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Changes in clinic visits and diabetes and metabolic control in patients with type 2 diabetes during COVID-19 pandemic: A real world evidence

  • Fatemeh Bandarian
    Affiliations
    Metabolomics and Genomics Research Center, Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
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  • Mostafa Qorbani
    Affiliations
    Non-communicable Disease Research Center, Alborz University of Medical Sciences, Karaj, Islamic Republic of Iran
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  • Maryam Aalaa
    Affiliations
    Cell Therapy and Regenerative Medicine Research Center, Endocrinology and Metabolism Molecular Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
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  • Maryam Peimani
    Affiliations
    Evidence-Based Medicine Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
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  • Bagher Larijani
    Affiliations
    Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
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  • Ensieh Nasli-Esfahani
    Correspondence
    Correspondence to: Diabetes Research Center, 5th floor, Diabetes Clinic, Shahrivar St., North Kargar Ave., Tehran, Islamic Republic of Iran.
    Affiliations
    Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
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Published:March 13, 2023DOI:https://doi.org/10.1016/j.pcd.2023.03.004

      Highlights

      • During covid-19 lockdown, glycemic control of diabetes patients improved significantly.
      • During lockdown lipid profile except for triglyceride improved significantly.
      • During lockdown BMI reduced significantly.
      • All metabolic improvement were statistically significant but not clinically.
      • This metabolic improvement indicates improved self-care.

      Abstract

      Purpose

      The study aim was to evaluate the effects of public lockdown during the covid-19 pandemic on glucose and metabolic parameters as well as body weight control in type 2 diabetic patients.

      Methods

      This study was conducted in two outpatient Diabetes Clinics and analyzed data available in database of Diabetes Clinic. Data related to a year before covid-19 pandemic and a year during covid-19 pandemic was collected from the database and analyzed. Patients with type 2 diabetes included in the analysis if they had referred to Diabetes Clinics both before and during covid-19 pandemic. Demographic information and data about metabolic status were collected from the records of previous outpatient Clinic visits and compared

      Results

      Finally 9440 patients with mean age of 61.08 ± 11.62 referred to Diabetes Clinics in both the year before and the year of the corona pandemic. Mean FBS and HbA1c in diabetes patients reduced significantly from 155.37 ± 62.93 and 7.97 ± 1.74 before pandemic, respectively to 138.77 ± 45.39 and 7.54 ± 1.34, respectively during covid-19 outbreak. During covid-19 pandemic, all metabolic parameters including glycemic and lipid profile (except for triglyceride) and BMI (body mass index) reduced significantly statistically, but, these changes were not clinically significant. However, triglyceride level increased statistically significantly but again it was not significant clinically.

      Conclusion

      During COVID-19 lockdown, glycemic and metabolic control of diabetes patients have improved significantly except for triglycerides.

      Keywords

      1. Introduction

      Outbreak of severe acute respiratory syndrome caused by a novel coronavirus (known as COVID-19) pandemic becomes a global health emergency [
      • Acter T.
      • Uddin N.
      • Das J.
      • Akhter A.
      • Choudhury T.R.
      • Kim S.
      Evolution of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as coronavirus disease 2019 (COVID-19) pandemic: a global health emergency.
      ,
      • Weston S.
      • Frieman M.B.
      COVID-19: knowns, unknowns, and questions.
      ]. According to the latest evidences, people suffered from chronic diseases such as Diabetes Mellitus (DM) are more vulnerable than others to severe outcome of the COVID-19 [

      Y. Chen, X. Gong, L. Wang, J. Guo, Effects of hypertension, diabetes and coronary heart disease on COVID-19 diseases severity: a systematic review and meta-analysis, MedRxiv, 2020.

