Explained: Why Patients With Uncontrolled Diabetes Can Contract Severe COVID-19

Patients with uncontrolled diabetes are at a greater risk of contracting a severe form of COVID-19 as well as mucormycosis.

Patients with uncontrolled diabetes are at a greater risk of contracting a severe form of COVID-19 as well as mucormycosis, according to Dr Nikhil Tandon.

After China, India has the highest number of diabetics in the world with 74 million diabetes patients with studies showing that close to 50% of people have diabetes and aren't aware of it. With severe diabetes and mucormycosis being associated with patients with diabetes, Dr Tandon, Professor and Head of Endocrinology at the All India Institute of Medical Sciences in New Delhi believes that the COVID-19 mortality risk for diabetics is 200 percent.

"What we have acquired as knowledge over the last year seems to indicate that if you have diabetes, especially, if it is long-standing, uncontrolled and if it is associated with complications, the odds are that if you do catch COVID-19, you are going to have a more severe form of disease. You will possibly more often than not require hospitalisation; you may require oxygen, you may require ventilation and you have a higher propensity to mortality," Dr Tandon told BOOM.

Dr Tandon urged diabetics to keep their condition under control so as to avoid contracting a severe COVID-19 infection and give physicians a fighting chance in beating the disease.

"With COVID-19 to contend with, it (diabetes control) becomes extremely important because if you arrive at the hospital with poor control, we cannot undo that prior period of poor control. So, the ravages of poor control are now established within your system and we will have to combat those along with COVID and it makes life very very difficult for the medical healthcare provider," Dr Tandon said.

Edited excerpts follow

Govindraj Ethiraj: How has diabetes played a role in making the COVID-19 pandemic worse for India?

Dr Nikhil Tandon: Let me start with a small anecdote so that you can understand how things have evolved. In the early part of the 20th century, there was an editorial in The Lancet that what is gout to the aristocracy of Britain, diabetes is to the aristocracy of India. Suggesting that this was a disease that was only restricted to those who were affluent and rich. 100 years from then and diabetes pervades everybody.

So, the first thing we must understand is that it is not merely genetic. Clearly, we carried the same gene pool 100 years ago as we are now. There is a lot of environmental influence and there is a lot of gene environment interaction possibly happening out there.

What has this done to us, and you have given some astounding numbers and that is a reality.

A lot of people have diabetes. But the other point which you raise is equally important to understand. There is a generally held rule of halves for all chronic asymptomatic or under symptomatic diseases: If for every 100 who have the disease only 50 know about it. Give or take a few percent.

And that means half of the people who have diabetes are unaware of this fact, and half of those who actually know they have diabetes, actually seek suitable medical attention. So, we are already down to 25%, and only half of those keep things within control.

So, 1 out of 8 people with diabetes are actually meeting the targets for control, whether it is their sugar, blood pressure or cholesterol or a combination thereof, which clearly predisposes them to a set of potentially irreversible complications. And given the fact that this happens at a relatively younger age, in an economically productive age, that means it has a huge impact on the individual, on the family, on the society and the nation in terms of its economic impact.

If everything has to be translated into rupees and dollars, it is a massive influence on that. This is an unfortunately sad evolution of a saga restricted to a small minority to now being all pervasive.

GE: As you look at what you have been seeing the last one year, how would you categorise the role of diabetes in the severity of infections, in the severity of illnesses patients who have come to you and who, perhaps, did not make it out?

NT: What we have acquired as knowledge over the last year seems to indicate that if you have diabetes, especially, if it is long standing, uncontrolled and if it is associated with complications, the odds are that if you do catch COVID, you are going to have a more severe form of disease; you will possibly more often than not require hospitalisation; you may require oxygen, you may require ventilation and you have a higher propensity to mortality.

So, it clearly has a significant (impact). It is not like mortality risk increases by 10% or 20% We are saying that it is a doubling of mortality risk. It is at 200%.

But I am specifying here that --there are actually a lot of people who have well controlled diabetes--they should not be really as worried because well controlled, short duration diabetes actually do not do that badly. It is only the ones who have had it for a long time, their bodies had to face the onslaught of diabetes for a long time and they have left it uncontrolled, for whatever reasons, they are definitely at a high risk for adverse clinical outcomes.

GE: Why is it that we have such high incidences of diabetes in our country and why is it more pervasive today than it was maybe some years or decades ago?

