# Diabetes and Coronavirus.



## Docb (May 22, 2020)

I have restarted this thread having now read and I think sort of understand the two papers on which the original announcements were made. I'll try and summarise where I am at which may or may not be helpful to others.

There are two documents, one by Barren et al and the second by Holmen et al.  Quite a few people appear on both lists of authors so it can be assumed that the papers are complementary and produced with collaboration rather than rivalry.

Both papers look at the mortality data for COVID up to the 1st of May.  Both use the data collected, and reported, by GPs to determine presence of diabetes in the population at large and in people who have died with the COVID virus present.  Both paper use statistical methods to try and separate out the effect of the presence of diabetes from other factors that influence the severity of the effect of COVID.  This needs to be done because the presence of diabetes can be associated with age and ethnicity and these confound ( that is obscure) the effect if not treated properly.

The Barren paper is the simplest.  It starts with the simple observation that a lot of people who have died with COVID had a diabetes diagnosis, far more than would be expected if you look at the prevalence of diabetes in the general population.  Some numbers.  There are 63 and a bit million people in the study of whom 2.8 million have type 2 diabetes, a ratio of 0.04:1  At the time of the report 28000 people had died with COVID of which 7500 had type 2 diabetes a ratio of 0.26:1  Note, I have rounded the numbers a bit.  At first sight this might suggest that you are six times more likely to die of COVID if you have diabetes than if you don't but like all things numeric, a little more scrutiny is needed, which is what the authors did.  What they did was to separate out the effect of diabetes from the effect of age, ethnicity, and a couple of other things that might be important.  This was done statistically using methods I only vaguely understand - its years since I did that sort of stuff - but it is reasonable to assume that knew what they were doing.

What they came up with is an odds ratio.  You take a characteristic, set a reference and then get the odds of finding people with other values of the characteristic in the group you are looking at.  Take the age data after eliminating the effects of all the other things.  Their reference age is the range 60-69, which has the odds ratio of 1.  If you look at the age range 80+, this ratio is just over 9.  Quite how you headline that I don't know but it illustrates the fact that age is a big factor when it comes to effect of COVID.  For the diabetes data (removing the effects of age and all the other stuff) they have used no diabetes as the reference.  The odds ratio for T1 is 3.5 and T2 it is 2.  All the results are significant.

So, what they have shown is that when all other things have been taken into account, there are twice as many T2's in the death stats than you might have predicted suggesting that the presence of diabetes in itself has some influence of the severity of the outcome of a COVID infection.  It is small compared with age.  A simple look suggests that having T2 is something like putting 10 years on your age once you are over 50.

The Holmen paper digs a bit deeper.  It uses the same data sources but as far as I can see a different subset to the Barren paper.  The interesting thing is that they introduce HbA1c and BMI as variables although the annoying thing is that they calculate a different statistic called the hazard ratio.  Quite how that relates to the "odds ratio" I don't know.  Eddy Edson might, he's more au fait with the statistical methods.

What this paper shows is that age and sex (quality not quantity) is the big factor, just like the Barren paper.  It also shows that HbA1c has an effect.  They take range, 49-53mmol/mol as their reference and the hazard ratio increases as HbA1c increases.  Nowhere near the effect of age, but it is there.   It also shows an effect of duration of diagnosis, particularly for T1.  Same with BMI.  There is an effect of BMI which is more pronounced in T1 than T2. 

So, what do I make of it?  The studies do show that patients with diabetes are more prevalent in mortality statistics than those without diabetes.   Out of control diabetes makes things a bit worse as does being overweight.  Age alone dominates everything.  To my mind the findings don't warrant scary headlines but they should be brought to the attention of people with diabetes so that they can work out what is best for them.

An interesting question which is not looked at is whether the same pattern is seen as you go down the severity scale, for example, do more people with diabetes finish up in hospital than you might expect and do more people with diabetes become infected than you might expect. 

Anyway, stop the seriousness and to go into newspaper mode. DocB's summary is:-

If you are a young,  well-controlled, svelte diabetic then carry on.  If you get it then you are in the same boat as the rest of the population.

If you are old, fat, male and have a screaming HbA1c then it's a bad idea to inhabit crowded sweaty places, unless you don't give a monkeys and are determined to have a good time before you go. 

