AbstractBackground

The COVID-19 pandemic has impacted every individual’s life. It has been shown that mortality in people with underlying diseases including diabetes has been high. The present study aimed to measure diabetes related worries (outcome) and their associations with social support and lifestyle (exposures) amongst people with diabetes during the COVID-19 pandemic.

Methods

An online cross-sectional survey was completed by 928 respondents (>18 years) between 15-11-2020 and 12-12-2020. The questionnaire comprised four sections: socio-demographic details, diabetic-related worries, social support, and behavioral changes due to COVID-19. Descriptive statistics, correlations and hierarchical regression analysis were performed in the study.

Results

Data from 928 respondents (51.61% male; mean age = 52.48 [SD = 11.76]; age range = 18-86 years) were analyzed. The mean score for COVID-19 specific diabetes worries was 3.13 out of 8. Hierarchical regression analysis showed that the mean COVID-19-specific diabetes worries score was significantly associated with lower age, cigarette smoking, perceived poor health status, presence of other diabetic complications. Lack of social support from family, friends, work colleagues and diabetes care team and also eating more than usual were also significantly associated with COVID-19 specific diabetes worry.

Conclusions

Diabetes related worries were strongly associated with a lack of social support during the COVID-19 pandemic. The findings suggest the need of social support as well as improving knowledge and guidelines is important for people with diabetes during the COVID-19 pandemic.