      ,
      • Verity R.
      • Okell L.C.
      • Dorigatti I.
      • Winskill P.
      • Whittaker C.
      • Imai N.
      • et al.
      Estimates of the severity of coronavirus disease 2019: a model-based analysis.
      ,
      • Bajgain K.T.
      • Badal S.
      • Bajgain B.B.
      • Santana M.J.
      Prevalence of comorbidities among individuals with COVID-19: a rapid review of current literature.
      ]. DM as global health issue cause to increase mortality related to the COVID-19 [
      • Gupta R.
      • Ghosh A.
      • Singh A.K.
      • Misra A.
      Clinical considerations for patients with diabetes in times of COVID-19 epidemic.
      ]. Type 2 DM is the most prevalent type of diabetes [
      American Diabetes Association
      Classification and diagnosis of diabetes: standards of medical care in diabetes—2019.
      ] which without glycemic control caused microvascular and macrovascular complications [
      • Cade W.T.
      Diabetes-related microvascular and macrovascular diseases in the physical therapy setting.
      ]. The importance of glycemic control in decreasing the incidence of complications has been recommended [
      • LeRoith D.
      • Smith D.O.
      Monitoring glycemic control: the cornerstone ofdiabetes care.
      ]. Additionally patients with poor glucose control affected with Covid-19 encountered with worse outcomes even increasing mortality and morbidity [
      • LeRoith D.
      • Smith D.O.
      Monitoring glycemic control: the cornerstone ofdiabetes care.
      ].
      Until now different approaches have been proposed to reduce risk of COVID-19 spread including Physical distancing, face masks, and eye protection [
      • Chu D.K.
      • Akl E.A.
      • Duda S.
      • Solo k.
      • Yaacoub S.
      • Schünemann H.J.
      • et al.
      Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis.
      ]. In this regard lockdown was imposed which restricted all outdoor activities, as well limited the face to face visit at diabetes clinics [
      • Capaldo B.
      • Annuzzi G.
      • Creanza A.
      • Giglio C.
      • De Angelis R.
      • Lupoli R.
      • et al.
      Blood glucose control during lockdown for COVID-19: CGM metrics in Italian adults with type 1 diabetes.
      ].
      Additionally as lockdown affects the lifestyle of the diabetic patients including physical activity, diet, and stress it is expected to influence the glycemic control [
      • Capaldo B.
      • Annuzzi G.
      • Creanza A.
      • Giglio C.
      • De Angelis R.
      • Lupoli R.
      • et al.
      Blood glucose control during lockdown for COVID-19: CGM metrics in Italian adults with type 1 diabetes.
      ]. Moreover, metabolic syndrome indicators such as hypertension and dyslipidemia should be considered in patients with type 2 diabetes to prevent and likely managed properly and in the right time [
      • Bornstein S.R.
      • Rubino F.
      • Khunti K.
      • Mingrone G.
      • Hopkins D.
      • Birkenfeld A.L.
      • et al.
      Practical recommendations for the management of diabetes in patients with COVID-19.
      ].
      Now in such a Covid-19 lockdown that patients with type 2 diabetes have no face-to-face visit and may have consulted virtually, or do not have any routine care, there are concerns about glycemic control, life style changes, metabolic control and well-being. [
      • Hartmann-Boyce J.
      • Morris E.
      • Goyder C.
      • Kinton J.
      • Perring J.
      • Nunan D.
      • et al.
      Diabetes and COVID-19: risks, management, and learnings from other national disasters.
      ]. As well fear of infection caused the reduced clinic visits [
      • Scott E.S.
      • Jenkins A.
      • Fulcher G.R.
      Challenges of diabetes management during the COVID-19 pandemic.
      ]. Since routine diabetes care in this unique condition differ by country, the effect of lockdown on glycemic control and diabetic care vary too. Accordingly there are different studies with different results from different countries on the Covid-19 restriction on diabetes management.
      Some studies reported glycemic parameters worsening during covid-19 restriction [
      • Munekawa C.
      • Hosomi Y.
      • Hashimoto Y.
      • et al.
      Effect of coronavirus disease 2019 pandemic on the lifestyle and glycemic control in patients with type 2 diabetes: a cross-section and retrospective cohort study.
      ,
      • Al Agha A.E.
      • Alharbi R.S.
      • Almohammadi O.A.
      • Yousef S.Y.
      • Sulimani A.E.
      • Alaama R.A.
      Impact of COVID-19 lockdown on glycemic control in children and adolescents.
      ] however the result of some studies suggested glucose control improvement [
      • Tornese G.
      • Ceconi V.
      • Monasta L.
      • Carletti C.
      • Faleschini E.
      • Barbi E.
      Glycemic control in type 1 diabetes mellitus during COVID-19 quarantine and the role of in-home physical activity.
      ,
      • Eberle C.
      • Stichling S.
      Impact of COVID-19 lockdown on glycemic control in patients with type 1 and type 2 diabetes mellitus: a systematic review.
      ,
      • Psoma O.
      • Papachristoforou E.
      • Kountouri A.
      • et al.
      Effect of COVID-19-associated lockdown on the metabolic control of patients with type 2 diabetes.
      ,
      • Rastogi A.
      • Hiteshi P.
      • Bhansali A.
      Improved glycemic control amongst people with long-standing diabetes during COVID-19 lockdown: a prospective, observational, nested cohort study.
      ].
      Due to the heterogeneous findings related to local lockdown caused, the current study was carried out to investigate the effects of lockdown during the covid-19 pandemic on glucose, metabolic parameters and body weight control in type 2 diabetic patients.