Everybody else is somewhere in the middle, but if you are a lady, then stay that way, and in any case don't grow old.


----------



## Eddy Edson (May 22, 2020)

Docb said:


> ... and in any case don't grow old.



Absolutely the best advice, IMO.

It's a scandal - already 2020, and researchers *still* haven't cured aging. Or invented personal spaceships. What do they do all day??


----------



## Robin (May 22, 2020)

Thankyou, a good explanation of the number crunching. I can manage Female and svelte(ish). Working on the age thing, picture in the attic, maybe?


----------



## Bruce Stephens (May 22, 2020)

Eddy Edson said:


> Absolutely the best advice, IMO.



Yes, overall your best bet is to be a wealthy, slim, white, young woman.


----------



## trophywench (May 22, 2020)

I always thought it was when I had 3 out of 4.  Still haven't achieved no 1 though - the price of 'toys' whatever age the recipient happens to be has increased far out of pace with me aging though!


----------



## Docb (May 22, 2020)

Sorry TW, but the numbers show the odds slightly worse for T1's - not massively so, but a bit worse.  At least you have your sex, HbA1c and sense of humour on your side.  Would not enquire about your BMI.


----------



## Claire Godfrey (May 22, 2020)

Hi, this has been good to read. When I tell anyone how worried I am all they see is how fit I am so how can i possibly be worried, but I am. yes I am a lady, not overweight , kind of well managed BG and just about the right side of fifty but i cant do anything about T1D.  So tell me as lock down eases will all you guys carry on as normal or will you hold back? If I was on my own I would hold back because I can, I can work from home and order my groceries, but I can't ask my 19 yr  and 15 yr old children do the same.


----------



## SB2015 (May 22, 2020)

Thanks for putting all that work in @Docb .  A very useful summary.

In answer to @Claire Godfrey, we are ‘stringently self isolating’ is being extra careful about hand washing, socially distancing and enjoying being at home when we can.  Much as we have been before we read the headlines.  I did wobble a bit but the discussions on here have reassured me.
We will continue to limit shopping trips to about once a week, whereas we used to pop in on route most days before.  That is easy to continue, with a bit of planning. I suspect we are being a bit more cautious than some of our friends.  We live in an area which was at the bottom of the list for fatalities, but since the relaxation of restrictions, with more travel, is rapidly rising, able it from a low point.

We can do nothing about the ageing, having T1, but (most of the time) we can be as sensible as possible.

Thanks again Docb for your input.


----------



## mikeyB (May 22, 2020)

With all this agonising about diabetes and coronavirus, there is a simple answer to it all. Don’t catch coronavirus.

Ignore the English government, stay at home, only go out for food, keep your distance and wash your hands regularly. There’s no need to wash your shopping, apart from loose fruit and veg - you should do that anyway. Just wash your hands after unpacking the shopping.

If you catch CV after following all those rules, you would be desperately unlucky, so unlucky that it would be a miracle if you’re still alive.


----------



## Docb (May 23, 2020)

Easy for us pensioned off beneficiaries of final salary pension schemes but maybe not so easy for the current generation.  

What I would like to see more analysis of the risks, which is what these papers start to do. The risk of doing something cannot be taken in isolation, it has to be compared to other things.

For example, suppose you open all the pubs in Preston for a Saturday night and allow all and sundry to have a right good night out.  Is the risk of an individual catching CV greater than finishing up in A&E with alcoholic poisoning, or overdosing on some noxious substance or being stabbed or succumbing to any other of the trials and tribulations of being out in a rowdy crowd. 

It's against that sort of thinking that the significance of the additional risks due to having a diabetes diagnosis needs to be assessed if you want to make rational decisions.


----------



## AJLang (May 23, 2020)

mikeyB said:


> With all this agonising about diabetes and coronavirus, there is a simple answer to it all. Don’t catch coronavirus.
> 
> Ignore the English government, stay at home, only go out for food, keep your distance and wash your hands regularly. There’s no need to wash your shopping, apart from loose fruit and veg - you should do that anyway. Just wash your hands after unpacking the shopping.
> 
> If you catch CV after following all those rules, you would be desperately unlucky, so unlucky that it would be a miracle if you’re still alive.


