Why Diabetes + COVID-19 Is So Dangerous

People with or at risk for diabetes are far more likely to experience severe complications if they become ill with the coronavirus

illustration of covid and diabetes Illustration: Ben Shmulevitch

After Olga Chalfant’s father, Michael, got COVID-19, he almost died—not because the virus shut down his lungs but because his type 2 diabetes raged out of control. While in the COVID-19 unit at a New York City hospital, the 74-year-old Russian émigré’s blood glucose spiked to dangerous levels. The blood glucose fluctuations became even more severe after he was sent home, says Chalfant, who translated for her father when he was ill.

“That’s the COVID effect,” says Ruth Horowitz, MD, chief of the division of endocrinology and metabolism at the Greater Baltimore Medical Center, who was not involved in Chalfant’s father’s care but has managed the complex cascade of symptoms that develop in many patients with both diabetes and COVID-19.

For Cody Wessel, 36, the pandemic triggered a diabetes crisis of another sort: Several months after being laid off in March, the St. Louis resident with type 1 diabetes lost his health insurance, compelling him to start a GoFundMe campaign to raise the $1,600 per month that he estimates he needs for his insulin and supplies.

And Maria León, 54, found herself overwhelmed when she received a diagnosis of type 2 diabetes in May, as the pandemic was exploding in her community of East Los Angeles. Getting a handle on the various drugs and tests she suddenly needed was hard enough, but concerns about exposure to the virus when she left her house made it hard for her to exercise or find the affordable, nutritious produce she needed to stick to a diabetes-healthy diet.

More on Diabetes

Living with diabetes—a disease in which the body doesn’t properly process glucose, or sugar, from food—has always been complicated.

In people with type 1 diabetes, the immune system mistakenly attacks and destroys the insulin-producing cells in the pancreas. Without insulin, the body can’t convert sugar into energy, which causes a buildup of sugar in the blood. In type 2 diabetes, the pancreas can’t make enough insulin to process glucose, or the body has grown insensitive to the insulin the pancreas does produce. Though the causes of type 1 and type 2 differ, both diseases tend to require changing exercise and dietary habits, frequently testing blood glucose levels, and often taking insulin or other medication. Without those steps, uncontrolled blood glucose levels can lead to heart disease, nerve damage, blindness, kidney disease, and more.

Black and Hispanic people are more likely than white people to say the pandemic has made it harder for them to pay for diabetes medications and supplies.
Source: Consumer Reports June 2020 survey.

But as the experiences of Chalfant’s father, Wessel, and León show, the arrival of the coronavirus has multiplied those challenges. As a result, many of the estimated 34 million Americans with diabetes (about 1 in 10 people) and 88 million with prediabetes (about 1 in 3 adults) may now be fighting for their lives in more ways than one.

COVID-19 Complications

“There are some things that are very unique to diabetes and COVID,” Horowitz says.

For one thing, having diabetes—especially if blood glucose levels are high—significantly ups the risks of COVID-19 complications, even death. A Centers for Disease Control and Prevention analysis of 2,681 people under age 65 who died with COVID-19 found that almost half of them also had diabetes.

Doctors are also seeing an increase in insulin resistance—an inability to use insulin to absorb glucose—in patients with diabetes and COVID-19, causing blood glucose levels to skyrocket. In addition, doctors are reporting cases of first-time ketoacidosis—a diabetes complication in which the body breaks down fat instead of glucose for energy, resulting in a potentially fatal buildup of acids in the blood.

Another cause for concern: COVID-19 and the steroids sometimes used to treat it can cause dangerously high blood sugar levels, says Brenda Swanson-Biearman, DNP, a nurse and assistant professor at the Rangos School of Health Sciences at Duquesne University in Pittsburgh. Chalfant suspects that contributed to her father’s soaring blood glucose levels while he was sick.

Emerging research even suggests that COVID-19 may trigger diabetes in some people who don’t yet have the disease. “COVID-19 has had a profound and unprecedented impact on glycemic control in many patients with and without a known history of diabetes,” says Joshua Miller, MD, medical director of diabetes care at Stony Brook Medicine in New York. “Insulin requirements [with COVID-19] are through the roof with many patients.”

What’s more, diabetes often goes hand in hand with other health concerns that make it more difficult to battle COVID-19, such as obesity, heart disease, and kidney disease, many of which can impair blood flow.

That’s a problem, says Arti Thangudu, MD, an endocrinologist at Complete Medicine in San Antonio, because “when you’re trying to heal an infection [like COVID-19], you need all the good healing properties that flow through the blood.”

Diabetes rates are especially high in Black, Hispanic, and Indigenous people—one of the likely reasons these groups have been disproportionately affected by COVID-19. Their COVID-19 mortality rate is more than three times that for whites of the same age, according to an analysis by APM Research Lab.

People of color also face more obstacles when trying to manage diabetes. Take the results of a new Consumer Reports survey of 2,911 people who have diabetes or live with someone who does. It found that Hispanic people report challenges finding healthy food more often than white people do. And Black and Hispanic people say the pandemic has made it harder to pay for diabetes medications and supplies, such as glucose monitors and test strips.

No surprise, then, that CR’s survey found that Black and Hispanic people with prediabetes or diabetes are far more apt than white people to say they’re extremely concerned about falling ill with COVID-19.

All too often, says Andrew Boulton, MD, president of the International Diabetes Federation, “wealthy means healthy.” Put simply, groups and communities with more resources are likely to have better medical care and to be better able to stay on top of their health.

This confluence of crises—the pandemic, the coronavirus-diabetes connection, and healthcare inequities—has made solving the problems in diabetes care more urgent than ever.

