of virtual and in-person diabetes visits in improving glycemic control in PWD in Saudi Arabia, where telemedicine is not widely available. We showed an

Conclusions

The utilization of diabetes telemedicine, both live audio-video or real-time telephone visits, is effective in improving glycemic control in PWD regardless of the type of diabetes and the baseline A1C, age, or gender of the patient. These findings add to the growing evidence that diabetes telehealth holds promise in transforming diabetes care, particularly in parts of the world where the gap between diabetes burden and availability of diabetes clinics and specialists continues to widen. The

Acknowledgements

We would like to thank our patients with diabetes and acknowledge the valuable contribution of Ms. Heba alkhateeb from the Strategic Center for Diabetes Research and the diabetes educators (Aeshah Almutairi and Eman Mohamed) and dietitians (Sara Almuammar and Nouf Alzuaibi) from the Specialized Diabetes Clinic at King Saud University.

Disclosure

The authors report no conflict of interest in this work.

Funding

This research did not receive any specific grant from any funding agency in the public, commercial or

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  • Cited by (2)

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    Adjunct Assistant Professor, Division of Endocrinology, Diabetes & Metabolism, Johns Hopkins University, Baltimore, MD, USA

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