Supporting people with diabetes during a pandemic

In this issue, Joensen and colleagues present the first data we have seen on the impact and experience of diabetes through the lens of the COVID‐19 pandemic. The research was completed in Denmark in March 2020, in the context of a marked shutdown of economic and social activities across the country, but without the devastating death tolls experienced by other Organisation for Economic Co‐operation and Development (OECD) countries. There are several notable findings, which have global relevance, and we should take the time to reflect on these for our own localized contexts.

First, people with diabetes are clearly receiving the message that, if they become infected with COVID‐19, they are at much greater risk than the general population of experiencing a severe form of the infection, hospitalization and death. These concerns are valid, and people are right to feel worried about this. With a lack of guidance (beyond the usual advice) to help people with diabetes to make sense of the situation and reduce their risk factors, we need to support people in managing their concerns and distress. The ‘Managing Worry About COVID‐19 and Diabetes’ leaflet [1], developed by Dr Rose Stewart and Sophie Augarde (NHS Wales), is an excellent example of a practical tool that may help people in this context and would seem to be a valuable resource to disseminate as widely as possible. This has already been adapted for the Australian context [2]. The key message, to focus on managing the things that are within your control, resonates in Diabetes Australia’s timely COVID‐19 campaign ‘DiaBEtes: (be) prepared, connected, healthy’ [3].

Although the rate of diabetes‐specific distress reported by Joensen and colleagues is no higher than that typically seen in other cohorts, their study does highlight the impact of COVID‐19 restrictions on people’s sense of loneliness and isolation, especially with regard to managing their diabetes. This points to the value of peer support for people with diabetes, especially the most vulnerable in these times, given the meta‐analyses showing its benefits [4, 5]. Developing strategies to enable peer support to be delivered through digital, as well as physically distanced face‐to‐face interactions, would seem to be a critical opportunity and priority for national diabetes associations. There is also a crucial role here for diabetes services and health professionals to encourage and promote peer support in their communications with people with diabetes. This means finding out local peer support options and how people with diabetes can access them.

Another point to consider is the potential for the COVID‐19 pandemic to exacerbate and increase the stigma experienced by people with diabetes. The World Health Organization (WHO) published guidance about the psychosocial considerations of COVID‐19 [6] and a guide about preventing and minimizing social stigma [7]. The WHO highlighted that our language has power to affect trust and impact our community’s risk perceptions, response and wellbeing. The potential negative effects of language are already known in diabetes, and the WHO notes that stigmatizing language ‘might contribute to a situation where the virus is more, not less, likely to spread’. Using criminalizing or dehumanizing language (e.g. ‘suspects’, ‘cases’, ‘victims’, ‘the elderly’, ‘the sick’) creates the impression that those who acquire COVID‐19, or who are at higher risk of its serious consequences, have either done something wrong or are less deserving of support than other people in society, and could potentially undermine peoples willingness to engage in protective behaviours. In the next phase of the pandemic, given their heightened risk for adverse outcomes, individuals with diabetes may choose to voluntarily retain some physical distancing precautions beyond those maintained by the general population, which could exacerbate this stigmatization. So, our communications will still need to be authoritative, timely, informative and empathetic, and will need to be all four, if we are to effectively help people to over‐ride their self‐interest and facilitate a proactive society focused on positive action in the collective interest.

It is also noteworthy that that the individuals who reported being most worried about the COVID‐19 risk, also reported positive changes in their diabetes self‐management. It could be interpreted that fear appeals motivate behaviour. We would caution against this interpretation. The meta‐analytic literature points to the fact that increased perceptions of severity and seriousness can have positive effects on health behaviours, but only when the individuals concerned have a strong sense of self‐efficacy or ability to do those behaviours [8]. Where self‐efficacy is low, fear appeals can have the opposite effect. This Danish sample is characterized as a group with largely in‐target HbA_1c, and relatively low diabetes distress. Thus, it seems likely that these self‐care behaviours (monitoring, medication taking, etc.) are already highly self‐efficacious behaviours for this particular group. It is unlikely that we would see the same effect in those who had less optimal blood glucose profiles prior to COVID‐19. The legislative restrictions imposed to suppress the transmission of COVID‐19 are likely to make it even more difficult for the least advantaged populations to access appropriate diabetes treatments, support, services and care. So the temptation to use fear arousal to motivate optimal diabetes self‐management, may do just that—create fear that cannot be addressed with preventative actions, and so is addressed with emotion regulation actions, commonly associated with increased consumption of high fat, high sugar and alcohol, reductions in physical activity and increased drug use (over‐the‐counter, prescribed and illicit).

Thus, at this time, as clinicians we need to provide people with resources to help them manage their anxieties, connect them with the supports that are available to them and consider our language even more carefully, when talking with and about people with diabetes and COVID‐19.

Diabet. Med. 37, 1155–1156(2020)