1. IntroductionThe recent emergence of COVID-19 has had a greater impact on people with comorbid conditions such as diabetes, hypertension, coronary heart disease, obesity, cancer and HIV/AIDS [[1]Hussain A. Bhowmik B. do Vale Moreira N.C. COVID-19 and diabetes: knowledge in progress.,[2]Singh A.K. Gupta R. Ghosh A. Misra A. Diabetes in COVID-19: prevalence, pathophysiology, prognosis and practical considerations.]. Diabetes has been the second most common comorbidity (9.7%) among COVID-19 patients after cardio-metabolic disorders (12.5%) [[1]Hussain A. Bhowmik B. do Vale Moreira N.C. COVID-19 and diabetes: knowledge in progress.,[3]Hill M.A. Mantzoros C. Sowers J.R. Commentary: COVID-19 in patients with diabetes.]. In 2019, the International Diabetes Federation (IDF) reported that 465 million (9.3%) people in the world were diagnosed with diabetes, and by 2045 the figure is predicted to grow to 700 million [[4]Akhtar S. Nasir J.A. Sarwar A. et al.Prevalence of diabetes and pre-diabetes in Bangladesh: a systematic review and meta-analysis.]. About 79% of people with diabetes live in low-income or middle-income countries, with more than 60% living in Asian countries [[5]Guariguata L. Whiting D.R. Hambleton I. Beagley J. Linnenkamp U. Shaw J.E. Global estimates of diabetes prevalence for 2013 and projections for 2035.]. In Bangladesh, there were 7.1 million people suffering with diabetes in 2015, with 3.7 million undiagnosed cases and nearly 129,000 deaths [[4]Akhtar S. Nasir J.A. Sarwar A. et al.Prevalence of diabetes and pre-diabetes in Bangladesh: a systematic review and meta-analysis.,]. Other reports suggest that there are almost 10 million diabetic patients in Bangladesh [] with almost one in ten adults living with diabetes [[8]Akter S. Rahman M.M. Abe S.K. Sultana P. Prevalence of diabetes and prediabetes and their risk factors among Bangladeshi adults: a nationwide survey.]. Nevertheless, to date, there are no data of how many people with diabetes patients have been infected with COVID-19 and what the mortality rate is in Bangladesh.It is known that people who are living with chronic diseases such as diabetes are at increased risk of morbidity and mortality if they are infected with COVID-19 [9Puig-Domingo M. Marazuela M. Giustina A. COVID-19 and endocrine diseases. A statement from the European Society of Endocrinology., 10Guan W.-J. Liang W.-H. Zhao Y. et al.Comorbidity and its impact on 1590 patients with COVID-19 in China: a nationwide analysis., 11Sanyaolu A. Okorie C. Marinkovic A. et al.Comorbidity and its impact on patients with COVID-19., 12Diabetes, infection risk and COVID-19.]. Maintaining good glycemic regulation is therefore important method in order to avoid complications arising from COVID-19 [[13]Banerjee M. Chakraborty S. Pal R. Diabetes self-management amid COVID-19 pandemic.,[14]Katulanda P. Dissanayake H.A. Ranathunga I. et al.Prevention and management of COVID-19 among patients with diabetes: an appraisal of the literature.]. It is also known that diabetes management may be difficult as a result of government policies to regulate transmission such as social distancing and lockdowns. It is likely that diabetic individuals will face barriers in controlling their glycemic levels. These can include restricted access to healthcare, limited availability of fresh food, and reduced physical activity due to confinement [[13]Banerjee M. Chakraborty S. Pal R. Diabetes self-management amid COVID-19 pandemic.]. Like many countries, in order to reduce the spread of the virus, the government in Bangladesh imposed strict social isolation and home quarantine measures [15Rahman M.E. Islam M.S. Bishwas M.S. Moonajilin M.S. Gozal D. Physical inactivity and sedentary behaviors in the Bangladeshi population during the COVID-19 pandemic: An online cross-sectional survey., 16Islam M.S. Emran G.I. Rahman E. et al.Knowledge, attitudes and practices associated with the COVID-19 among slum dwellers resided in Dhaka City: a Bangladeshi interview-based survey., 17Ferdous M.Z. Islam M.S. Sikder M.T. Mosaddek A.S.M. Zegarra-Valdivia J.A. Gozal D. Knowledge, attitude, and practice regarding COVID-19 outbreak in Bangladesh: an online-based cross-sectional study.] that would invariably affect regular physical movement and healthcare access.The COVID-19 has an immense negative impact on diabetic patients. A previous study reported that individuals admitted to intensive care units (ICU) were more likely to have pre-existing diabetes compared to patients with the COVID-19 who did not receive intensive care [[18]Wang D. Hu B. Hu C. et al.Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China.]. As diabetes mellitus and cardiovascular conditions are contributing factors for worsening COVID-19 severity and consequences, including higher infection and death rates [[19]Lim S. Bae J.H. Kwon H.-S. Nauck M.A. COVID-19 and diabetes mellitus: from pathophysiology to clinical management.]. Individuals with such medical conditions are more likely to suffer from mental health problems such as depression panic attacks and anxiety [[20]Hasan S.S. Clavarino A.M. Mamun A.A. Kairuz T. Anxiety symptoms and the risk of diabetes mellitus in Australian women: evidence from 21-year follow-up.]. A recent study conducted in Brazil reported emotional distress (29.2%), eating disorders (75.8%), and moderate/severe sleeping disorders (77.5%) among diabetes patients during the COVID-19 [[21]Alessi J. de Oliveira G.B. Franco D.W. et al.Mental health in the era of COVID-19: prevalence of psychiatric disorders in a cohort of patients with type 1 and type 2 diabetes during the social distancing.].It is to be expected that the COVID-19 epidemic, mass media coverage of the trajectory of the pandemic worldwide, and the terrifying death rates would lead to a decrease in mental well-being and increase in psychological disorders, including anxiety, depression and stress [22Bao Y. Sun Y. Meng S. Shi J. Lu L. 2019-nCoV epidemic: Address mental health care to empower society., 23Lima C.K.T. de Medeiros Carvalho P.M. Lima I de A.S. et al.The emotional impact of Coronavirus 2019-nCoV (new Coronavirus disease)., 24Islam M.S. Potenza M.N. Van Os J. Posttraumatic stress disorder during the COVID-19 pandemic: upcoming challenges in Bangladesh and preventive strategies.]