In response to the growing number of cases of coronavirus disease 2019 (COVID-19), after the World Health Organization (WHO) had already characterised the disease as a pandemic,1 the Spanish government, in an extraordinary session, declared the state of alarm, in which the chief measure was the imposition of a nationwide lockdown that came into effect at 00:00 on March 15, 2020. This measure was one of the emergency measures taken to reduce transmission, and forced every inhabitant to remained confined in their usual place of residence with the exception of various specific situations, such as shopping for food or medicine, commuting to work or attending an emergency. Physical exercise outside the home was not allowed. The state of alarm came to an end on June 21, and was preceded by a progressive de-escalation of confinement measures that started on April 26 with allowing children aged less than 14 years to leave the home to walk, play and exercise for one hour a day during restricted hours.

Type 1 diabetes (T1D) is one of the most frequent chronic diseases in the paediatric population. Management is based on insulin therapy, nutrition, physical exercise and self-management. Adjustments to insulin therapy are mainly based on measurements of capillary blood glucose levels and/or continuous monitoring of interstitial glucose levels with a sensor. The child and/or the caregivers must know how to modify the insulin regimen taking into account the effects of nutritional intake and exercise, changing the dosage when levels of glucose are outside the target range for several consecutive days. Achieving adequate glycaemic control is a very complex process and poses an ongoing challenge as it requires taking into account numerous aspects of everyday life.2,3

Since there had been no precedent, the actual impact of the measures adopted during the state of alarm in patients with T1D has not been assessed in the past. Nevertheless, given the drastic change in the daily routine of the patients, the decrease in physical activity, the increased risk of consuming an imbalanced diet, the stress associated with confinement and the difficulty of accessing health care services, their potential negative impact on glycaemic control was a reasonable concern.4–6 The main aim of our study was to assess the impact of home confinement on glycaemic control and daily routines in children and adolescents with T1D.

Of the 122 patients followed up by the child and adolescent diabetes unit at the time of the study, 87 used CGM/FGM systems. We excluded 2 patients: 1 that received the diagnosis of T1D 48h before the start of the lockdown and 1 undergoing treatment for cancer. In the end, a total of 80 patients (45 male and 35 female) agreed to participate. The mean age was 12.61±3.32 years (range, 2.98–18.05 years), with a mean duration of diabetes of 5.85±3.92 years (range, 0.8–15.64 years). When it came to treatment, 66.2% of the patients were managed with CSII and 33.8% with MDI. The pump models used for CSII were the Medtronic® MiniMed 640G (n=46), the Medtronic® MiniMed 670G (n=6) and the Roche® Accu-Chek Aviva Insight (n=1). The interstitial glucose monitoring systems used were the Medtronic® Guardian 3 in 65% of cases, the Abbott® FreeStyle Libre in 18.8% and the Novalab® Dexcom G6 in 16.2%. Of the 80 patients recruited, 75 provided information through a questionnaire regarding their routines during the confinement. None of the patients experienced symptoms compatible with COVID-19.

The lockdown imposed in the wake of the COVID-19 pandemic allowed us to analyse the impact of a sudden and radical change in lifestyle in children and adolescents with T1D in an unprecedented context. Our findings show that home confinement was not only not associated with a deterioration of glycaemic control, but that there was actually an overall improvement in glycaemic control. Patients with adequate control before the lockdown experienced a modest improvement during home confinement, and it was precisely patients with suboptimal control (either in terms of HbA1c or the time in range) that exhibited the greatest improvement. In our opinion, patients with adequate control and their caregivers tend to exhibit greater motivation and adherence to treatment, and very likely continued to maintain a similar attitude during the confinement. On the other hand, we attribute the improvement in glycaemic control observed in patients that had exhibited poorer control at baseline to the opportunity to invest greater effort in diabetes care during home confinement.

