Roughly 42% of people with diabetes who tested positive for COVID-19 and had to be admitted to hospital in the Western Cape had died as of 16 July. Spotlight reports that the preliminary data, presented during a recent digital press conference of the Western Cape Health Department, is in line with reports from countries hardest hit by the pandemic.
Even before the COVID-19 pandemic diabetes was recognised to be one of the leading causes of illness and death worldwide. According to a recent article penned by leading experts in internal medicine, endocrinology and metabolism and published in the South African Medical Journal (SAMJ), diabetes and obesity globally accounted for “43.4% of all deaths in 2012, compared with 33.6% of deaths from HIV/Aids and TB combined”.
“In South Africa, high body mass indexes (BMIs) and DM (diabetes) are the second and third leading risk factors for early death and disability, respectively, and the increasing overlap with infectious diseases is a growing concern,” the authors wrote.
While it is known that diabetes claims many lives, not that much is known about how many people in South Africa have the disease. “Accurate current data on the prevalence of diabetes in South Africa is quite difficult to find as there are no recent robust studies in all provinces in South Africa,” says Professor Joel Dave, head of endocrinology at the University of Cape Town and co-author of the SAMJ article.
Dave points out that, while there are estimates, there is also significant uncertainty over how many people have uncontrolled diabetes. The Western Cape’s 2019 Burden of Disease Report estimated that around 70% of people with diabetes in the province had poorly controlled or uncontrolled diabetes.
Spotlight reports that in another WC digital press conference, Dave revealed that 42% of people with diabetes who were hospitalised for COVID-19 in the Western Cape had died as of 16 July. This does not mean people with diabetes are at higher risk of contracting COVID-19, but rather that once they do contract the disease they are at higher risk of serious illness or death.
On an earlier digital press conference, Professor Mary-Ann Davies from UCT indicated that 52 out of every 100 COVID-19 deaths in the Western Cape were in people with diabetes. Spotlight reports that in trying to explain the reason for the increased risk in the press conference, Dave referred to a study that found that in COVID-19 patients with hyperglycaemia (raised blood sugar levels) there is increased expression of the ACE2 receptor. It is through the ACE2 receptor that SARS-CoV-2 (the virus that causes COVID-19) gains access to cells, particularly the heart and kidneys.
“In diabetics, they have a completely dysregulated immune system. Such that they have a much greater risk of developing what has been labelled a cytokine storm, a release of a whole lot of inflammatory mediators, that ultimately leads to multi organ disfunction,” Dave explains. He says available data show “this is happening in patients with mainly type 2 diabetes, who are mainly at an increased age, they are usually overweight or obese and often they have pre-existing vascular disease or pre-existing kidney disease”. “All of these factors in their own right have shown to lead to more severe COVID-19,” Dave says.
Spotlight asked Professor Naomi (Dinky) Levitt, director of the Chronic Disease Initiative for Africa, why so many people living with diabetes are at risk of dying from COVID-19. One reason, says Levitt, is poorly controlled diabetes, which means poor blood sugar control.
“We know that poor glycaemic control based on international literature is associated with poorer outcomes (in COVID-19 patients),” says Levitt. This not only poses a risk when it comes to COVID-19, but also other infections.
“Poorly controlled diabetes is associated with an increased risk of all infection… It’s like honey, and bugs love honey,” she says.
Levitt explains that there are a variety of factors involved in blood sugar control, both within the individual and his or her circumstances and within the health system and society at large.
She says that the patient’s relationship with the health system can contribute to how well they manage their blood glucose levels. For example, how they are treated by health professionals, and whether their medication is available when they have to collect it, can all have an impact.
“It’s extremely complex… You can’t blame the patient… You do not know whether it lies at the individual or at the system or at the society,” says Levitt.
Margot McCumisky, the national director of Diabetes SA, says in the report that one reason for poor blood sugar control is that blood sugar levels tend to fluctuate throughout the day for various reasons. These include diet, certain medications, stress, temperature changes, and not eating enough before exercise. “It is one of the hardest (diseases) to manage and people are (often) just not provided with ways to control it, education-wise or with tools,” she adds.
One reason for the poor outcomes of COVID-19 patients living with diabetes in the Western Cape is that people often only go to hospital once they are already very seriously ill.
“The early data (from the Western Cape) shows that people (with diabetes who get COVID-19) who got admitted to hospital and died, died within a very short time of admission. The assumption being that they waited very long,” says Levitt.
Levitt explains that waiting too long to get help when you have COVID-19 makes it harder for interventions to be effective.
“If you present late, the opportunity for intervention that is going to be meaningful is going to be limited,” she says. “Whereas, if you get admitted earlier in the disease process, the chances of intervening are going to be very much greater.”
[link url="https://www.spotlightnsp.co.za/2020/08/17/covid-19-understanding-the-increased-risk-in-people-with-diabetes/"]Full Spotlight report[/link]
[link url="http://www.samj.org.za/index.php/samj/article/view/12991/9424"]SAMJ article[/link]