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7IMPACT OF COVID-19 SOCIAL ISOLATION ON CARDIOVASCULAR OUTCOMES IN MIDDLE-AGED PATIENTS WITH DIABETES
IN ADJARA, GEORGIA
LIANA JASHI, RUSUDAN KVANCHAKHADZE, DAVID AGMASHENEBELI, TAMAR PESHKOVA, KETEVAN DUNDUA, TAMAR SHERVASHIDZE,
Batumi, Georgia
Abstract:
Introduction Diabetes mellitus is a common non-communicable disease, ranking fourth in mortality after cardiovascular diseases, cancer, and chronic respiratory diseases. During COVID-19, diabetic patients had a higher mortality rate. A study in Georgia assessed metabolic control and complications during isolation from COVID-19. The study aimed to provide insight into diabetes management during the pandemic.
Methods. A cross-sectional study was conducted using a special questionnaire for doctors and patients. The sample size for patients was calculated based on the disease prevalence in the country, and only those under 65 years of age were included. 276 doctors and 742 patients participated in the study. Descriptive statistics were used, and a single-sample chi-square test was used to determine statistical significance with p < 0.05 as the cutoff point.
Results: A comparison between doctors and patients reveals that under conditions of social isolation, both groups exhibit similar levels of unmeasured sugar at 29.1% and 31.2%, respectively, while unmeasured blood pressure levels are 9.3% for doctors versus 23% for patients. Also, most patients were "not tested", and doctors "did not ask" about glycated hemoglobin 59.5% versus 40.6% and cholesterol levels 36.1% versus 15.7%. The following drugs were most commonly prescribed: Metformin, sulfonylurea, and a combination of insultard and actrapide.. Both groups experienced cardiovascular complications, with hypertension being the most common. Approximately 17% of patients were hospitalized due to heart disease.
Conclusions: Social isolation has reduced sugar levels and blood pressure self-control due to limited access to face-to-face medical consultations. Incorrect control of cholesterol and glycated hemoglobin and insufficient prescription of new sugar-lowering drugs increases the incidence of cardiovascular complications.
Keywords: Social isolation, COVID-19, Diabetes mellitus, Blood Pressure, Blood Glucose, CVD (cardiovascular complications)
Introduction:
The COVID-19 pandemic, declared by the WHO in 2019, is considered the biggest challenge the world has faced [1]. The rapid spread of the virus and the disease resulting from viral infection have profoundly changed people's lives and their personal relationships. Due to the COVID-19 pandemic posing a serious threat, social distancing and isolation have been recognized as reliable and effective measures to mitigate the virus spread, which has been well demonstrated in China [2] since these measurements lasted over time, short-term and long-term secondary damages amidst social isolation should be taken into account when assessing the risk.
Before the COVID-19 pandemic, loneliness and social isolation were so prevalent in Europe, the United States, and China (10-40%) [3,4] that they were described as a "behavioral epidemic" [5]. Loneliness is associated with a variety of physical and mental health issues, including an increase in systolic blood pressure and an increased risk of heart disease. Both loneliness and social isolation are associated with an increased risk of death from coronary heart disease, even in middle-aged adults who have not had a history of myocardial infarction [6, 7]. To prevent the spread of the virus during the COVID-19 pandemic, most countries of the world went into quarantine and isolation, which included staying at home, curfew, sanitary and social restrictions. [8,9] According to a meta-analysis
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conducted in China, the prevalence of diabetes among patients infected with COVID-19 was 9.7%, [10] corresponding to the total incidence. Another study comparing mortality in diabetic and non-diabetic patients found that people with diabetes have a higher risk of developing cardiovascular disease [11]. During the Covid-19 pandemic, diabetes was one of the leading causes of death in infected patients. [12] Therefore, its proper treatment and prevention of complications are very important.
In particular, the mortality rate from COVID-19 in China was - 7.8% - 2.7%, the United States - 28.8% - 6.2%, England 31.4% - 14.4% and Russia - 15.2%, respectively [13-14].
