Malaysia should prepare for a double pandemic: COVID-19 and diabetes

The unprecedented COVID-19 pandemic has caused considerable loss of lives, health and psychosocial issues, as well as economic ramifications globally. One recent observation that captures many clinicians and public health practitioners’ attention is the bidirectional relationship between diabetes and COVID-19.

An article by Professor Dr Noran Naqiah Hairi, Professor Dr Moy Foong Ming, and Dr Wan Kim Sui (our Doctor of Public Health candidate) has been published by The Malaysian Medical Gazette. They aim to highlight the double pandemic of COVID-19 and diabetes to healthcare professionals and the general public. In addition, they share their thoughts on the public health management of this syndemic.

On the one hand, diabetes patients have more severe COVID-19 and increased mortality than those without diabetes. An unusually high number of COVID-19 patients with diabetes developed hyperglycaemic hyperosmolar syndromes and diabetic ketoacidosis, where the mortality rate was high.

On the other hand, there is emerging evidence that SARS-CoV-2 could induce new-onset diabetes. SARS-CoV-2 spike proteins bind to angiotensin-converting-enzyme 2 (ACE2) receptors, particularly those on pancreatic beta cells, potentially causing damages leading to insulin deficiency.

The routine screening and early diagnosis of diabetes (especially those without symptoms) may be disrupted as health resources are redistributed from preventive to acute care of COVID-19.

Optimisation of A1C, blood pressure and cholesterol control become even more important as a mean for primary prevention of COVID-19 infection. The paradox here is that this pandemic makes optimal metabolic control more difficult due to interruption of routine healthcare and changes in diabetes self-care.

Previous studies have demonstrated legacy effects where early and tight glycaemic control reduced microvascular and macrovascular complications, including deaths. Hence, delayed diagnosis and management of new diabetes patients, coupled with more inadequate metabolic control among known diabetes patients (also potentially new COVID-19-induced diabetes), can inadvertently increase the burden of diabetes complications over the long term.

In public health management of diabetes during this pandemic, we need to be dynamic, continually monitoring the COVID-19 situation and our available resources. With the pandemic currently showing no sign of abating, we may need to re-strategise and play the ‘loser game’, e.g., minimising disruption of health services and using telemedicine to maintain some contact with diabetes patients. Once the COVID-19 situation improves, we should restart preventive programmes judiciously, such as screening for diabetes in the community. Besides that, follow-up of recovered COVID-19 patients is important to monitor long-term complications of the disease. One practical way for this surveillance activity is to join an established registry such as the CoviDiab Registry.

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