Introduction
The coronavirus disease-2019 (COVID-19) pandemic, which is caused by the severe acute respiratory syndrome-coronavirus-2, originated in late 2019 in the People’s Republic of China (1). Within a matter of weeks, COVID-19 swiftly spread to nearly all nations, prompting the World Health Organization to classify it as a pandemic. Diabetes mellitus (DM), another global pandemic, is an important public health problem worldwide, with its increasing prevalence at the beginning of the 21st-century. The data in our country show that the number of patients with diabetes has doubled in ten years, and the prevalence of diabetes in adults reached a critical level of 13.4% in 2010 (2). The coexistence of these two pandemics results in a poor prognosis in these patients (3).
One of the measures taken worldwide during the pandemic is social distancing, which includes maintaining a safe distance from others, avoiding large gatherings, and limiting physical contact. This has resulted in the interruption of the daily routines of the populace. In a prospective cohort study involving 1,565 Dutch patients with cardiovascular disease, a significant decrease in the amount of time spent exercising was observed, whereas sedentary time increased during the lockdown period (4). According to a recent study conducted by Elliot et al. (5), the percentage of people meeting the recommended levels of physical activity decreased during the lockdown period, dropping from 43% to 33%. In a cross-sectional study conducted in the adult population of Israel during COVID-19 measures, it was found that 70% of Israelis reduced their training compared with their usual routine (6).
In our nation, from March 2020 until June 2021, a series of social distancing measures, including lockdowns, were implemented to mitigate the transmission of COVID-19. The objective of this study was to assess the effect of the lockdown period on the management of glycemic control in patients with type 2 DM.
Methods
Study Population
This retrospective, cross-sectional study was conducted at a single center in accordance with the principles of the Declaration of Helsinki. Approval for the study was obtained from the İstanbul Medeniyet University, Göztepe Training and Research Hospital Clinical Research Ethics Committee (approval number: 2021/0374, date: 30.06.2021).
The records of patients with type 2 DM who were under regular follow-up at our hospital’s obesity and diabetes outpatient clinic and who visited the clinic within the three months before the onset of the lockdown (visit 1) and within the two months following the beginning of the return to normalcy (visit 2) were retrospectively reviewed. The inclusion criteria comprised individuals who were 18 years of age or older and possessed comprehensive records of antidiabetic medication usage, anthropometric measurements, blood glucose levels, and HbA1C levels at both visits 1 and 2. Exclusion criteria included pregnancy or breastfeeding, diagnosis of malignancy, initiation of drugs affecting weight and body fat distribution (such as glucocorticoids), presence of critical illness that may impact nutritional status, and failure to attend regular follow-up after the lockdown. Eligible patients were consecutively included in the study.
Clinical Assessment
Patient data, including age, gender, height, body weight, treatment status, and results of full blood count and biochemical tests, were collected from the medical records of the obesity and diabetes clinic and the hospital’s electronic information system (Nucleus®).
Height and weight measurements were obtained using an height scale and automatic weight machine, and the body mass index (BMI) was calculated.
Laboratory examinations were conducted after an overnight fast of 8-12 hours, including fasting plasma glucose, HbA1C, triglycerides, and high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C). Complete blood counts were performed using venous blood samples on a Mindray BC-6800 (Mindray BioMedical Electronics Co., Ltd., Shenzhen, China) device. Thyroid function tests were performed using the Roche Cobas e801 (Roche Diagnostics, Basel, Switzerland) module.
Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) was calculated using the following equation: glucose (mg/dL) x insulin (mU/L)/405.
Statistical Analysis
Descriptive statistics, including mean, standard deviation, number, and percentage frequencies, were used to summarize the characteristics of the study participants. The normality of the continuous variables was assessed using the Kolmogorov-Smirnov test.
For the assessment of differences between dependent variables, the Wilcoxon signed-rank test was used. Statistical analysis was conducted using IBM SPSS Statistics 18 software. The significance level was set at 0.05 for all analyses.
Results
Of the 200 patients included in the study, 45 (22.5%) were male and 155 (77.5%) were female. The mean age of the patients was 55.2±10 years. The mean height of the patients was 161.1±8.3 cm, mean weight was 91.4±16.0 kg, and mean BMI was 35.3±6.2. Table 1 presents the demographic data and clinical characteristics of the patients. Among the participants, 78 (39%) had a history of hypertension, 57 (28.5%) had hyperlipidemia, 25 (12.5%) had hypothyroidism, and 4 (2%) had coronary artery disease.
During the lockdown (between visit 1 and 2), laboratory examinations indicated a significant increase in the mean fasting glucose levels from 136±43.1 mg/dL to 148.0±53.6 mg/dL (p=0.003). The HbA1C levels of the patients also showed a significant increase from 7.2±1.3 to 7.9±1.7 (p<0.001). Other parameters associated with metabolic syndrome were examined, revealing that the mean triglyceride level increased from 176±153 mg/dL to 190±133 mg/dL (p=0.001). No significant changes were observed in HOMA-IR and HDL cholesterol levels (p=0.171 and 0.889, respectively). Additional laboratory findings are presented in Table 2. The mean weight of the patients increased from 91.4±16.0 kg to 93.1±16.3 kg (p<0.001), leading to a significant increase in the mean BMI (p<0.001). Table 2 presents a comparison of patients’ anthropometric measurements between visits 1 and 2.