A lot of people have no choice about going out to work. My partner will have to go back soon, he works in a University, and our house is too small for us to live separately. I’m sure that a lot of people with diabetes are in similar situations.


----------



## Jane50 (May 26, 2020)

With the article I saw yesterday saying that diabetics may be told to shield, which diabetics would have to shield is the question, those with higher blood glucose levels, or high HBa1C levels, my average for 30 days by my machine is 10.3 this morning, which is higher than it should be, my morning glucose test was 10.0 this morning, although last night it was 5.6, and in the middle of the night 4.7, so do not know why it went to 10.0, blood pressure is up most days, even though on tablets, would I be classed as one who should shield or be asked to shield


----------



## Docb (May 26, 2020)

The data on which this is all based looks at whether a death was associated with blanket T1 and T2 diagnoses and the (presumably) most recent HbA1c result for the individual.  It also looked at lots of other factors.

To my mind, using it in the way that some have to suggest the diabetic group as a whole should be shielding shows a complete lack of understanding of the results of the analysis.  You might think about shielding for a T1 with a HbA1c 86+mmol/mol but then you would have to shield anyone with a BMI over 40 or under 20 because the additional risk for them is of the same order.  What best illustrates the care that has to be taken in interpreting the data is that if you use it to recommend shielding all diabetics, then to be logical you would have to recommend shielding all men.   The additional risk of being male as opposed to female is as near as dammit the same as being diabetic as opposed to non-diabetic.

To my mind, the data suggest that the risk for diabetics, in general, is little different to the risks for non-diabetics.  You need to add HbA1c, time since diagnosis, age, sex, and BMI into the mix to get a proper assessment of the additional risk for any individual.  My statistics are far too rusty to try and work out what the added risk would be for various combinations but if I were you I would not be worrying unduly.


----------



## Lesoxley (May 27, 2020)

Docb 
I have been a type1 for just over 37 years, my hba1c has always been very good, not sure of the newish scale, but never been above 7 on the old scale except for the year I had back surgery, which was 16 years ago.
I will be 55 in july,.This is my question, why is there so much focus on diabetics being at risk rather than telling diabetics to control there sugar levels better, because that seems to be the main potential problem for diabetics rather than non diabetics.
Should there not be a push by the government or NHS spokespeople or diabetes uk to give proper advice, to those who are at potentially significant risk.
Regards
Les


----------



## Docb (May 27, 2020)

Good question Lesoxley.  

To my mind, much of the journalism these days is very sloppy.  Getting a story out, especially one that catches headlines and gets picked up by the media circus is more important than providing accurate information.  As far as I can make out all of the stuff about diabetes and coronavirus emanates from the two NHS papers but I bet most of those who are making the noise have never read them.  

It does not help that the government is fronted by journalists.  They can only think in slogans and headlines, telling the general population about CV in the same way they would sell soap powder.  

Eventually, everybody gets lulled into the same thought processes, using words and phrases without really thinking.  Sort of herd acceptance rather than herd immunity.  Your post has a brilliant example of this.  You use a phrase heard a lot in the media - "potentially significant risk".   Have you ever thought about what it means or even if it has any meaning at all? That's not a dig at you personally, far from it.  Its is a phrase that has come into common usage and has as much value to deciding whether a risk is worth taking as the slogan "Persil Washes Whiteest" has to choosing a washing powder.


----------



## trophywench (May 28, 2020)

Same as "Mazda bulbs stay brighter longer - always ask for Mazda!"   Well yeah, when your fiancé and his dad both worked at the firm that made Osram (GEC) funnily enough (not) it was more likely to be them at their house whereas my mom always bought hers in the Electric showroom (whatever make they stocked) when she needed to go past it or was in there paying the elec bill anyway.


----------



## Docb (May 29, 2020)

Yes, you can substitute any make in the slogan because they all have the same performance.  A claim that "Persil Washes Whiter" might make it worth buying but would not be allowed because it is not true, all washing powders made to the same basic formula wash to the same whiteness.  Potential significant risk can be normally substituted with probable insignificant risk without changing the value of the sentence.

In my world, phrases like potentially significant risk would be banned unless accompanied by a numerical assessment of the risk together with confidence intervals.  I would never let PR men get involved providing information to a population faced with the risks involved in dealing with a pandemic.


----------