In 2022, the ADA and EASD updated the treatment of hyperglycemia in diabetes. Along with the study of glycemia and glycosyl hemoglobin, blood pressure, and cholesterol control and using guidelines, choosing pharmacology medications is essential, but also crucial nonpharmaceutical prevention, such as diet, physical activity, and sleep quality. [15]. A deterioration of metabolic parameters in patients with diabetes mellitus was observed in countries with low socioeconomic development [16] [17], while in highly developed countries, there tends to be an improvement. The study conducted on 63 diabetic patients in Italy amidst isolation reported improvements in metabolic parameters [18] [19] Another large review describing the frequency of experiencing loneliness and the emotional status of the patients has been published by the "Nordic study group" (Denmark, Finland, Sweden, Iceland). [20]
Georgia reported its first COVID-19 case in Feb 2020, leading to multiple shutdowns. As of Oct 2021, COVID-19 caused 8,976 deaths, with a mortality rate of 1.46. Older patients had the highest mortality rate, with ages 70-74 at 12.8% and 80-84 at 18.05%. Middle-aged people were also affected, with ages 55-59 at 6.78% and 65-69 at 14.5%. Since Apr 2020, Tbilisi has had the highest mortality rate, except for Oct-Nov 2020, when the highest rate was in the Ajaria region. (NCDC review VI, VII) [20] [21]
Relevance of the Study: due to current practices, humanity may again be at risk of emerging new epidemics or a worldwide global pandemic.
It was for the first time that research on the management of diabetes mellitus and its complications during social isolation, due to the COVID pandemic, was conducted simultaneously in two separate study populations in Georgia.
The pandemic seems to have stopped other diseases, but diabetic patients with accompanying complications (arterial hypertension, cerebro-cardiovascular diseases, microangiopathy) appeared to be one of the most vulnerable groups in this pandemic era, especially when social relations are restricted.
The purpose of the study was to determine the degree/level of metabolic control, to compare the opinions of doctors and patients <65 years with diabetes mellitus, how they conducted the disease, as well as the progression of its complications during the period of social isolation caused by the COVID-19 pandemic.
Ethical Compliance: All procedures performed in studies involving human participants were by the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The Ethics Committee of University No. 451 approved the protocol.
Material and methods:
This is a cross-sectional study that used a special survey questionnaire. The study had two stages. In the first stage, a sampling frame of family physicians and endocrinologists was selected, and 276 respondents were chosen. The second stage involved selecting patients with Diabetes mellitus using a 95% confidence level and an acceptable margin of error of 5%. The primary sample size was determined to be 99 people, and the sample size required for data analysis equals 594 respondents (99 X 1.5 X 4 = 594). Finally, taking into account the response rate (0.8), the number of respondents with diabetes mellitus was 742.
In order to gather information, we conducted online surveys, face-to-face interviews, and visits to various regions. We use the Galaxy Tab S8 5G and had some visits to high mountain regions In Ajara.
To analyze the data, we used version 27 of SPSS software. Descriptive statistics were used to compare the opinions of physicians and patients, with frequency and percentage as the primary metrics. We used the one-sample Chi-square test for distribution and considered a p-value < .05 as the 95% confidence interval (CI) cut-off point for statistical significance.
Barriers to the Study: The study runs from March 2022 to February 2023. Incomplete surveys or refusal to participate is possible. Due to absent state registers, patients were interviewed during consultations in different regions.
Results:
Similar key parameters for metabolic control between doctor and patient questionnaires. The questions discussed in the article: Frequency of blood glucose monitoring, Fluctuation of glycemia level, Average level of glycosylated hemoglobin, Variability, and testability of blood pressure, Checking the cholesterol level, Frequency of complications amidst isolation, Medications used to treat diabetes mellitus.
The study involved 752 patients, of which 27 patients did not agree to fill out a questionnaire. Sex distribution: female 55.21% (n = 392), male 44.79% (n = 318)
44.2% (n = 314) live in Batumi, 23.20% (n = 165) live in Kobuleti, 19.6% (n = 139) live in khelvachauri and 13% (n = 98) live in mountainous Adjara. The majority of respondents, 72% (n = 505) were Christian, 25% (n = 175) were Muslim. The mean age was 50±15,2 years, the majority of patients were aged 51-60 years, 49% (n = 354) patients, 58% (n = 412) were married, and 18% (n = 131) were widows. Most had higher education: 32% (n = 229), 27% (n = 194) had secondary technical, and 18% (n = 131) had unfinished higher education. 51% (n = 359) of patients were employed, 25% (n = 179) were unemployed, 15% (n = 106) reported job losses due to the pandemic, and only 9% (n = 65) retired. The majority of patients, 87% (n = 617), had type 2 diabetes.
Out of the total 278 physicians who participated in the study, 265 agreed to complete the survey questionnaire, while 13 physicians declined to refuse, respectively 57%(n=158) of doctors worked in Batumi Family Centres and insurance companies, 17% (n = 47) in Highland Adjara15%, (n = 41) in Kobuleti Chakvi and 11% (n = 31) in Khelvachaur district.