. We hypothesized that these mental health parameters like worry would be higher in people with diabetes due to the higher risk of mortality and morbidity in this group [[25]Joensen L.E. Madsen K.P. Holm L. et al.Diabetes and COVID‐19: psychosocial consequences of the COVID‐19 pandemic in people with diabetes in Denmark—what characterizes people with high levels of COVID‐19‐related worries?.], making them even more vulnerable to worries. This in turn would affect their glycemic control. It is also likely that the management routine of people with diabetes has been disrupted, increasing worries amongst patients and leading to changes in their behavior. However, during this crucial time, people with diabetes p may also experience reduced social support due to various government restrictions. In addition to uncontrolled diabetes can increase the risk of diabetic complications such as retinopathy, neuropathy, diabetic foot and nephropathy [[26]Mørkrid K. Ali L. Hussain A. Risk factors and prevalence of diabetic peripheral neuropathy: A study of type 2 diabetic outpatients in Bangladesh.,[27]Abraham G. Varughese S. Thandavan T. et al.Chronic kidney disease hotspots in developing countries in South Asia.].Several studies conducted with different cohorts have included general population, university students, medical students, slum-dwellers, health workers, and COVID-19 survivors have highlighted various mental health problems (e.g., anxiety, depression, panic, stress, post-traumatic stress disorder, suicidal ideation and addictive behaviors such as problematic use of smartphone, internet, social media) in Bangladesh during the pandemic [28Islam M.S. Sujan M.S.H. Tasnim R. et al.Problematic smartphone and social media use among Bangladeshi college and university students amid COVID-19: The role of psychological wellbeing and pandemic related factors., 29Tasnim R. Sujan M.S.H. Islam M.S. et al.Prevalence and correlates of anxiety and depression in frontline healthcare workers treating people with COVID-19 in Bangladesh., 30Al Banna MH Sayeed A. Kundu S. et al.The impact of the COVID-19 pandemic on the mental health of the adult population in Bangladesh: a nationwide cross-sectional study., 31Islam M.S. Ferdous M.Z. Sujan M.S.H. et al.The Psychometric Properties of the Bangla Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): A Large-scale Validation Study., 32Islam M.S. Tasnim R. Sujan M.S.H. et al.Depressive symptoms associated with COVID-19 preventive practice measures, daily activities in home quarantine and suicidal behaviors: Findings from a large-scale online survey in Bangladesh., 33Tasnim R. Islam M.S. Sujan M.S.H. Sikder M.T. Potenza M.N. Suicidal ideation among Bangladeshi university students early during the COVID-19 pandemic: Prevalence estimates and correlates., 34Islam M.S. Ferdous M.Z. Potenza M.N. Panic and generalized anxiety during the COVID-19 pandemic among Bangladeshi people: an online pilot survey early in the outbreak., 35Islam M.S. Ferdous M.Z. Islam U.S. Mosaddek A.S.M. Potenza M.N. Pardhan S. Treatment, persistent symptoms, and depression in people infected with COVID-19 in Bangladesh., 36Islam M.S. Sujan M.S.H. Tasnim R. et al.Problematic internet use among young and adult population in Bangladesh: Correlates with lifestyle and online activities during the COVID-19 pandemic., 37Islam M.S. Sujan M.S.H. Tasnim R. Sikder M.T. Potenza M.N. van Os J. Psychological responses during the COVID-19 outbreak among university students in Bangladesh., 38Islam M.S. Rahman M.E. Banik R. et al.Correlates of financial concerns, depression symptoms, and posttraumatic stress disorder symptoms among impoverished urban dwelling individuals in Bangladesh during the COVID-19 pandemic: A face-to-face interview approach., 39Islam M.S. Akter R. Sikder T. Griffiths M.D. Prevalence and factors associated with depression and anxiety among first-year university students in Bangladesh: a cross-sectional study., 40Safa F. Anjum A. Hossain S. et al.Immediate psychological responses during the initial period of the COVID-19 pandemic among Bangladeshi medical students.]. To date, there is no prior study examining COVID-19-specific worries and diabetes related social-support among diabetic patients in Bangladesh. We developed a questionnaire based on published literature to assess worries [[25]Joensen L.E. Madsen K.P. Holm L. et al.Diabetes and COVID‐19: psychosocial consequences of the COVID‐19 pandemic in people with diabetes in Denmark—what characterizes people with high levels of COVID‐19‐related worries?.], social-support and behavioral changes among people with diabetes during the COVID-19 pandemic. Consequently, the present study aimed to assess the diabetes related worries, and to determine their factors associated with social support and lifestyle among the diabetic patients due to the COVID-19 outbreak in Bangladesh.2. Methods2.1 Study design and procedureA cross-sectional study design was utilized for conducting the present study. Convenient sampling technique also utilized in the study. Data were collected between 15 November and 12 December 2020, during the second wave of the COVID-19 pandemic in Bangladesh. The target population were Bangladeshi citizens who could speak and understand the common language Bangla. Participants had to have been diagnosed with diabetes for at least six months prior to the study. A self-reported and semi-structured e-questionnaire was developed from previous literature [[25]Joensen L.E. Madsen K.P. Holm L. et al.Diabetes and COVID‐19: psychosocial consequences of the COVID‐19 pandemic in people with diabetes in Denmark—what characterizes people with high levels of COVID‐19‐related worries?.]. This was disseminated via social platforms (such as Facebook, WhatsApp, online blogs, etc.). Before data collection, a pilot test comprising 50 samples was carried out to ensure the validity and reliability of the questionnaire. These data were not included in the final sample. Where needed, data were collected with the help of Research Assistants (RA) who had access to diabetic patients. For participants above the age of 70 years, those who did not have any smartphones or were digitally illiterate, responses were collected by family members who completed the online questionnaire. The inclusion criteria for the participants included being (i) above 18 years old, (ii) diagnosed as diabetese patient at least more than 6 months ago, and (iii) Bangladeshi citizen. The exclusion criteria were being (i) individual with no diabetes, and (ii) incomplete survey.2.2 Sampling procedureThe sample size was calculated using the following equation:

