• Ariel Warren, RDN, CDCES

How to Stay Safe with Type 1 Diabetes and COVID-19

Updated: Mar 20

#coronavirus #t1d #immunecompromised #COVID19diabetes





The CDC has determined COVID-19 as a serious public health threat - and on top of the list of people who are at increased risk of those who have serious chronic conditions. However, according to many physicians whose expertise includes T1D, people with T1D are NOT more susceptible to coming down with COVID-19. Experts further say that if someone with T1D gets COVID-19, they are not at an increased risk for serious complications from the virus. The people who are at greater risk are those with long-term poor control which has contributed to a second chronic disease (i.e. heart disease, renal failure, or have a immune compromised condition).


If you are well-controlled and in otherwise good health, you are at a very similar risk of someone without diabetes. Well-controlled diabetes is typically defined as an average A1c of 7% or less. But even still, it's not the diabetes that states someone as immune-compromised (even if above 7.0%), it's if someone has a second or more chronic condition(s) in addition to diabetes.


However if you do fall into the immune compromised category or you just want to be careful, then take a deep breath, you will be okay.


The purpose of this article is go over the reality of COVID-19, give tips to prevent getting sick, learn how to prepare if you have to quarantine, give guidelines to monitor blood sugar and ketones if you do get sick, and learn about the foods you should stalk up on that keep well, boost your immune system, and allow you to keep good blood sugar control.


Before diving in, understand that COVID-19 is far from the first illness that has caused alarm and remember that it is a global event. Meaning, we have thousands of scientists and researchers putting in overtime all across the world to find better ways to treat and detect the virus. This is but a small moment, and it too shall pass.


COVID-19 FAQ


What exactly is COVID-19?


COVID-19 (short for coronavirus disease 2019) is part of the family of viruses known to cause respiratory illness or SARS (Severe Acute Respiratory Syndrome). Most viruses cause illness in animals, but seven known types of coronaviruses cause illness in humans. These human versions are believed to have originated from a human eating an infected animal. SARS-CoV-2 is one of the human of the seven viruses and is the cause for the COVID-19 strain.

What are the COVID-19 symptoms?

People who test positive for COVID-19 exhibit signs such as mild to severe respiratory illness with a fever, coughing, and a shortness of breath. With the respiratory illness, infected people may also experience aches and pains, nasal congestion, runny nose, sore throat, and/or diarrhea. However these additional symptoms usually develop gradually after the onset of the virus.

How will you know if you have COVID-19?

The virus is spread from person to person and it's most common way of being spread is by being within 6 feet of someone who is contagious. Presently, only the CDC can test if you have COVID-19. If you think you have been exposed, you should contact your healthcare provider immediately because you can be contagious for 5-11 days before showing any symptoms.


What should I know about the incubation period?


The estimated average incubation time of COVID-19 is around 5 days. Symptoms may appear as late as day 11. Fewer than 3% show symptoms before day 2. The estimated incubation for a fever from COVID-19 is around 5-6 days.


Because you can be contagious for many days before showing any symptoms, if you have come in contact with someone who has COVID-19, it is best to quarantine for 14 days immediately after exposure.




How to Protect Yourself from COVID-19


This post is broken into the four following sections:


  • Critical Steps to Prevent COVID-19

  • Must-Know Tips for People with Diabetes who are Immune Compromised

  • What to Do if You Do Get Sick with COVID-19 when you have Diabetes

  • T1D Food Checklist to Boost your Immune System with COVID-19



Critical Steps to Prevent COVID-19


These four steps are tips for everyone, but are still relevant to help anyone (with or without diabetes) keep from being infected with COVID-19.



1. Avoid crowds at all costs


Max number for a gathering is ten and with "healthy" people. Healthy is in quotations because someone can appear healthy for 5 or so days before showing any symptoms.


2. Space yourself from others


If you have to go to the grocery store, go during hours that are less busy. Better yet, send a spouse or friend off with your shopping list to go for you instead. Keeping distance is public areas is rather necessary if you are immune-compromised.