      2. Methods

      This study was performed using registered data in Diabetes Registry databank which was collected in two outpatient Diabetes Clinics affiliated to Tehran University of Medical Sciences, Tehran, Iran and analyzed data available from the cohort of Diabetes Clinic.
      Serial data of all type 2 diabetes patients refer to these Diabetes Clinics for diabetes management are recorded in related database after each visit regularly since 4 years ago. Therefore, data related to a year before covid-19 pandemic (20 Feb. 2019–19 Feb. 2020) and a year during covid-19 pandemic (20 Feb. 2020–19 Feb. 2021) was collected from the database and analyzed.
      All patients with type 2 diabetes included in the analysis if they had referred to Diabetes Clinics both before and during covid-19 pandemic and those referred only in one period (before or during covid-19 pandemic) were excluded (the patients were the same in the two periods).
      After considering inclusion and exclusion criteria, finally 9440 patients remained for analysis.
      Demographic information and data about metabolic status including glycemic control and lipid profile, as well as liver and kidney function were collected from the records of previous outpatient.
      Clinic visits in order to compare the findings before and after pandemic.
      The IRB approval was obtained from the ethics committee at Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences and all patients gave consent to use their data.

      2.1 Data analysis

      Data are presented as mean and standard deviation (SD) for numerical data and number and percentage for categorical data. Between groups comparison of numerical data was performed using paired-T-test or Wilcoxon signed-rank test as appropriate. Categorical data was compared using chi-squared (chi2) test. All analyses was conducted by SPSS software ver. 20.00 for Windows and p_values less than 0.05 were considered significant.

      3. Results

      Information of diabetes clinic visits during one year of beginning of covid-19 pandemic and corresponding before pandemic was collected, retrospectively and analyzed. During this two-year period, totally 31,918 diabetes visits was registered, of them 21,044 occurred before covid-19 pandemic and 10,874 during pandemic. The comparison of periods showed approximately 50 % reduction in diabetes visits during corona pandemic (Fig. 1).
      Fig. 1
      Fig. 1Number and percentage of Diabetes Clinic visits before and during covid-19 pandemic.
      Overall, a total of 9440 patients (52.8 %, 4990 F) with mean age of 61.08 ± 11.62 y and mean duration of diabetes 12.86 ± 7.97 y, referred to diabetes clinic in both the year before the pandemic and the year of the corona outbreak.
      Mean FBS and HbA1c in diabetes patients reduced significantly from 139.09 ± 46.09 and 7.54 ± 1.29 before pandemic, respectively to 136.24 ± 42.43 and 7.44 ± 1.25, respectively during covid-19 outbreak (Table 1). During covid-19 pandemic, all metabolic parameters including glycemic and lipid profile (except for triglyceride) and BMI (body mass index) reduced significantly statistically, but, these changes were not clinically significant (Table 1). However, triglyceride level increased statistically significantly but again it was not significant clinically (Table 1).
      Table 1Demographic characteristics of diabetes patients referred to diabetes clinic in both the year before and the year during covid-19 pandemic.
      ParameterNumber of patientsBefore Covid-19 pandemicDuring Covid-19 pandemicP_value
      FBS, (mean±SD) mg/dL1626139.09 ± 46.09136.24 ± 42.430.02*
      BS2hpp, (mean±SD) mg/dL1036197.58 ± 74.06190.21 ± 69.710.002*
      HbA1c, (mean±SD), (%)16447.54 ± 1.297.44 ± 1.250.003*
      Total cholesterol, (mean±SD)814143.39 ± 34.49140.45 ± 33.100.01*
      Triglyceride, (mean±SD) mg/dL1001146.05 ± 71.72150.82 ± 80.280.02*
      HDL, (mean±SD) mg/dL65143.65 ± 11.2442.88 ± 10.730.03*
      LDL, (mean±SD) mg/dL96575.68 ± 25.8373.16 ± 26.170.004*
      BMI, kg/m2 (mean±SD)80028.36 ± 4.5328.21 ± 4.580.001*
      Before pandemic about 74.73 % of diabetes patients were overweight and obese that during covid-19 outbreak did not change significantly and remained 74.91%. Also, the rate of obesity (BMI ≥ 30) did not change significantly during the pandemic (31.05 % before vs. 30.37 % during pandemic).
      In elderly adults aged ≥ 65 years, 62.5 % had optimal glycemic (treatment goal) control with HbA1c less than 8 % and 35.2 % HbA1c ≤ 7 before pandemic while 72.8 % and 39.7 % during corona pandemic (p < 0.001). The differences were significant statistically but again these differences were not clinically significant.
      Among all ages, 3359 of 5591 patients (60.1 %) had HbA1c less than 8 % before pandemic while 72.4 % (1526 of 2109 patients) during the pandemic, which among all of them, the age group with most patients with HbA1c < 8 (54.3 %) was group 45–65 years before and during pandemic.
      Among all ages, during pandemic only 40 % had HbA1c less than 7 % while before pandemic 33.6 % had, which among all of them, the age group with most patients with HbA1c < 7 (54.1 % and 54.9 % before and during pandemic, respectively) was group 45–65 years before and during pandemic.
      Before corona, the prevalence of cholesterol level > 200 was 11.4 %, which decreased to 5.2 % during corona pandemic. In addition, frequency of LDL levels > 100 decreased from 23.1 % before corona to 12.1 % during corona pandemic.
      Serum cholesterol in 69.8 % of people with cholesterol level > 200 before corona decreased below 200 during corona pandemic, which was a significant difference (P < 0.001). Also, in 66.9 % of those with LDL level > 100 before corona, it decreased below 100 during corona pandemic as well (p < 0.001).
      Before corona pandemic the prevalence of LDL level ≤ 100 in age groups of < 45, 45–65 and > 65 was 6.9 %, 54.1 % and 39.0 %, respectively. During corona pandemic frequency of LDL ≤ 100 reached to 4.9 %, 54.4 % and 40.7 %, respectively.

