According to the WHO, older people and people with pre-existing conditions such as heart diseases, diabetes and respiratory conditions appear to be more susceptible to becoming severely ill with the COVID-19 virus. 

But why? To learn more about the links between diabetes and COVID-19 infection and mortality, WDF spoke with Dr Anil Kapur. A global expert in the field of diabetes, Dr Kapur has worked in the pharmaceutical industry and in the philanthropic sector, serving as WDF’s Managing Director from 2006-13. 

Dr Kapur is currently the Chairman of the WDF Board, as well as an advocate for improved diabetes prevention and care worldwide. We reached him at home in Bangalore, where he is riding out the pandemic.

What causes the higher risk of infection and poor outcomes that we’re seeing in people with diabetes and COVID-19?

There are two main issues. The first is primarily related to poor control of diabetes. People with poor control are relatively more vulnerable to acquiring any kind of infection because their immune system is compromised, and they are more likely to have poor outcome. This is true for regular flu, H1N1, TB, bacterial pneumonias; it was true during the SARs and MERs epidemic where the highest mortality was seen in people with diabetes as it is now with COVID-19. 
 
People with long-standing poorly controlled diabetes also have poor lung function. The lung membranes thicken hindering gas exchange. Also, oxygen binds more strongly to glycated haemoglobin so it is not released as easily for the tissues. 

People with poorly controlled diabetes are also likely to have underlying kidney and heart disease. When the whole body is under stress, the underlying sub-clinical pathology may unravel, leading to multiple organ system failure.  

Once severe infection sets in, diabetes control becomes difficult. The patient’s endocrine system is affected by stress and the counter-regulatory hormones, that the body releases in response to stress makes diabetes control difficult. The usual diabetes treatment regimen may have to be modified, requiring higher doses of medications or preferably addition of insulin. Sometimes insulin requirements become very high. 
 
These patients may develop secondary bacterial infection in the lungs – setting up a vicious cycle of severe, life-threatening lung inflammation and worsening diabetes control. 
 
What is the second issue?

The other problem may be related to the fact that many people with diabetes have hypertension and the most preferred antihypertensives in people with diabetes are angiotensin converting enzyme inhibitors (ACE inhibitors) or the angiotensin receptor blockers (ARBs). These drugs increase the level of Renin angiotensin which is believed to help the SARS-CoV-2 virus gain attachment in the respiratory system. 
 
How much this is responsible for the higher rate of COVID-19 in people with diabetes and hypertension and in their poor outcomes is not clear.

What can healthcare systems do to protect vulnerable patients from the virus, and treat those who are infected?

The critical thing is to ensure diabetes control and regular monitoring. 

People with diabetes who do not do home monitoring are particularly vulnerable. Access to health facilities may be restricted due to lockdowns and the fact that health facilities discourage routine visits - to avoid acquiring infection from the clinic visit. 

So the most critical priority for health authorities during this – or any – pandemic is to ensure that people with diabetes have access to care providers (even if remote) and ensuring diabetes supplies. 
 
What can the global NCD community, including WDF and our partners, do to support this? 
 
We need to highlight the higher risk of infection and poor outcome in people with diabetes with POOR CONTROL. People with poorly controlled diabetes who come in close contact with a COVID-19 carrier are at a relatively higher risk of acquiring infection compared to those who are well controlled, they are also at a much higher risk of complications.

We need to advocate for and support the availability of diabetes medications including insulin, as well as monitoring strips and equipment, despite lockdowns preferably delivered to the patients. 

Diabetes clinics and outpatient services need to have stringent infection control policies and only patients that require urgent medical services should be allowed to visit the clinic
 
We should also stress the importance of home monitoring and teleconsultation, so that patients can seek guidance from physicians on changes in medications and other topics.
  
Finally – and critically – we should raise awareness among people with diabetes about the importance of good control. Good self-care, always important for people with diabetes, is essential during a crisis. Together with social distancing, the use of face masks and hand washing, good diabetes control significantly reduces their risk for becoming severely ill.