NT: I am again going to share a small sort of vignette. There was this study done, which was called the Indian Migration Study, which actually went through all the industrial workers, therefore currently urban. But they identified those who had actually migrated from a rural background and who had a sibling approximately in the same age band. And did a whole bunch of investigations including looking at whether diabetes prevalence, blood pressure, cholesterol, etc.

And if you have a brother back in the village there is a likelihood that you will carry very very similar genes. But the odds of diabetes and cardi-vascular risk factors in those who have migrated was maybe twice as much as those who had stayed back in the village.

So, the same gene pool but a very different environment. So, urbanisation and industrialisation that takes away from certain activities of daily living that previously people used to do. So, you know in India, when you talk of physical activity, which is a very important part in preventing chronic non-communicable disease, we were usually involved in work-related physical activity. Leisure time physical activity is not a common construct or a normal part of life.

So, a lot of people who were doing large amounts of work-related physical activity have now ceased to do that, we have changed our dietary pattern, urban stresses have come into play.

All of these and as a result has led to an increase in body fat, whether generalised in terms of overall weight gain, or regional in terms of a lot of fat around the belly. Which is again metabolically very bad fat.

So, I think all of these are contributing factors, whether they are the only explanation, I do not know. Whether the genes are interacting within an environmental queue/cue, or whether the genes are getting triggered to do things which they would not have done in the absence of the environmental clue, we can speculate.

GE: We are seeing a lot of mortality now in rural India as well--particularly in the second wave. Is there any correlation with diabetes here?

NT: I do not think we have the data yet. I mean capturing data on cause of death is a complex story. I do not think we are really equipped to answer. But I think this a very good question to ask and hopefully time will give us the answer to that.

GE: The number of cases is coming down. But we are all in some ways mentally or otherwise preparing for a third wave. What is your sense? What should people do if they have to be better equipped? Immunity is a very general term. For those who have already been diagnosed as diabetic, could they be doing something? If you are not diagnosed as diabetic, what could you be doing? And how could you be better prepared to at least reduce the chances of a severe infection were you to get it?

NT: So, a quick comment about the third wave. Historically, a lot of pandemics have had multiple waves. So, it will not be inappropriate to keep that and be prepared for it. Being over prepared for a situation like that cannot be a bad thing.

And then of course, the preparedness has to be at the level of the individual, at the level of the community, at the level of the administrative or governance issue; that is a broad statement.

If you want to narrow this down for people with diabetes or at risk for diabetes, I think what is very clear to us is that you need to be very well controlled. And COVID is maybe just one more additional reason to make the case for good control. I mean even if there was no COVID, we would still make a case for good control because you reduce the likelihood of kidney disease, reduce the likelihood of heart disease, reduce the likelihood of retinal blindness, I mean there is a lot of good that happens by keeping your diabetes under control.

And I am not just talking of sugar at the moment. Diabetes in the broader perspective of glucose control, blood pressure control and lipid control and the cessation of tobacco, as a whole package. And that is very very important to us, if there was no COVID to contend with.

With COVID to contend with, it becomes extremely important because if you arrive at the hospital with poor control, we cannot undo that prior period of poor control. So, the ravages of poor control are now established within your system and we will have to combat those along with COVID and it makes life very very difficult for the medical healthcare provider.

So extreme precautions, be careful, be cognizant and there is a need for periodic screening for a known non-diabetic population. You can do it once a year or once a couple of years because as you said there is a very high proportion of people who have diabetes.

So why is everybody assuming that they are in it 'we do not have it' category. They should test and reassure themselves or test and if they find it address the problem.

GE: And that is only like a simple blood test. It is not like a very challenging RT-PCR test which is also becoming much easier now…

NT: Absolutely not. And remember, the Government has programmed the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular diseases and Stroke. And under that programme, there is a provision for universal screening for diabetes and blood pressure.

Obviously urban communities can do a lot of this on their own. Semi urban or rural communities have that provision in Government settings that they will be screened for this even as low as a sub-centre level. You know sub-centre is an entity that is located at the level of a village. So, there is that provision and people should make use of it.

GE: Dr. Tandon what do you advise diabetic patients to do in peacetime?

NT: So, I actually am very fond of that word, peacetime. Thank you for using it. It's really, I think we need to do peacetime preparedness so that we can combat the wars better, that is very clear.

So, what does a diabetic, a person with diabetes need to do? You should get screened so that you know whether you have it or you don't have it. Secondly, if you have it, what are the three or four pillars of care? Obviously, diet and physical activity for me are the two foundation interventions, right? You can't eat wrongly and be sedentary and say I am going to pop a pill and expect that is going to do magic. It won't do magic and diet is, in broad principles again, quantity, quality, timing and spacing, right?