n=z2pqd2; n=1.962×.5×1-.5.052=384.16≈384

Here,

n = number of samples

z = 1.96 (95% confidence level)

p = prevalence estimate (50% or .5) (as no study found)

q = (1−p)

d = precision of the prevalence estimate

The calculated sampling size was 384. There are limited studies to base this on however p = .5 was initially selected. Our sample size exceeds this by a substantial proportion. Out of 1052 received responses, 928 responses were analyzed after removing incomplete or ineligible data. The survey was designed in such a way that individuals first gave informed consent by accepting the fact that they were willingly and voluntarily participating in this study. There was no compensation for completing the questionnaire. Following that, a confirmation of their diabetes status was obtained by ‘Have you been diagnosed as having diabetes?’ if the answer of the person was “no”, then a blank response was submitted. If the individual responded “yes”, the full survey form became accessible.

2.3 Measures

The e-questionnaire consisted of four sections: socio-demographic, COVID-19-specific diabetes worries, social support, and behavioral changes due to the COVID-19.

2.3.1 Socio-demographic measuresSocio-demographic data included questions on age, sex, occupation, marital status (single/married/divorced or widow or widower), and residence (urban/rural). In addition, data on smoking habits (yes/no), physical exercise (yes/no), and average number of sleep hours were acquired. Average sleeping hours were classified into three categories according to previous literature: normal (7-9 h), less than average ( 9 h). [[33]Tasnim R. Islam M.S. Sujan M.S.H. Sikder M.T. Potenza M.N. Suicidal ideation among Bangladeshi university students early during the COVID-19 pandemic: Prevalence estimates and correlates.,[36]Islam M.S. Sujan M.S.H. Tasnim R. et al.Problematic internet use among young and adult population in Bangladesh: Correlates with lifestyle and online activities during the COVID-19 pandemic.] Less than average (9 h) of sleep were classed as sleep disturbance. Self-rated health status was obtained from three possible responses: good, moderate or poor (Table 1).