3. Keep Sterile and Wash your hands


COVID-19 has been deemed as an airborne transfer virus, meaning that if someone sneezes who is a carrier, you can potentially walk into their "droplets" and be infected. Therefore, if you HAVE to go somewhere that may put you in danger, it is better to be well covered with gloves, a mask, and possibly goggles. Don't feel odd about your COVID-19 attire, your safety is much more important that feeling a tad silly for a moment.


4. Avoid travel. Period.


You are exposed to far too many unknowns while traveling, so to keep safe, cancel all travel plans for the next couple of weeks. If you were planning to fly or had reservations, call the airline(s), hotel, event, etc to see if you can receive a refund. Your situation is not uncommon given the circumstances, and you will likely receive some sort of reimbursement.



Must-Know Tips for People with Diabetes who are Immune Compromised


The following steps are specific tips to help someone with diabetes prepare if quarantining is necessary or if sickness occurs.


1. Refill your Insulin and Medication Prescriptions


My advice for you is to have a minimum of 3 months worth of insulin and medication(s). Granted, you will likely not need to self-quarantine for that long, but my general rule is to stick to the amount you know you will need, then add 1 more month. The reason for this is that if you have insulin or medication that breaks or goes bad, you are not put in a tough spot.


If you can't afford 3 months+ of insulin and your other medication(s) or you can only get a single month prescription, get what you can, then if you are running low (don't go below a 2 week supply), call your HCP for samples.


Another option is to ask your Endo if you can get an rx for the off-brand fast-acting insulin such as lispro, aspart, or glulisine or other necessary medications. Just double check that your preferred pharmacy stalks that insulin before pick up. On a side note, off-brand fast acting insulin should work the same as brand name, and perhaps, you may even like this insulin better! Win-win!


You can also double check with your clinic to see if there are any programs going on to make your desired insulin or medication more affordable. You can also always serach online. Two of my favorite websites to check for discounted medications are the following.


needymeds.org

goodrx.com


You can also go the website of the drug manufacturer to check for money saving programs and/or coupons.



However, you can also ask your Endo for more samples to get you by. Granted, a higher percentage of patients will be asking for samples during such times, but the drug reps know this and are making arrangements to meet the patient demand. Better yet, call sooner than later so your Endo can ask his/her MA to stash you samples when they become available from the reps.


When you do need to pick up the samples, have your friend, family member, or significant other go in your place, but have him/her take your government-ID (to prove they are picking up the goodies for you). The reason this may be a good idea is the people who go to the doctor are more likely sick or immune-compromised than the general public. You don't want to get sick and you don't want others who may have a weaker institution get sick from you. If you are extremely immune-compromised, have your person be even more careful when they go to the clinic (AKA have them wear the whole get up of gloves, goggles and mask). You can even very politely ask him/her to take a shower or change their clothes once they get home with your goodies (insulin and medication).


If for some reason your Endo does not have any samples or your clinic has shut down so you cannot get samples, ask your community. You can do this by asking a neighbor, or asking a local FB group. If talking to a group, let other group members know of your current predicament about having insulin-dependent diabetes and that you need insulin (STAT). Also add in there that once you have your prescription refilled, you will gladly give back the amount so kindly given to you during your time of need. To be extra nice, you can give back the amount with a nice note or a "diabetic friendly" treat.


Another option, is to always have a point of contact before you are in this situation. For me, I have a grandma who has insulin-dependent, type 2 diabetes. Worst case scenario, I know I can ask her for insulin to get me by in an emergency situation, and then restore what she gave me when I get access to my prescription. Of course, this only works if your friend/family member has extra supplies.


Lastly, you can always call urgent care or other nearby clinics that are open so you can get access to insulin. Hopefully you are never in this predicament, but if you are, understand that people have diabetes EVERYWHERE and you have access to people and a community who can get you the supplies you need to keep safe during times when you may be in need.


2. Stalk Up on Durable Medical Equipment (DME)


First off, I want to clear the air of any scares about infected pump or CGM supplies that are then sent to your house. As a pump trainer and a CDCES, I have special knowledge about the level of sterilization and protocol that goes into DME production so do not worry about your supplies being contaminated.


