SUDANESE JOURNAL OF PAEDIATRICS

2023; Vol 23, Issue No. 2

ORIGINAL ARTICLE

Impact of lockdown during COVID-19 on glycaemic control in children with type 1 diabetes mellitus following at diabetes clinic, Omdurman, Sudan

Sara Ahmed Elrheima (1), Omer Osman Babiker (2)

(1) Pediatric Specialist, Ahmed Gasim Teaching Hospital, Khartoum, Sudan

(2) Consultant Paediatric Endocrinologist, Omdurman Teaching Hospital, Omdurman, Sudan

Correspondence to:

Sara Ahmed Elrheima

Ahmed Gasim Teaching Hospital, Khartoum, Sudan.

Email: Sara.ahmed09036 [at] gmail.com

Received: 03 December 2022 | Accepted: 26 March 2023

How to cite this article:

Elrheima SA, Babiker OO. Impact of lockdown during COVID-19 on glycaemic control in children with type 1 diabetes mellitus following at diabetes clinic, Omdurman, Sudan. Sudan J Paediatr. 2023;23(2):163–170.

https://doi.org/10.24911/SJP.106-1670090324

ABSTRACT

Corona Virus Disease-2019 (COVID-19) is a novel pandemic disease. There have been many challenges for diabetic patients, which might have resulted in an increased risk of complications and significant lifestyle changes, including physical inactivity and psychological distress. This study evaluated the effects of lockdown on paediatric patients with type 1 diabetic mellitus (T1DM) in terms of acute metabolic complications and psychological deterioration. A questionnaire-based cross-sectional study was conducted between November 2020 and February 2021 at Mohammed Alamin Hamid Diabetic Clinic, Omdurman, Sudan. Data was collected from direct interviews with patients and their caregivers. Out of 208 children with T1DM aged from 1–18 years, 48.1% had persistent hyperglycaemia, and 20.6% had hypoglycaemia. Insulin doses were missed in 20.2% of them, glucose monitoring was not done in 28.8%, and 20.6% reported decreased physical activity during the lockdown. Mean HbA1c levels were the same in pre and post-lockdown periods. There was an insignificant relationship between physical activity, dietary changes, and glycaemic control (p values=0.519 and 0.146, respectively). On the other hand, there was a significant weak positive correlation between psychological and behavioural disorders such as aggression, anxiety, isolation, and glycaemic control (p-value=0.032, 0.002, and <0.0001; r=0.115, 0.135, and 0.169, respectively). The negative impact of the COVID-19 lockdown found on blood glucose measures and psychological status may correlate with glucose monitoring equipment shortage, lifestyle changes, and mood deterioration.

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KEYWORDS

COVID-19; Type 1 diabetes mellitus; Lockdown; Children; Sudan.

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INTRODUCTION

The first case of coronavirus disease Severe Acute Respiratory Syndrome of Corona Virus-2 (SARS-CoV-2) was reported in China in December 2019 [1]. The viral transmission rate was high despite measures to control it in this country, and the World Health Organization (WHO) declared it a pandemic on the 11th of March 2020 [2]. Although reports suggest high mortality in adults with diabetes [3], none indicated that children with type 1 diabetes mellitus (T1DM) are more severely affected than non-diabetics. Nevertheless, the International Society for Paediatric and Adolescent Diabetes (ISPAD) has established continuous care during a pandemic to avoid hospitalization [4].

In Sudan, the first case was reported on 13th March 2020. The government has implemented preventive measures during the pandemic, such as partial lockdown, social distancing, and isolation, to decrease the spread of the virus [5]. The complete lockdown was started on the 13th of April and continued till the third of July 2020; during this period, hospitals closed their outpatient services and delayed non-urgent healthcare activities. These measures led to a reduction in newly infected cases [5].

T1DM is one of the most significant chronic diseases targeting children and adolescents worldwide [6]. The Sudanese Childhood Diabetes Association has established more than 25 clinics in all states of Sudan with comprehensive teams. Mohamed Alamin Hamid is one of these clinics [7].

Tight glycaemic control is considered an essential strategy to prevent chronic complications in patients with T1DM, achieved by Insulin use and regular monitoring of glucose level and haemoglobin A1c (HbA1c). During the lockdown, people stayed in their homes, resulting in a change in the individual’s physical activity, dietary patterns, and psychological status. All of these can affect glucose control in patients with diabetes. Also, the lockdown has affected the availability of treatment facilities for patients [8,9].