      4. Discussion

      In general, although the number of outpatient visits reduced significantly during COVID-19 lockdown, metabolic parameters including FBS, BS2hpp and HbA1c as glycemic control indices in patients with type 2 diabetes improved significantly compared before pandemic. In addition other metabolic parameters including total cholesterol, HDL and LDL as well as BMI reduced significantly statistically but however these changes were not clinically significant. Triglyceride was the only indicator that did not improve during the lockdown.
      Other studies also showed reduced number of outpatient visits in diabetes and cardiovascular diseases during covid-19 lockdown similar to our study as well [
      • Patel S.Y.
      • McCoy R.G.
      • Barnett M.L.
      • Shah N.D.
      • Mehrotra A.
      Diabetes care and glycemic control during the COVID-19 pandemic in the United States.
      ,
      • Solomon M.D.
      • Nguyen-Huynh M.
      • Leong T.K.
      • Alexander J.
      • Rana J.S.
      • Klingman J.
      • Go A.S.
      Changes in patterns of hospital visits for acute myocardial infarction or ischemic stroke during COVID-19 surges.
      ].
      Although lockdown in Covid-19 pandemic reduces the infection spread, it increased specific worries and reduced physical activity among patients [
      • Peimani M.
      • Bandarian F.
      • Namazi N.
      • Nasli-Esfahani E.
      COVID-19-specific worries among people with type 2 diabetes following the continuation of the pandemic and occurrence of multiple waves of COVID-19 in Iran.
      ,
      • Peimani M.
      • Bandarian F.
      • Namazi N.
      • Larijani B.
      • Nasli-Esfahani E.
      Physical activity behavior during the COVID-19 outbreak in individuals with type 2 diabetes: role of social support and other covariates.
      ] and caused challenges in the treatment of chronic diseases that require constant care and follow-up like type 2 diabetes and cardiovascular diseases. There are many studies about the effect of covid-19 pandemic lockdown on diabetes control in different countries but the results are controversial [
      • Patel S.Y.
      • McCoy R.G.
      • Barnett M.L.
      • Shah N.D.
      • Mehrotra A.
      Diabetes care and glycemic control during the COVID-19 pandemic in the United States.
      ,
      • Selek A.
      • Gezer E.
      • Altun E.
      • et al.
      The impact of COVID-19 pandemic on glycemic control in patients with diabetes mellitus in Turkey: a multi-center study from Kocaeli.
      ,
      • Önmez A.
      • Gamsızkan Z.
      • Özdemir S.
      • et al.
      The effect of COVID-19 lockdown on glycemic control in patients with type 2 diabetes mellitus in Turkey.
      ,
      • Karatas S.
      • Yesim T.
      • Beysel S.
      Impact of lockdown COVID-19 on metabolic control in type 2 diabetes mellitus and healthy people.
      ,
      • Biancalana E.
      • Parolini F.
      • Mengozzi A.
      • Solini A.
      Short-term impact of COVID-19 lockdown on metabolic control of patients with well-controlled type 2 diabetes: a single-centre observational study.
      ,
      • Khare J.
      • Jindal S.
      Observational study on effect of lock down due to COVID 19 on glycemic control in patients with diabetes: experience from Central India.
      ]. Some studies about glycemic control during lockdown in type 2 patients showed increased HbA1c and mean glucose [
      • Selek A.
      • Gezer E.
      • Altun E.
      • et al.
      The impact of COVID-19 pandemic on glycemic control in patients with diabetes mellitus in Turkey: a multi-center study from Kocaeli.
      ,
      • Önmez A.
      • Gamsızkan Z.
      • Özdemir S.
      • et al.
      The effect of COVID-19 lockdown on glycemic control in patients with type 2 diabetes mellitus in Turkey.
      ,
      • Karatas S.
      • Yesim T.
      • Beysel S.
      Impact of lockdown COVID-19 on metabolic control in type 2 diabetes mellitus and healthy people.
      ,
      • Biancalana E.
      • Parolini F.
      • Mengozzi A.
      • Solini A.
      Short-term impact of COVID-19 lockdown on metabolic control of patients with well-controlled type 2 diabetes: a single-centre observational study.
      ,
      • Khare J.
      • Jindal S.
      Observational study on effect of lock down due to COVID 19 on glycemic control in patients with diabetes: experience from Central India.
      ]. The main reason to the mentioned deteriorations in glycemic control may be changing pattern of lifestyle (reduced compliance to diet and exercise, excessive sedentary behavior) [
      • Selek A.
      • Gezer E.
      • Altun E.
      • et al.
      The impact of COVID-19 pandemic on glycemic control in patients with diabetes mellitus in Turkey: a multi-center study from Kocaeli.