About stalking on supplies. My rule to aim for 3 month still applies. This is not always an option for those who have to stick to a month-to-month prescription, however, I would ask your DME supplier and your HCP to see if you can either extend your usual month-to-month prescription amount to 3 months or, at least see if you can order your next shipment with your DME supplies early.


Below is a Detailed Supply Checklist if you are use a pump and CGM...



If you cannot increase your supplies by ordering more or sooner than usual, I would be absolutely trigger-happy to get replacements for poor CGM sensors and/or pump equipment. Meaning, if you have a bad site, sensor, etc, make sure to write down the date, lot number, and reason for the DME that went bad. Then call customer service of the pump or CGM device such as Dexcom, Medtronic, Insulet (Omnipod), Tandem (do not call your DME supplier). Call within 30 days of the event and call sooner than later so you can get it over and done with and have extra supplies on hand if needed. Customer service for these companies are open 24/7 so do NOT call on a Monday morning. You have way more important things to do rather than sitting on hold for hours and wondering why you didn't listen to my advice!


Lastly, the well-known DME companies have distributed public statements about their supply chains (listed below). They do not expect any changes in supply, however below is a list that provides current updates on supply status.





3. Have a Back Up Plan


Have your usual supplies, but along with those supplies, it is critical to have a backup plan. If using a pump, you will already having fast-acting on hand (Novolog, Humalog, Apidra, Fiasp, etc), but you will also need to have a vial or pen of long-acting insulin (Tresiba, Toujeo, Lantus, Basaglar, etc).


It's important to note, that if you are using a pump, your total daily dose (TDD) will likely be significantly less than your TDD compared to multiple daily injections (MDI), especially if using pens rather than syringes for your back-up plan, The reason for this is because you generally have much better insulin absorption with a pump. Therefore, it is best to acquire personalized dosing instructions that are calculated either by your PCP, Endo, or a CDCES (Certified Diabetes Care & Education Specialists). Have these dosing instructions written down and easily accessible with your backup supplies.


Along with your back up insulin, make sure you have the necessary accompanying supplies to administer the insulin (think pen needles and/or syringes).



What to do if you do get Sick with Type 1 Diabetes


As you are likely aware, your blood sugar tells you something is "off" before you show symptoms. If you see that your having irregularly high blood sugar that won't come down and it's not related to a bad infusion site, old insulin, or simply not taking insulin (missed dose), you may be fighting an illness, stress, or worst case COVID-19. This is obviously stating worst case scenario, but it is best to be prepared just in case. This section is to inform you on what to do in case you do get sick.



1. Stick to your normal routine of Insulin and Medications


This can be difficult when you are feeling under the weather, especially if you are having a hard time keeping food and liquid down, but try to keep to what you know and what has given you decent results in the past.


Beyond insulin, many over-the-counter (OTC) medications also affect blood glucose levels. You will need to consider how cough syrups and drops, even decongestants and medication with coating can contain sugar and can worsen already high blood sugar.


Aspirin in large doses can lower blood sugar levels. Acetaminophen can cause false or no readings in CGMs, and too much acetaminophen can be toxic to the liver and kidneys. If you have kidney complications, you need to be cautious about using drugs with acetaminophen. Also, it's important to know that Ibuprofen should be handled with care because it can increase the blood sugar lowering effect of insulin.



2. Closely Monitor Blood Sugar and Ketones (even more than usual)


When you are not feeling well, you will likely not feel like eating and drinking as you usually do, especially if you are taking medications to lower a fever or relieve muscle aches. Feeling this way is very normal while fighting an illness, but for those who are insulin-dependent, it is even more critical to continue to take your insulin (likely an adjusted dose), monitor your blood glucose levels and be checking for ketones.


One way to closely monitor your blood sugar is through the use of a CGM, However, be more cautious about your CGM values because you will likely feel "off" compared to your usual low and high blood sugar symptoms while being sick. If you don't have access to a CGM, test every 3-4 hours to keep close watch (which includes during the night).