So now having diabetes, not eating the wrong stuff, ensuring that there is adequate spacing between meals and don't eat at funny hours. Just do your standard thing; odd hours, bunching of meals, long separation, not good. Physical activity, whatever works for you in your condition, at your age. Half an hour of walk a day, medication in consultation with a medical professional, right and then monitoring.

You know, there are people saying "Doc, why are you getting upset that we have not come to you for three years, we are taking your medicine?" I said, well, that medicine was pertinent three years ago, whether it's still doing its job, I don't know, unless you get periodic check-ups. These four things are mandatory for peacetime diabetes management.

GE: Many of us are getting vaccinated, so that reduces the chance of getting severely affected. If I know today that I have diabetes and whether I get a vaccine or not obviously the probability of the infection getting worse is high. What can I do today to essentially prevent from becoming a Covid patient at any level tomorrow?

NT: So, if everybody else is taking a hundred percent precautions, you take hundred and twenty percent precautions, right? So, there's no letting up. In cricketing parlance, I keep saying, you know, the batsman has to be lucky with every ball, the bowler has to be lucky only once, right?

So, you can be very good with your precautions and you let your guard down once, it may be that one unfortunate moment when you get access, the virus gets access to you. So, we need to be extremely stringent and we assume that we're doing the right stuff but you know simple things like wearing a mask properly and ensuring that it fits well around the nose and the mouth is something, washing our hands, keeping distance; sitting together and eating meals, not a great idea. So, all of that needs to be done.

Clearly, try and get vaccinated. I know there are challenges, there have been issues about, availability, etc., but you know whatever you can do at least go and put your name on the app, right? There is no problem with that.

You must get vaccinated because it does reduce, it'll reduce your odds of getting severe disease, it reduces the chance of hospitalization, reduces the chance of mortality. So, I see there's no downside in getting vaccinated and that everybody should do.

People with diabetes should do much more and they should not say, 'oh, there's COVID-19, I couldn't do this, I have got something else, I'll stop this medicine.' Please don't, continue the medicines and make whatever effort possible to monitor, so that at least, you know, you are well controlled and if you are not well controlled, you need to reach out to your doctor and take their guidance to get well controlled.

A small message to physician colleagues - If a patient comes into the hospital with diabetes and you ask them and say, do you have diabetes and sorry, comes in with COVID-19 and you ask if they have diabetes and they say, no, it doesn't make a difference. Still measure their sugars because there will be a strong chance that they may come out because COVID-19 can unmask diabetes, and even if they are not diabetic, or the sugars are normal on the day of arrival, if their disease takes a turn for the worse or they are given steroids as a necessary treatment, their sugars can get worse even then. So that must be looked at. You must measure, so that, you know, what is to be done.

GE: If you were to look back at the last one year and look at the way the disease has progressed across the first wave and the way it's progressing across the second wave, what in your mind should we be aware of or looking out for, particularly, in terms of the propensity to get infected or for that infection to get worse?

NT: So, when we look at factors, we broadly categorize them into two things, which are modifiable and things which are non-modifiable right. In terms of one of the important things, which is emerging, I am sure data will again emerge, is that there seem to be new variants of concern, which have come in with this particular wave.

Now, clearly that is beyond the control of an individual, right and these variants, it appears may have been responsible for this rather dramatic, I mean, everybody said, there would be a second wave, but I don't think, you know, the force of the storm was really anticipated with the same extent and not merely the total burden, but the rapidity with which we vaccinate people.

So, it just swamped the system but that is non-modifiable as an individual right. In terms of individuals, what is becoming clearer and maybe a quick word about the new concern, which is coming up with this Mucormycosis. Virtually all the people are getting mucor today are those who had COVID-19 and nearly all, if not all, ninety plus percentage is happening in those with diabetes, which is uncontrolled, right? So fine, we can't do anything about variants of concern, but you can definitely do something about diabetes.

The third thing which, as you also spoke in the beginning was, you know, a thing which needs to be looked at more carefully is whether the steroids have contributed to this and doctors obviously will have to adhere to guidelines but what is also happening is a bunch of self-prescriptions.

My neighbour got some things, so I would also take that same something, it might just help, not realizing that a lot of these drugs, while they may be good, have defined times duration and doses and must be taken under medical supervision and not extrapolated from a neighbour's experience. So, I think these are the three things which are important for us at this point in time.

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