Table 4.

Challenging Aspects of Type 1 Diabetes Management During the COVID-19 Pandemic

Theme	Selected Representative Quotations
Theme 1: Challenges adjusting to new or lack of daily routine
Lack of extracurricular activities and organized sports participation	“I guess the most notable way is that it reduced what she did outside of the house. So last spring when we were quarantined from school, she had a lot less activity and of course all of her extracurricular activities like dance and gymnastics were cancelled so that made it a little bit trickier because activity is important for all kids, but you know diabetic kids especially.” “You know, they’ve lost friends, their school activities, they played sports . . . I was watching them yesterday, they’re really, both him and his brother, are just, they’re just kinda out of shape.”
Lack of exercise built into school day	“Gym class is virtual. . . . So, there has been slightly less on the physical aspect of things. . . . I think you run faster when you’re playing dodgeball in a gym than the effort you put into when the teacher says okay everybody do 10 jumping jacks on the screen.” “We used to walk to and from school and it’s about 3 quarters of a mile so that’s activity he’s not getting . . . it’s that walk to and from school and you know stopping at the playground on the way home and playing with some of his friends, that hasn’t happened.” “It’s been harder because he’s just sitting around and he’s using a lot more insulin because he’s sitting around . . . it’s a big change in routine.”
Increased screen time	“Screen time has definitely gone up because all his classes are a hundred percent online. So, he basically looks at the screen all day long but it’s also gone up outside of school hours because the way he interacts with his friends is playing video games while they’re talking on facetime on the phone. So, all of his scouts, all of his taekwondo, everything’s on the screen. So, he spends a lot of time right now on the screen.” “Oh my gosh holy moly yes [laughter]. We used to be a weekends only family and only a couple hours on weekends, and it exponentially has increased. I would say at the beginning of the pandemic it was honestly 10 to 12 hours a day with school plus games just because we needed to work and whatnot. It was kind of insane.”
Challenges with child’s independence in managing their diabetes	“Since he’s at home he’s reverted to mom gets to do all of his shots. I feel like he was more independent when he was at school - it was a point of pride . . . and since he’s been home it’s like okay mom can you do this? So, he’s very capable of doing it all himself but he chooses to let me handle a lot of it.” “I actually think he regressed in terms of taking personal responsibility for his diabetes, I think he went backwards. . . . His dad feels like he has to do it, it’s his thing he needs to deal with it and give his own shots. So, I started doing that but then I noticed too that he was starting to be like, ‘Mom will you give me my shot mommy?’ He wasn’t doing it as much himself.”
Theme 2: Psychosocial aspects of pandemic impacted diabetes management
Lack of social support with regards to diabetes	“I just don’t love doing everything virtually; I think it’s also great to meet other families who have type 1 diabetes because we don’t know anybody . . . it would be nice to interact with other kids and families who also have type 1 diabetes in person.” “We have a neighbor who lives probably a quarter of a mile away and she has type 1. She was diagnosed when she was 3 so she’s been living with it for several decades and I would see her at pickup at the school and we’d chat, and she’d ask how he was doing and that was really reassuring for me . . . so not having that shoulder to lean on certainly did make things a lot harder and there’s only so much reassurance you can get from a text.” “I think that not being able to go to diabetes camp last year, not being able to connect with some families in our county that have kids with type 1 diabetes and talk to them face to face and have playdates with them who have the same concerns about high blood glucose or playing so hard that your numbers go down and you have to stop for a minute, and you know those kinds of things; it was a missed opportunity because of freaking covid.”
Lack of face-to-face interaction	“We found that after lunch, his blood sugar would go high right after he ate and he would have a really hard time focusing. So, the second half of the school day was kind of a wash for him. It would take a little bit for the insulin to catch up to what he ate and then by the time everything was back in line, it was the end of the school day. . . . The teachers weren’t able to see like what was happening . . . it’s so two dimensional when you’re virtual, so they would just see that he wasn’t paying attention and he would get himself in trouble for it.” “I think the personal aspect of it is better to be in there. You need to be in there talking to your doctor - how can she check the sites on his body you know, that’s up to me to look and see. He has a tendency [to] want to give his injection over here in his leg and sometimes he gives it too much in that spot - I can kind of check that myself but I think the doctor also needs to be doing that. So, telehealth is okay, but I don’t think it can replace the face to face.”
Limited social interaction due to being at higher risk for COVID-19 infection	“I think because he doesn’t have the experience with his friends and that sort of thing, I think he has kind of internalized the diagnosis a little bit more than he probably would otherwise if he had other distractions. I think from a mental perspective that might have been to a detriment as far as the quarantine.” “I didn’t want them to go outside and play with other kids. I didn’t know where those kids’ families have been. Because [of] the diabetes, our risk tolerance was a lot lower than a lot of other people.”
Parental concern about their child becoming infected with COVID-19	“I think the biggest challenge for me is just worry . . . I definitely worry more, especially with higher risk factors - him getting sick especially since he can’t get the vaccine yet. So, I feel like we’ve been more cautious than we would’ve been with the other kids.” “Hearing about all the complications and the risk factors with diabetes actually ended up causing me a lot of anxiety so my doctor prescribed me an anti-anxiety medication because it was just that snowball of worry and concern.” “So we isolated pretty significantly. I think in part because the first news of the pandemic was diabetes and they didn’t differentiate between type 1, type 2, or well managed . . . she has never bounced back from any respiratory virus easily compared to my son who’s nondiabetic . . . so that for me was an extra layer of hesitancy to return to school or whatever else.” “Obviously when the pandemic first started, we were very concerned when it came to our son’s health especially since he has type 1 and he’s immune compromised.”