While solutions to some of these issues remain in the future, several strategies can help you make needed dietary changes and also afford the drugs and supplies necessary to manage the disease. Below is some specific advice on managing diabetes now during the pandemic.

Managing Diabetes During the Pandemic

Wear a mask. Wash your hands. Social distance. Those now-familiar tips for avoiding COVID-19 are especially important for people with diabetes, says Leonor Corsino, MD, at the Duke University School of Medicine. That’s because people with high blood glucose levels who contract COVID-19 are more likely to need mechanical ventilation or to die.

portrait Hasa and son

“I wanted to be sure I’d be covered in terms of both my insulin and my infusion sets, reservoirs, and sensors that I need in order to manage my diabetes.”

Hasa Kingo

New York City resident who struggled to manage his type 1 diabetes during the early days of the pandemic.

But the constraints of the pandemic have made it more difficult to control diabetes. Hasa Kingo, a 35-year-old lawyer in New York City with type 1 diabetes, says that sheltering in place last spring while juggling child care and managing the stress of living in what was then the coronavirus epicenter made exercising problematic, causing his blood sugar levels to fluctuate.

He was also concerned about potential shortages of medication and supplies for his insulin pump, so he says he stocked up as much as he could. “I wanted to be sure I’d be covered in terms of both my insulin and my infusion sets, reservoirs, and sensors that I need in order to manage my diabetes,” Kingo says.

If you face similar challenges, experts have identified key steps to take.

Get meds and supplies delivered. “If you don’t have to go out, please stay home,” Corsino says. Instead of going to the drugstore, arrange for 90-day prescriptions and home delivery. Doug Hoey, CEO of the National Community Pharmacists Association, says almost all independent pharmacies offer this and curbside pickup. Some CVS, Walgreens, and Walmart stores have drive-thru pickup as well—and may ship free.

Be sure to move. Thirty-four percent of people in CR’s survey said the pandemic made it more challenging to exercise. Although being outdoors is generally safe if you wear a mask and socially distance while around others, not everyone has access. Diabetes educators suggest setting up a workout area at home. No weights? Consider doing a body-weight workout (think pushups). For cardio, try a Zoom exercise class or a free YouTube workout video, or move to a dance or sports video game, such as Zumba Fitness.

of people say COVID-19 has made it harder for them or a family member to go to the doctor for diabetes-related care.
Source: Consumer Reports June 2020 survey.

Keep healthcare appointments. Almost a third of people in CR’s survey said COVID-19 made it harder for them to go to doctors’ appointments for care. In some cases, this was because of concerns about leaving the house.

For many people, telehealth provided a solution. But for others, especially some Blacks and Hispanics, the crisis revealed a substantial digital divide, Corsino says—a lack of computer equipment or internet access. “A lot of our minority patients unfortunately couldn’t see a provider even though telehealth was available,” she says.

While in the early days of the pandemic many people stayed away from doctor offices even for serious health problems, experts now stress the importance of continuing to get care during the crisis. And providers have learned a lot about preventing the spread of COVID-19 in healthcare settings. “Most institutions have a very strict protocol for patients opting to see them in person,” Corsino says. Call your doctor’s office to get details.

Create a diabetes care plan. Write down the medications you take, including any insulin dosing instructions, and keep it in a place with easy access. That way, if you do contract COVID-19, family or friends can make your doctors aware of your diabetes treatment plan, and if you’re at home, help keep your blood sugar under control. If you do end up in the hospital, alert the staff about your diabetes, and request a consultation with an endocrinologist, if possible. Thangudu, the endocrinologist in San Antonio, says when intensive care physicians are focused on combating COVID-19, a patient’s blood sugar might not be “the most pressing thing at that moment in time, so I think it gets forgotten often.” But asking for an endocrinologist in the hospital can be vital to improving COVID-19 outcomes.

Ask the hospital about continuous blood glucose monitors (CGMs). These devices have a small sensor inserted under the skin that reads blood glucose levels continuously and a small transmitter that sends readings to a receiver, which can display the readings. The info could also be sent to a smartphone or computer. In the spring, the FDA issued new guidance making it easier for hospitals to use CGMs to check the blood sugar of admitted patients with COVID-19 rather than use traditional glucose meters with finger sticks. The devices allow hospital staff to monitor blood sugar consistently and remotely—without having to enter patients’ rooms, thereby preserving personal protective equipment. The CGMs “would give us a more complete story about the patient’s overall glycemic control in the hospital,” says Miller, at Stony Brook Medicine, who used CGMs for this purpose.

Stay in touch with your doctor while recovering from COVID-19. Doctors often prescribe steroids to people with COVID-19 because the medication can improve survival in people with severe symptoms. But steroids can also cause huge spikes in blood glucose. “We have seen some patients who have required extraordinarily high doses of insulin to control their glucose levels in the intensive care unit who have COVID,” says Horowitz, at Greater Baltimore Medical Center. And some people with diabetes have needed insulin for the first time. But if the insulin dose isn’t carefully monitored while people are weaning off steroids, it can cause dangerously low blood sugar levels.

That’s what Chalfant believes happened to her father. Steroids prescribed in the hospital caused his glucose to soar “completely out of control,” she says. But the insulin prescribed to lower his glucose levels ultimately caused his blood sugar levels to crash when he returned home, causing him to lose consciousness. “Thank god my mom was there” to call 911, Chalfant says, and the paramedics were able to revive him.

“It’s logistically very difficult to teach somebody how to use insulin when they’re very ill,” says Horowitz, which is one of the reasons she suggests people ask their healthcare provider for clear instructions upon discharge from the hospital, and then stay in close contact while recovering from the virus—until they are stabilized.

Editor’s Note: This article also appeared in the January 2021 issue of Consumer Reports magazine.