Table 1Descriptive analysis of each variable and association with COVID-19-specific diabetes worries.

2.3.2 COVID-19-specific diabetes worries measures and diabetes related questionsWith regards to assessing COVID-19-specific diabetes worries, a total of eight questions with dichotomous responses (yes/no) were asked during the survey, adopted from previous published literature [[25]Joensen L.E. Madsen K.P. Holm L. et al.Diabetes and COVID‐19: psychosocial consequences of the COVID‐19 pandemic in people with diabetes in Denmark—what characterizes people with high levels of COVID‐19‐related worries?.] (Table 2). Respondents were also asked additional questions regarding diabetes, including type of diabetes (type 1/type 2/LADA/gestational), and the presence of diabetic complications (e.g., retinopathy, nephropathy, neuropathy, and foot ulcer).

Table 2Descriptive analysis and gender differences with regard to each item of COVID-19-specific diabetes worries questionnaire.

2.3.3 Social support related questionsSocial support related data were collected by asking five questions (Table 3) with three possible responses (i.e., 1 = Not supportive, 2 = Somewhat supportive, and 3 = Very supportive). Information about support from family members/friends/relatives, work colleagues, other people in the community (neighbors), and other diabetic patients were obtained (e.g., are you getting enough support from your family members/friends/relatives to maintain your diabetes during the COVID-19?). Furthermore, questions regarding support from healthcare providers were also included: Are you getting sufficient care from your health care team (such as doctors, nurses) in this COVID-19 situation? [[25]Joensen L.E. Madsen K.P. Holm L. et al.Diabetes and COVID‐19: psychosocial consequences of the COVID‐19 pandemic in people with diabetes in Denmark—what characterizes people with high levels of COVID‐19‐related worries?.]

Table 3Descriptive statistics, reliability indices, and correlations between items regarding social supports, behavioral changes and COVID-19-specific diabetes worries (see item 12) (N = 928).

Note: α = Cronbach’s alpha or coefficient alpha; SE = standard error; SD = standard deviation.

Social support: Items number (1-5) were scored 1-3 (i.e., 1 = Not supportive, 2 = Somewhat supportive, and 3 = Very supportive);

Behavioral changes: Items number (6-11) were scored 0-1 were scored as yes/no (i.e., 0 = No, and 1 = Yes); and

COVID-19-specific diabetes worries: The higher score indicates the greater level of COVID-19-specific diabetes worries.

2.3.4 Behavioral changes due to COVID-19Behavioral changes due to the COVID-19 pandemic were ascertained using ‘yes/no’ questions (Table 3: items 6-11). These included questions such as are you measuring your blood glucose level more than usual due to fear of COVID-19? Are you taking medicine more regularly and carefully than before? Are you doing less physical exercise than before? are you doing more physical exercise than before? Are you eating less than before? And are you taking more food than before?2.4 Statistical analysis

Descriptive statistics (i.e., frequencies, percentages, means, standard deviations) were calculated. Inferential statistics included conducting t-tests or one-way Analysis of Variance (ANOVA) to determine the mean differences in the score of COVID-19-specific diabetes worries in relation to background variables, social support, and behavioral changes due to COVID-19. Additionally, Skewness, Kurtosis, and Pearson correlation between all items regarding social support and behavioral changes in relation to the COVID-19-specific diabetes worries were calculated. Parameters that were statistically significant in the group difference analyses (t-tests/ANOVA) and Person correlations analyses, were included in a hierarchical regression analysis. These were categorized into different blocks:

Block 1: Background variables (i.e., age, residence, sleep disturbance, smoking habits, physical exercise, health status, and complications due to diabetes).