      ,
      • Izzo I.
      • Santonastaso A.
      • Cotticelli G.
      • Federico A.
      • Pacifico S.
      • Castaldo L.
      • et al.
      An Italian survey on dietary habits and changes during the COVID-19 lockdown.
      ,
      • Sidor A.R.P.
      Dietary choices and habits during COVID-19 lockdown: experience from Poland.
      ], psychological stress related to pandemic [
      • Peimani M.
      • Bandarian F.
      • Namazi N.
      • Nasli-Esfahani E.
      COVID-19-specific worries among people with type 2 diabetes following the continuation of the pandemic and occurrence of multiple waves of COVID-19 in Iran.
      ] and lack of adherence to diabetes treatment regimen.
      While in line with our findings, there are some studies [
      • Psoma O.
      • Papachristoforou E.
      • Kountouri A.
      • et al.
      Effect of COVID-19-associated lockdown on the metabolic control of patients with type 2 diabetes.
      ,
      • Rastogi A.
      • Hiteshi P.
      • Bhansali A.
      Improved glycemic control amongst people with long-standing diabetes during COVID-19 lockdown: a prospective, observational, nested cohort study.
      ] which glycemic values significantly improved during COVID-19 pandemic compared before. It seems that self-care and digital diabetes management would be particularly effective in diabetes management in the pandemic era. Since the patient in our study have not receive any tele-health services and digital treatments, it is likely the improvement in glycemic control were related to the patient self-management [
      • Hartmann-Boyce J.
      • Morris E.
      • Goyder C.
      • Kinton J.
      • Perring J.
      • Nunan D.
      • et al.
      Diabetes and COVID-19: risks, management, and learnings from other national disasters.
      ]. In this regard type 2 diabetic patients during pandemic had access to the educational materials, mobile phone apps, websites, text messaging and instagram page as Diabetgram. Probably feasibility to access a variety of educational materials cause the life style positive changes.
      Another important point emphasized in similar study [
      • Psoma O.
      • Papachristoforou E.
      • Kountouri A.
      • et al.
      Effect of COVID-19-associated lockdown on the metabolic control of patients with type 2 diabetes.
      ] was the opportunity to work from home which lead to improved eating behavior (like regular eating time and home-made food) and daily time for routine physical activity. Actually the majority of patients in the current study were 45–65 years and in this age group they are mostly have a labor. Accordingly it could be noted that Covid-19 restriction prepared a flexible work schedule for patients to have healthier lifestyle. In view of similar study [
      • Capaldo B.
      • Annuzzi G.
      • Creanza A.
      • Giglio C.
      • De Angelis R.
      • Lupoli R.
      • et al.
      Blood glucose control during lockdown for COVID-19: CGM metrics in Italian adults with type 1 diabetes.
      ] the improved glucose control in diabetic patients may see because of more time for self-care and increased sleep duration which highlighting the importance of stable rhythm of life, including more regular mealtimes, diet and physical activity and less stressful life [
      • Capaldo B.
      • Annuzzi G.
      • Creanza A.
      • Giglio C.
      • De Angelis R.
      • Lupoli R.
      • et al.
      Blood glucose control during lockdown for COVID-19: CGM metrics in Italian adults with type 1 diabetes.
      ].
      In this regard our study decreasing lipid profile and BMI could suggest the healthy lifestyle during Covid-19 among type 2 diabetic patients compared before. However some studies showed lack of enough outdoor physical activity, weight gain and poor glycemic control followed by lockdown due to Covid-19 [
      • Karatas S.
      • Yesim T.
      • Beysel S.
      Impact of lockdown COVID-19 on metabolic control in type 2 diabetes mellitus and healthy people.
      ] while others did not find any weight gain [
      • Selek A.
      • Gezer E.
      • Altun E.
      • et al.
      The impact of COVID-19 pandemic on glycemic control in patients with diabetes mellitus in Turkey: a multi-center study from Kocaeli.
      ] similar to ours. It should be noted that part of the results of our study in line with this research, showed an increase in TG level independent of weight gain in the patients. It is noteworthy that decreasing in the TG level in diabetics was not clinically significant.
      It should be mentioned that remote diabetes services as tele-healthcare system indicated helpful consequences with continuous patient support [