Although the impact of corona virus disease-2019 (COVID-19) on general health has been reported in various studies, there is a lack of literature on the effect of lockdown on the management of patients with chronic illnesses like diabetes in Sub-Saharan countries.

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MATERIALS AND METHODS

This study was a retrospective, cross-sectional study on children with T1DM, conducted at Mohamed Alamin Hamid Hospital Diabetes Clinic in Omdurman, Sudan, between November 2020 and February 2021. Demographic and clinical data were collected, including insulin administration and types of insulin. Hypoglycaemic and hyperglycaemic episode data were collected depending on the recall method. Blood glucose <70 mg/dl was considered hypoglycaemia [10]. On the other hand, persistent hyperglycaemia is considered when the blood glucose level is >400 mg/dl for >3 consecutive days. HbA1c results of the pre-and post-lockdown phase were taken from patients’ records and analysed with paired sample t-tests (data taken only for those who have pre-lockdown and immediately post-lockdown results). Data regarding dietary habits was obtained by asking about the number of meals and types of diet. Psychological data collected and classified depended on parents’ consideration. Only those >5 years were included in the assessments. All children and adolescents with T1DM aged 1–18 years who have had diabetes for more than one year, of gender and all ethnicity were included. Patients with non-type 1diabetes, chronic complications were excluded.

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RESULTS

51.4% of the participants were males. The minimum and maximum age of enrolled patients was between 1 and 18 years, with a mean age group between 10–15 years. Most of the children’s families (138%, 66.3%) were self-employed, 10 (4.8%) were unemployed, and only 60 (28.8%) had family income from fixed jobs. The mean duration of diabetes was 4.59 ± 3.349 years. Associated celiac disease was present in 17 (8.2%) patients, and hypothyroidism in 6 (2.9%) patients. A total of 197 (86.1%) used premixed insulin, while none used insulin pumps (Table 1).

During the lockdown, blood glucose monitoring was not performed by 60 (28.8%) and was due to shortage of strips in 40 (66.6%), and the average analysis per week was 3 ± 1 times. Insulin doses were missed in 42 (20.2%) patients; half of them due to the unavailability of insulin. Of the participants 48.1% had persistent hyperglycaemia, and 43 (20.6%) had hypoglycaemia. The study revealed that 35 (16.8%) children needed hospital admission and in 15 (7.2%) of them for diabetic ketoacidosis (DKA) management. Non-COVID febrile illness (malaria, upper respiratory tract infection) has led to hospital admission in 5 (2.4%) patients, whereas 4 (1.9%) were admitted for severe hypoglycaemia management (Table 2).

Table 1. Distribution of study participants according to clinical data.

Parameter	Number (%)
Insulin regimen Multiple daily injection (MDI) Twice daily Intermediate acting + short acting Insulin pump	21 (10.1) 179 (86.1) 8 (3.8) 0 (0)
Insulin administration Parents Self Both Others	31 (14.9) 116 (55.8) 53 (25.5) 8 (3.8)
Associated illnesses Celiac disease Hypothyroidism Asthma	17 (8.2) 6 (2.9) 1(0.5)

Regarding celiac patients, 82% developed persistent hyperglycaemia, and only 23.5% had hypoglycaemia, even though there was no significant difference in their mean HbA1c value before and after lockdown (p-value=0.62).

Independent paired t-test analysis showed that the mean HbA1c of pre-lockdown and post-lockdown phases were 9.42% ± 2.5% and 9.42% ± 2.4%, respectively, and the difference was not statistically significant (p-value=0.981).

About half (51%) of these children reported that their diet had been affected during the lockdown. Despite most of the patients consumed the same number of meals per day before and during the lockdown, 12 (5.8%) revealed a decrease in the number of meals, and 50 (24%) experienced a reduction in meal content with no relation between dietary changes during the lockdown and glycaemic control (p-value=0.146) (Table 3).

During the lockdown, we observed a decrease in daily physical activity in 43 (20.6%) of the children; nearly half, 20 (46.5%) of them were from the early teen group (10–15) years, with significant relation between decreased physical activity and the age of the patients (p-value=0.049) (Table 3).

We noticed marked behavioural changes in those above 5 years of age in the form of aggression, anxiety, and isolation; 65 (33%), 67 (34%), and 42 (21.3%), respectively. ANOVA analysis revealed non-significant differences between the age groups for isolation, anxiety, and aggression during the lockdown period (p-value=0.345, 0.332, and 0.651) but a significant positive relationship between the above variables and glycaemic control (p-value=<0.0001, 0.002, and 0.032, respectively) (Table 3).