According to physicians (31.1%), the patients did not measure their blood glucose levels at all, 37.7% - measured it once a week, 16.7% - once a day, and 14.5% - several times a day, respectively.
Remarkably, the assessment of physicians and patients concerning the monitoring of blood sugar levels is somehow identical, as according to 29.1% of patients they did not undergo blood sugar testing, while 33.1% - measured it once a week, 15% - once a day and 22% - several times a day, respectively. (Figure1.)
Figure 1. Comparison of blood glucose control
37,70%
31,10%
29%
33,10%
16,70% 1l,50% 16,70% 1l,50%
22,10%
15,70%
1
Not measuring
Measuring once a day
Measuring once a week
Physicians
Patients
According to the majority of physicians (53.1%), the blood sugar levels of the patients fluctuated between 140-250. Also, according to the majority of patients (35.9%), their blood sugar level fluctuated between 140-250, but Systematically over 250mg% was 26.5% vs18.8% physicians.
It was differences were observed between physicians and patients, suggesting that total blood sugar levels reported by physicians did not align with those reported by patients, although, the response - "Was not asked" was expressed in a high percentage in physician's 13.3% groups.
The majority of physicians (37.6%) reported blood pressure readings in patients - 150 mmHg and higher. Also, the majority of patients (39.7%) reported elevated blood pressure - 140/90 mmHg. that is, the responses of physicians and patients differ by 9.3%vs22.9% respectively from each other, while the blood pressure readings more or less coincide. According to physicians, the
Figure 2. Comparison "Not measuring" metabolic
parameters
■ HbA1c
■ Blood pressure
■ Blood cholesterol
Patients Physicians
cholesterol level in 47.5% of patients was above 200; in 17% - above 300; in 15.7% it was not measured; and in 19.7% - up to 180, respectively. Among the patients, 37% were found to have elevated cholesterol levels and were taking medications, 36.4% reported not measuring their cholesterol levels and having no information about it, 10.7% - within the norm, and 15.6% - had high cholesterol levels, but did not take any medications. As for Glycated Hemoglobin level, according to physicians, 7% showed 11.9%, 8% - 36.6%, 9%-8.9%, 6%- 2.0%, respectively, while 40.6% was assigned to the responses - "did not know" / "not measuring». According to patients, the responses -"don't know/ no measuring" were recorded in 59.5%, 6 -7% in 18.8%, and 8-9% in 21.5% of cases, respectively. Comparison "Not measuring" metabolic parameters Figure 2. In terms of treatment, 25.8% of patients received metformin, 23.2% - a combination of Actrapid and Insultard. 13% for insulin analogs, sulfonylureas, and DPP-4 inhibitors, 8.5% for SGLT2 inhibitors, and 2.7% for GPP-1 agonists. In physician responses, 37.5% used metformin, 17.6% Actrapid and Insultard, 14.8% sulfonylureas, 9.7% DPP-4 inhibitors, 7.9% took insulin analogs, only 6.4% SGLT2 inhibitors, and 5.7% GPP-1 agonists. 18.6% of patients had no complications. Hypertension, crisis - in 36.1%, heart failure - in 14.8%, and myocardial infarction - in 13.12%. 17.2% of patients required inpatient treatment during isolation. In the physician group, 14.9% of patients had no complications. 32.6% had a hypertensive crisis, 18.1% had a myocardial infarction and heart failure, and 16.3% had a stroke. (Figure 3.)