Sickness and Your Higher Risk of DKA


If you are sick, you will likely have a decreased appetite. If you are not eating, you will likely take substantially less insulin. The issue with this is that when you are sick, your body is under a higher amount of stress which causes increased insulin resistance and blood sugar levels that are higher and more difficult to correct. By having low amounts of insulin (from not eating) while having increased insulin resistance, you are at a higher risk of developing ketones. If left untreated, increasing ketones in your blood can quickly turn into Diabetic Ketoacidosis (DKA) which requires an emergency room visit for treatment.


If you are sick, and experiencing stubborn blood sugar, use the chart below to figure out what to do.


Understand that symptoms of ketones can be similar symptoms of the flu or a severe sickness, which is another reason why you need to closely monitor ketones during this time.


If you have large ketones through blood or urine, you will need to call your provider, 911, or go the Emergency room if you are also presenting any of the signs/symptoms listed below:


  • Can’t eat or drink

  • Severe headache/migraine

  • Vomiting more than 6 hours

  • Trouble breathing

  • Large ketones more than 9 hours

  • Incoherent (Not making sense or not waking up)


3. Have an Action Plan if You Do Get Sick


Before getting into a predicament, along with having supplies and a backup plan, you will also need to have at least 2 points of contact.


#1 Healthcare provider (PCP, Endo, CDCES)

#2 Friend, partner, or family member


You should have access to a healthcare provider for emergencies as a contact, but you also need a friend, partner, or a family member to help you when you are sick.


T1D Food Checklist to Boost your Immune System with COVID-19



As a Dietitian and a CDCES, here is a list of foods that keep well during storage, but also boost your immune system while keeping your blood sugar stable.


These foods are my own personal list that I always keep on hand either in my fridge, freezer or as dry storage in the pantry. These foods are nutrient dense and are high in fiber which allow for a healthy gut, a boosted immune system and foods that allow for me to keep good blood sugar control.



And let's be real, if you are quarantined, you better have a little stash of something delicious!


My final thoughts as someone who also has type 1 diabetes.



This can be a scary time, but when I was talking to a patient at the Endo clinic the other day, I asked her how she was doing during all of this. Her reply was perfect and I think this is how we should all be thinking. She simply said, "Catching [COVID-19] is not my destiny. I have way too many things I need to be doing for others, so I'm not worried."


This article is to help you be prepared, but my lasting message is to find ways to stay positive and make the most of this time while you spend it with your family and loved ones. And let's be real, also to spend time cleaning and organizing parts of your house that have probably been neglected for an embarrassingly long time (I know I'm guilty!).


During this time, my kids and I have been having fun watching lots of Disney movies, playing games, and making plates full of fun treats that may or may not contain copious amounts of chocolate chips!



What is something positive that has come from your COVID-19 quarantine time? I'd love to hear from you, share in the comments below.


♥♥♥♥♥


As always, if you are struggling with your diabetes (newly diagnosed or a long-time veteran). Perhaps you need pump adjustments, insight on how your nutrition is affecting your insulin sensitivity, you want to understand how to go about making your own insulin changes, maybe you want to work with a HCP who understands on a personal level what it feels like to have diabetes, or maybe you are a little scared about all the news on COVID-19. Do not hesitate to write me an email or schedule with me for a consultation. I'm here to help and I love helping people with diabetes increase their control and quality of life.


Sincerely,


Ariel Warren, RDN, CD, CDCES

UT-ADCES Chair-Elect

Diabetes Care & Education Specialist

Type 1 Diabetes for the Newly Diagnosed










Works Cited


“Coronavirus.” Coronavirus | ADA, www.diabetes.org/diabetes/treatment-care/planning-sick-days/coronavirus.


“Coronavirus.” JDRF, www.jdrf.org/coronavirus/.


“If You Are at Higher Risk.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 12 Mar. 2020, www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-complications.html.


Lauer, Stephen A., et al. “The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application.” Annals of Internal Medicine, 10 Mar. 2020, annals.org/aim/fullarticle/2762808/incubation-period-coronavirus-disease-2019-covid-19-from-publicly-reported.

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