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DISCUSSION

Since the lockdown began, several studies have been published about its effect on diabetic patients and their families [11,12], unfortunately, minimal studies have been published from Africa. This study demonstrates an association between lockdown and poor glycaemic control of T1DM patients in Sudan. Furthermore, it also provides a positive association between glycaemic control and some behavioural changes (anxiety, isolation, and aggression).

There were no hospital admissions due to COVID-19 infections during the lockdown period among participants, which is similar to the survey done across different countries, which showed that hospitalizations due to severe COVID-19 manifestations in children practically were absent [13]. This is also in concordance to reports from paediatric endocrinology colleagues in Wuhan, China, and Italy who stated that they have not had cases of COVID-19 in children or adolescents with Diabetes who needed hospitalization [14].

Table 2. Distribution of study participants according to the impact of lockdown on parameters related to glycaemic control.

Parameter	Number (%)
Number of patients having hypoglycaemia	43 (20.6)
Number of patients having persistent hyperglycaemia	100 (48.1)
Home blood glucose monitoring during lockdown Yes No	148 (71.2) 68 (28.8)
Insulin dose missing during lockdown Yes No	42 (20.2) 166 (79.8)
Hospital admission during lockdown DKA Hyperglycaemia Severe hypoglycaemia COVID-19 infection Febrile illnesses Others	35 (16.8) 15 (7.2) 10 (4.8) 4 (1.9) 0 (0) 5 (2.4) 1 (0.5)
Dietary changes during the lockdown Decrease in meals content Decrease in meals number Increase in carbohydrates use Increase in sweets use Others Unchanged	50 (24%) 12 (5.8%) 11 (5.3%) 4 (1.9%) 29 (13.9%) 102 (49%)

During lockdown patients faced difficulties in attending their follow-up visits and many cancelled visits. In our survey, 44.2% of participants, irrespective of localities, needed help to follow up with doctors. With global restrictions set in order to contain the spread of the virus, COVID-19 phobia, and financial constraints played vital roles in the disruption of diabetes care in low-income countries [15].

Several other reasons may stand behind the poor glycaemic control of those children, such as illiteracy among parents. Nevertheless, poor glycaemic control in diabetic children during the pandemic, especially in low resources countries, may increase the risk of diabetic microvascular complications in the future and reduce their quality of life [16]. Despite poor glycaemic control before the lockdown period (9.24% ± 2.5%), the difference in HbA1c in the pre- and post-lockdown phase was insignificant. Verma et al. [12] in a study from India showed a significant deterioration in HbA1c after the lockdown period (8.8% ± 1.3% vs. 10% ± 1.5%). In agreement with this study, a study in Saudi Arabia conducted between April and June 2020 reported no significant difference in HbA1c before and after the lockdown period (7.45 ± 1.67 vs. 7.40 ± 1.54) [17].

Contrary to the present study, a study done in Italy in May 2020 revealed improvement in glycaemic control without any outpatient visits, and severe hypoglycaemic and DKA events were never reported during the two periods. They were probably due to sharing glucose data through glucose monitoring devices and telemedicine [18].

Discrepancies in health have been exacerbated during the pandemic mainly due to poor socioeconomic status that existed before the pandemic, as many parents were self-employed (66.3%) and earned less during the lockdown. Of the participants, 28.8% did not monitor their blood glucose. In most of them this due to the unavailability of strips which negatively impacted diabetes management, including acute metabolic complications. Of our study participants 1.9% were admitted with hypoglycaemia, 4.8% with hyperglycaemia, and 7.2% with DKA. Our results are higher in comparison to those from Jordon [11], primarily due to the implementation of Telehealth and its use in providing communication between patients and medical care particularly in dose adjustments and medical advice, in addition to facilitating means of accessibility to insulin supply.

The current COVID-19 pandemic provided an incentive to expand the use of telemedicine for patients with diabetes [19]. Africa’s telecommunication infrastructure is still lacking behind due to the long history of wars that set economies back from developed countries. Regarding North African countries, there is a reduced number of relevant articles regarding the development of telemedicine and electronic Health [20,21].

Table 3. Study characteristics and relation to post-lockdown haemoglobin Ac1(HbA1c).