Figure 3.Comparison of CVD Complications
■ No
239
Pacients
72
33 ,40 40 36
Physicians
I Arterial hypertension- hypertensive crisis
Heart Failure
Acute Myocardial Infarction /Angina pectoris attack I Stroke
Discussion
The data obtained suggests that in critical situations (quarantine, isolation, and limitation of access to medical care), patients have abdicated responsibility for managing their health or diseases. Even though most patients have home monitoring of blood pressure (BP) and blood glucose (BG), they did not use it because most doctors had worked with COVID-19 patients, which proved to indicate that their responses regarding the frequency of BP and BG measurement coincided. No difference was observed between the indicators of blood sugar level and cholesterol level as well. The testability of glycosylated hemoglobin was found to be low as well, and no difference was detected in either group, and the majority of the responses received were "I don't know"/" not measuring." The patients with diabetes mellitus have initially experienced more anxiety and feelings of loneliness amidst social isolation. Major emphases were shifted to the assessment of glycemic and metabolic parameters and outcomes in infected patients [23,24]. Metabolic control of patients with diabetes mellitus varied around the world and depended on the strictness of isolation measures and access to healthcare services [23] [24] [25] 26][27,28]. The main recommendations of ADA EASD (Introduction: Standards of Medical Care in Diabetes—2021 2020) are metabolic parameters and glycemic control. It is crucial to educate diabetes patients and physicians on self-management skills, focusing on access to health care, nutrition, physical activity, and sleep. [29] However, during the isolation, some developing countries established poor glycemic control. To compare to a study in India, a study published in Diabetes and Metabolic Syndrome and researchers call for action for all medical community in general and experts in diabetes in particular, to ensure implementation of previously recommended and evidence-based interventions for the patients, even more aggressively than hitherto been the case [30]. The study from Brazil analyzed the impacts of social restriction measures imposed by the COVID-19 pandemic on the control of metabolic parameters in diabetic patients. They accessed the medical records of patients between July 2019 and June 2021. The sample consisted of 288 patients (111 adults and 177 older individuals). their finding was Among adults, an increase in body weight and LDL-C levels, especially for insulin users. Adults assisted by the public health care system showed higher HbA1c levels, and among older individuals using insulin, blood glucose levels decreased. [31]
Another study from Jordan aimed to identify factors associated with poor glycemic control among patients with Type 2 diabetes. A sample of 917 patients was selected, and a pre-structured questionnaire was used to gather information about sociodemographic, clinical characteristics, self-care management behaviors, medication adherence, barriers to adherence, and attitudes toward diabetes. The study found that longer duration of diabetes, not following recommended eating plans, negative attitude towards diabetes, and increased barriers to adherence were significantly associated with poor glycemic and blood pressure control [32], but in highly developing countries, during the lockdown measures in Germany, the study included 24,623 patients aged over 18 years with documented data in 2019 and 2020 from the Diabetes-Prospective Follow-up Registry (DPV). They
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found that during the lockdown period, metabolic control remained stable for the patient, with only slight changes in their glucose and BMI levels. the study shows that despite restrictions, patients were able to maintain their metabolic control. [33] No difference regarding the utilization of glucose-lowering drugs was also detected in our study and the most prescribed medication in both groups was Metformin, sulphonylurea, and the combination of Insulin and Actrapid. Maybe explained due to the existence of a universal health program that provides patients with insulin, metformin, and sulfonylurea free of charge. (Georgian Healthcare State Programs). [34]
In both groups, the utilization frequency of new-generation drugs, such as - SGLT-2 Inhibitors and GLP-1 agonists, was significantly lower, n=59 and n=19 among patients, and n=52 and n=16 among physicians, respectively.
The progression of cardiovascular complications was high in both groups. According to the diseases, arterial hypertension crisis was found to be the prevailing condition (32.6%) in both groups.17% of patients required hospitalization due to heart disease; a similar percentage was observed in the group of physicians, according to the diseases.
In an Australian study, Poor social health is associated with an increased risk of cardiovascular disease (CVD). A study of 11,486 Australians aged 70 and over found that social isolation and low social support predicted incident CVD, but not loneliness. The study also revealed that all measures of poor social health predicted ischemic stroke. The findings suggest that social isolation and low social support may be more critical than loneliness as cardiovascular risk factors among healthy adults. Therefore, social health domains should be included in future CVD risk prediction models. [35]
Conclusions:
Social isolation/distancing has significantly changed the daily lives of patients and physicians. Consequently, they turned out to be unprepared to fight diabetes in a crisis.
In conditions of social isolation, a comparative survey of patients and doctors revealed a marked decrease in the practice of self-monitoring of blood sugar and blood pressure at home, primarily due to the restriction of access to face-to-face medical consultations. Incorrect control of cholesterol and glycated hemoglobin leads to a greater risk of developing cardiovascular complications. The frequency of prescribing new hypoglycemic drugs in both groups is extremely low. Since we do not have an electronic accounting system in our country, we cannot compare it with data before the pandemic and isolation. It is desirable to continue the research in conditions without restrictions.
Recommendations:
It is essential to ensure adequate patient education regarding the necessity and methodology of home self-monitoring, particularly, in terms of limited social interactions; establishment of a register of patients with diabetes mellitus in regions enabling timely assessment of needs, monitoring of metabolic indicators, as well as proactive prevention of potential complications, is of great importance. It is essential to keep family physicians and endocrinologists updated and informed about the advantages of new medications in terms of reducing cardiovascular risks.
Conflict of interest- not declare
Acknowledgments: The authors are grateful to all colleagues and patients, who participated in the survey.
Founding: This research (PHDF-22-2943) was supported by the Shota Rustaveli National Science Foundation (SRNSF).
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