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Partha Kar: Covid-19—time for parity in commissioning diabetes services

BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2154 (Published 02 June 2020) Cite this as: BMJ 2020;369:m2154

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  1. Partha Kar, consultant in diabetes and endocrinology
  1. Portsmouth Hospitals NHS Trust
  1. drparthakar{at}gmail.com
    Follow Partha on Twitter: @parthaskar

Recent data on the impact of covid-19 on people with diabetes has produced a range of responses.1 The data suggest that diabetes is an independent risk factor for mortality related to covid-19, with type 1 diabetes carrying a higher risk than type 2. The scientific community has tried to decipher the signals, and reactions in the diabetes community have ranged from relief to anxiety.

Overall, the data don’t present huge surprises, but some nuggets require further investigation. The fact that diabetes is a risk factor for a poor outcome with any infection is not a surprise per se. Splitting risks on the basis of type, although eyebrow raising to some, is again not fundamentally new. As any physiology or medical textbook will tell you, the basic tenets of types 1 and 2 diabetes are different, so it’s not surprising that outcomes are different too. Similarly, higher weight and higher overall glucose levels being additional risk factors isn’t surprising; nor is the association between poor outcomes and socioeconomic deprivation.

Yet two factors deserve closer inspection. One is the link between glucose control and the risk of poor outcome, which seems to be U shaped. The other is the lack of association between duration of diabetes and the risk of poor outcome from covid-19. The basic message, however, is simple: age is the predominant factor associated with poor outcomes, and people under 40 seem to have lower risk. The important message is to focus on modifiable factors, such as weight and glucose control, as you can’t change your age or ethnicity.

Society as a whole needs to try to retain an NHS that can pride itself on providing equality of access and service. Whether you look at these recent data or the work of Ben Goldacre,2 where you live does matter—and the pandemic shows this in stark focus. The work done by Julian Tudor-Hart or Michael Marmot shouldn’t be confined to textbooks but needs to be reflected in efforts to improve services and outcomes.

Data on covid-19 and diabetes also raise the question of how useful it would be to produce a risk calculator to help people with diabetes estimate their risk from covid-19. This could help others, such as employers, schools, and wider society, as we move gradually towards a degree of normality while protecting vulnerable people.

The figures also highlight the need for health systems to learn from data and ensure parity of focus on all types of diabetes, rather than just trying to tick all boxes relevant to diabetes by having a “prevention” strategy. Type 1 diabetes is neither preventable nor simply a “young person’s disease.” About 46% of people with type 1 diabetes are over 50,3 and about 69% of all people with type 1 diabetes have levels of glucose control that raise their risk of complications in general—and, as per the recent study, worse outcomes from covid-19.

Type 1 diabetes deserves as much focus on self-management, education, and access to technology as the focus we see in type 2 diabetes on prevention, appropriate dietary interventions, and modern medicines to improve outcomes. These are different pathologies, under a common nomenclature umbrella, which need parity of investment throughout the NHS—and it’s time for local health economies to recognise and implement that.

A third of people who have died from covid-19 in the UK have had diabetes as one of their comorbidities,1 and statistics also show that diabetes is an independent risk for poor outcomes in people with covid-19. There is no more apt time for healthcare systems to ensure that diabetes gets the attention it deserves. But let’s also ensure that we base the effort to improve diabetes services on the principle of giving everyone equal access, irrespective of where they live or their race. The NHS takes a lot of pride in its system and notions of equality, and it’s time we lived up to what we believe in.

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