Parameter	Number (%)	Mean HbA1c (%)	SD (±)	p-value
Physical activity during lockdown
Decrease	43 (20.6)	9.7	2.5	0.519
Increase	13 (5.8)	8.2	1.8
Unchanged	153 (73.6)	9.5	2.6
Dietary change during lockdown
Decrease in contents of meals	50 (24.0)	9.23	2.72	0.146
Decrease in the number of meals	12 (5.8)	8.73	2.55
Unchanged	102 (49)	9.5	2.6
Aggression
No	132 (67)	9.7	2.8
Yes	65 (33)	9.2	2.5	0.032*
Anxiety
No	130 (66)	9.7	2.8
Yes	67 (34)	9.3	2.7	0.002*
Isolation and lack of interest
No	155 (78.7)	9.5	2.6
Yes	42 (21.3)	9.5	3.2	<0.000*

*Significant.

HbA1c, haemoglobin Ac1; SD, standard deviation.

Lockdown policies in the current pandemic have significantly affected people’s daily routines, including their level of physical activity. This showed a significant decrease in 20.6% of our patients during the lockdown compared to before, especially among older children (ages 10–15 years). This change was a function of sedentary habits, namely watching TV and using phones. This was similar to a study done in the USA in May 2020, which reported a profound impact on physical activity and increases in a sedentary life, especially among older children (ages 9–13) [22].

Evidence shows that a large number of paediatric patients, especially diabetic adolescents, experience a greater incidence of disease-related impairment of quality of life, depression, anxiety, and other psychological states in comparison to non-diabetic peers [23]. This study showed the direct impact of the pandemic on participants’ mental health. Near third of participants became aggressive and anxious, and (21.3%) felt lonely. These results are similar to those from European countries (Italy and Spain) published in November 2020 by Orgilés et al. [8] in children between (3–18) years, which revealed that 28.4% of them became more anxious, 38% were nervous, and 31.3% of them were isolated.

Children and young people with chronic poor metabolic control, including recurrent DKA, are more likely to have underlying psychosocial problems or psychiatric disorders than children with reasonable metabolic control [24]. The present study revealed a significant but weakly positive correlation between psychological and behavioural disorders (isolation, anxiety, and aggression) and glycaemic control (p-value=<0.0001, 0.002, 0.032; and r=0.135, 0.169, 0.115, respectively). This result was inconsistent with a study conducted in Dallas in 2005, which reported an increased risk for hospitalization for disease complications in those who show high levels of depressive symptoms and a negative impact on glycaemic control [25]. Results from the SEARCH study in the USA by Ruggiero et al. [26], found that 14% of adolescents with diabetes reported mild depression, and 8.6% reported moderate to severe depression. Depression was associated with poorer glycaemic control and increased diabetes-related hospitalization. This was not the case in the present study and may be attributed to the lack of formal assessments for depression in our study participants [26].

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CONCLUSION

Our study is one among the very few studies from Africa on the negative impact of the COVID-19 lockdown on T1DM management. We concluded that despite no significant change in HbA1c levels yet there was a significant effect on diabetic care, in the form of a decrease in glucose self-monitoring, an increase in missed insulin doses, and frequent hospitalization due to acute metabolic complications. We also showed a significant association between psychological impacts and glycaemic control. Our findings highlight the importance of more studies on the impact of COVID-19 lockdown on diabetic children, needed in particular from resource-limited countries.

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RECOMMENDATIONS

We recommend sharing the contact numbers of insulin and glucose meter stripes manufacturers’ nodal person to facilitate the resolution of shortage problems.

To dedicate a helpline number (HOTLINE), supported by diabetes educators, available to provide solutions to day-to-day problems.

Children and adolescents and their families should be educated frequently through online videos shared through social media about the symptoms and management of hypoglycaemia and DKA.

Mental health professionals should be available to interact with patients and families at clinic visits to conduct screening and more complete assessments of psychosocial functioning and help recognize and manage mental health and behaviour problems.

Providing medical, financial, and social support for diabetic children and their families.

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ACKNOWLEDGEMENT

The authors would like to thank Dr. Maaza for her assistance in data collection.

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CONFLICT OF INTEREST

The authors declare that they have no financial interests that could have affected the work reported in this paper.

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FUNDING

None.

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ETHICAL APPROVAL

The study was approved by the Sudan Medical Specialization Board Ethical Committee and the hospital’s authority under the survey. Informed consent was obtained from the patient’s parents before they participated in the study.

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