      M. Benaissa, B. Malik, A. Kanakis, N.P. Wright (eds.), Tele-healthcare for Diabetes Management: A Low Cost Automatic Approach, 2012 Annual International Conference of the IEEE Engineering in Medicine and Biology Society, IEEE, 2012.

      ] though it is not widely accessible for our diabetic patients. However remote support of patients suffering from diabetes still challenging and.
      The main limitation of this study is that there is no information about glycemic and metabolic control of those patients whom did not refer to the Clinic during covid-19 pandemic which may change these results.

      5. Conclusion

      According to the results, during COVID-19 lockdown glycemic and metabolic control of diabetes patients has improved significantly except for triglyceride. Such metabolic improvement may be due to improved self-management and free-living of type 2 diabetes with flexible life style at home. However, all of these changes were significant only statistically but not clinically. It should be noted that these results belong only to those patients referred to Diabetes Clinic regularly before and during covid-19 pandemic which may indicate their better access to care, paying more attention to priority of diabetes care and control, having more knowledge about covid-19 complication and outcome and better self-management.
      In this regard the effectiveness of self-management during the pandemic would be important. However, telehealth, virtual visit, and teleconsulting with health care providers in diabetes clinic were not available during corona outbreak. So, it is essential to implement a variety of online services for diabetes management and prevention of complications such as routine diabetes care, foot screening, eye screening, blood tests and urgent diabetes care. It seems that virtual communication with peers in virtual social network, potentially feasible in pandemic aiming to optimize self-care of diabetes should be considered.

      CRediT authorship contribution statement

      FB: concept of study, data collection and analysis, interpretation of results, writing first draft of manuscript, approving final manuscript. MQ: Data analysis and approving final manuscript. MA: writing first draft of manuscript, approving final manuscript. MP: data collection, approving final manuscript. BL, ENE: concept and design of study, approving final manuscript.

      Consent for publication

      Not applicable.

      Funding

      The study was supported by a grant from Endocrinology and Metabolism Research Institute of Tehran University of Medical Sciences.

      Declarations

      The present study was approved by the Ethics Committee of Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences (TUMS) (code: IR.TUMS.EMRI.REC.1399.052). Moreover the authors seriously considered ethical issues.

      Conflict of Interest

      The authors have no conflict of interest to report.

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