Discussion
Our study revealed significant increases in patients’ body weight, fasting blood glucose, HbA1C, and triglyceride levels during the post-lockdown examination compared with the pre-lockdown findings.
To mitigate the transmission of the COVID-19 infection, social distancing measures were implemented in our country and worldwide during the pandemic. Previous studies have investigated the influence of these measures, including lockdown, on changes in weight, which are of significant importance for cardiometabolic diseases. A population-based study involving 3,473 American adults revealed that 48% of participants reported weight gain one year after the pandemic, with a higher tendency for weight gain among those who were already overweight before the pandemic (7). Our study aligns with these findings because, we observed a significant increase in weight during the lockdown period. A recent meta-analysis, which evaluated data from 36 studies, also revealed a prevailing tendency for weight gain during lockdown (8).
Studies investigating changes in metabolic parameters and anthropometric measurements during the pandemic period suggest that the increase in body weight during this period is associated with sudden lifestyle changes. A study conducted in Spain demonstrated that type 2 diabetes patients experienced physical inactivity during house arrest (9). According to a survey study on house arrest during the pandemic period, daily sitting time increased from 5 to 8 h and eating quality worsened (10). Although our study did not specifically examine patients’ lifestyle changes, we excluded other factors such as medications and inflammatory processes that could contribute to weight change.
In our study, we found significant increases in patients’ fasting blood glucose, triglyceride, and HbA1C levels. Numerous studies investigating the course of diabetes during the pandemic have also reported impaired metabolic parameters. In a study, Karataş et al. (11) evaluated the impact of COVID-19 on patients with diabetes and healthy individuals. They found weight gain in both groups, impaired glucose metabolism, and increased triglyceride levels in patients with diabetes (11). The recently conducted meta-analysis demonstrated a significant increase (p<0.05) in HbA1C levels, fasting glucose, and BMI among patients with type 2 diabetes during the COVID-19 lockdown, which is consistent with our findings. Interestingly, they also found that total cholesterol, triglyceride, and LDL cholesterol levels were lower than those in the pre-lockdown period. Similarly, in our study, we observed a significant decrease in LDL cholesterol and total cholesterol, which could be attributed to improved adherence to statin medication during the pandemic period (12).
The management of chronic illnesses was interrupted during the pandemic period (13,14). In their study, Khader et al. (15) demonstrated that the disruption in diabetes care during the lockdown has contributed to the decline in glycemic control among patients with diabetes. However, in our country, the fact that medications could be obtained from pharmacies without the need for a prescription during the lockdown period and the examination of post-lockdown medical records revealed no decrease in medication adherence among patients, challenges the assumption that healthcare access difficulties are the primary cause. In a study with type 2 diabetes, significant improvement in medication adherence was observed during the lockdown period (16). A review by Eberle et al. (17), which investigated the effect of COVID-19 quarantine on glycemic control in patients with diabetes, observed significant improvement in glycemic values among individuals with type 1 diabetes during the quarantine period, attributed to compliance with insulin treatment and scheduled meals. Taking into account these combined findings, we are inclined to believe that the decline in glycemic control during this period is primarily a result of sudden lifestyle changes.
Study Limitations
The strength of our study lies in the detailed examination and exclusion of other factors that could contribute to weight changes and deterioration of glycemic control, apart from lifestyle changes. However, there are some limitations to our study. First, since it was conducted in a single diabetes center with a homogeneous population, the findings may not be applicable to different populations. Second, we did not have information regarding whether patients continued their active work life during the lockdown, engaged in exercise, or had any dietary habits. Therefore, our study did not specifically investigate which lifestyle changes were more closely associated with a deterioration in glycemic control, such as alterations in diet quality, adherence to dietary recommendations, meal timings, frequency of snacking, consumption of ready-made meals, frequency of ordering food from external sources, fruit consumption, alcohol consumption, exercise duration and frequency, and the duration of time spent at home. Finally, upon reviewing the patient files during post-lockdown visits, although all patients indicated that they obtained their medications from the pharmacy during the lockdown period, we do not have any data to confirm whether they consistently used their medications.
Conclusion
Our findings indicate that during the lockdown period implemented because of the COVID-19 pandemic, there was a tendency for diabetes patients to gain weight and experience deterioration in glycemic control. The reason behind this is the sudden lifestyle changes resulting from the restrictions, and these results confirm the role of lifestyle recommendations in disease management for patients with diabetes.
Ethics Committee Approval: Approval for the study was obtained from the İstanbul Medeniyet University, Göztepe Training and Research Hospital Clinical Research Ethics Committee (approval number: 2021/0374, date: 30.06.2021).
Informed Consent: Retrospective study.
Peer-review: Internally peer-reviewed.
Authorship Contributions: Surgical and Medical Practices - F.B.D., M.T., Ö.D.; Concept - F.B.D., M.T., C.T.; Design - F.B.D., M.T., Ö.D.; Data Collection or Processing - F.B.D., M.T., Ö.D., C.T.; Analysis or Interpretation - F.B.D., M.T., Ö.D., C.T.; Literature Search - F.B.D., M.T., Ö.D., C.T.; Writing - F.B.D., C.T.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study received no financial support.