Block 2: Social support (i.e., from family members/friends/relatives, colleagues, diabetes care teams, other people in the community [neighbors], and other people with diabetes).

Block 3: Behavioral changes due to COVID-19 (i.e., checking blood glucose more often than usual, less exercise than usual, eating less than usual, and eating more than usual).

All analyses were executed using Statistical Package for the Social Sciences (SPSS) version 25 using a p-value less than .05.

4. ResultsA total of 928 diabetes patients were included in the final analysis with a mean age of 52.48 years (SD = 11.76; age range = 18-86 years). Of these, the majority were male (51.6%), housewives (39.7%), living in urban areas (63.1%), and most were married (86.4%) (Table 1). A sizable majority had experienced sleep disturbance (42.8%), and did not undertake physical exercise during the pandemic (60.5%). Smoking was reported by 13.9%, and majority reported their perceived health status as moderate or poor (69.8% + 9.6%). The mean duration of diabetes was 7.28 years (SD = 5.96), and the majority suffered from type-2 diabetes (48.0%). In addition, participants also reported the number of complications (such as retinopathy, nephropathy, neuropathy, foot ulcer) due to diabetes as follows: no complications (46.7%), 1 complication (37.9%), 2 complications (12.5%), 3 complications (2.4%), and 4 complications (.5%).4.1 COVID-19-specific diabetes worriesThe mean score of COVID-19-specific diabetes worries was 3.13 (SD = 1.90) out of a total score of 8, with a higher score indicating the higher level of COVID-19-specific diabetes worries. Table 2 presents the descriptive analysis and sex differences with regards to each item of COVID-19-specific diabetes worries questionnaire. 81.1% of people were worried that people with diabetes have a higher risk of infection. 64.5% were worried that they might not be able to manage diabetes if infected with coronavirus. 17.8% worried about diabetes medications. 26.4% worried due to lack of diabetes equipment (e.g., test strips). 27.4% worried about that they are getting inadequate treatment/diabetic care as a diabetic patient during COVID-19 pandemic. 32.% worried that they might not be able to manage their normal blood glucose level during the pandemic. 17.0% worried about possible food shortages. Chi-square test showed no significant difference between males and females (p > .05).The mean score of COVID-19-specific diabetes worries was significantly higher (p Table 1).Table 3 shows reliability indices, the mean score, and Pearson correlations between all items regarding social support (items 1-5), behavioral changes (items 6-11) computed for COVID-19 diabetic-specific worries (item 12). COVID-19-specific diabetes worries were negatively correlated with social support (i.e., from family/friends/relatives, colleagues, diabetes care teams, other people in the community [neighbors], and other people with diabetes); conversely, behavioral changes due to COVID-19 (i.e., checking blood glucose more often than usual, less exercise than usual, eating less than usual, and eating more than usual) were positively related with COVID-19-specific diabetes worries.4.2 Hierarchical regression analysisThe findings of the hierarchical regression analysis predicting COVID-19-specific diabetes worries are presented in Table 4. Overall, the regression model predicted about 24% of the total variance in COVID-19-specific diabetes worries [F(16,911) = 19.48, p 

Table 4Hierarchical regression analysis predicting COVID-19-specific diabetes worries.

Note: B = unstandardized regression coefficient; SE = Standard error; β = standardized regression coefficient.

The COVID-19-specific diabetes worries were significantly associated with lower age, smokers, poor self-reported health status, presence of multiple diabetes complications, lack of social support (i.e., from family/friends/relatives, colleagues, and diabetes care teams), and eating more compared to pre-COVID period (Table 4).

Other variables (i.e., residence, sleep disturbance, physical exercise, and other people in your community [neighbors], other people with diabetes, checking blood glucose more often than usual, less exercise than