In our sample, the group of patients managed with CSII exhibited better glycaemic control before the confinement compared to patients managed with MDI. Usually, this treatment modality is associated with a greater degree of motivation and skill in the management of disease by patients and caregivers. Our findings show that this group of patients, which exhibited a good baseline glycaemic control, generally maintained a similar level of control during the confinement, with a modest improvement in some variables. The results were similar in the subset of patients that used the hybrid 670G system, despite a longer daily time of CGM. In any case, the algorithm for automated basal insulin infusion seems to have adapted well to the needs imposed by the confinement.

Nearly one third of the patients reported decreased regularity in mealtimes and a similar percentage reported increased consumption of unhealthy foods. A more objective finding in patients managed with integrated systems that caught our attention was that the total number of portions entered in the bolus calculator of the pump remained constant, while the number of delivered prandial boluses was significantly lower during the confinement. This finding suggests that patients may have tended to skip snacks, like the snack typically consumed mid-morning during school hours, despite having increased their carbohydrate intake in the main meals.

Exercise is associated with beneficial effects in patients with T1D in a cardiovascular health, lipid levels, mental health or sleep quality. However, the correlation is not as exact when it comes to blood glucose levels largely due to the variations that can be attributed to physical activity.8 In our study, glycaemic control during home confinement did not change in association with regular physical activity. In contrast, Tornese et al.9 did find better glycaemic control in adolescents managed with the hybrid MiniMed 670G that exercised regularly during the confinement.

In March 2020, Europe became the epicentre of the pandemic, and most countries around Spain mandated varying degrees of confinement. The results of our study are consistent with those of other published works on the subject. Several studies published in Spain and abroad in both the paediatric and the adult populations also found no deterioration of glycaemic control during confinement periods. A study conducted in Greece10 that included 34 children managed with the integrated Medtronic® MiniMed 640G system, patients maintained glycaemic control in degrees similar to those exhibited before confinement. There were also no significant changes in insulin requirements (although there was an increasing trend in the percentage delivered as basal insulin during confinement) or carbohydrate intake, although patients reported substantial changes in their meal schedule. Another multicentre study conducted in Israel11 that included 102 children and adolescents with T1D that used the Dexcom G5 CGM system found that glycaemic control remained relatively stable during confinement, without significant changes in the percentage of time spent in the target range. Yet another study, conducted in Italy12 in 22 patients aged 3.5 to 10.5 years and managed with the Tandem Basal-IQ system, which features a predictive low-glucose suspend algorithm, found an improvement in the time spent in the target range, and the authors remarked on the positive effect of parental care during the confinement. The study did not find significant changes in daily insulin requirements, but there was an increase in the mean bolus dose and in the number of correction boluses.

The results in the adult population with T1D practically overlap. With a similar design to ours, a study conducted in Spain13 in 307 adults found an increase in the time spent in the target range and a decrease in HbA1c estimates comparing the 2 weeks that preceded the lockdown and the past 14 days after 8 weeks of confinement. As occurred in our study, the authors found a greater reduction in the estimated HbA1c and an increase in the time spent in the target range in patients that had started out with higher levels of HbA1c. Another study in Spain14 that included 92 adults with a history of recurrent or inadvertent severe hypoglycaemic episodes found similar outcomes, with an improvement in the estimated HbA1c and the time spent in the target range, although the time in hypoglycaemia remained unchanged. Several studies conducted in Italy in adults with T1D had similar findings. Bonora et al.15 observed an improvement in glycaemic control in patients that stayed home in the first week of confinement, while glycaemic control remained stable in those who were essential workers and continued to work outside the home (although the baseline glycaemic control in this group had been better and most used CSII). Capaldo et al.16 reported a significant increase in the time in range and a reduction in the time below range with levels of less than 54mg/dL and in the CV in a cohort of 207 adults. The study by Maddaloni et al.17 did not find significant changes in ambulatory glucose levels in the first 2 weeks of confinement, although patients with greater times spent in hypoglycaemia before the lockdown did exhibit a significant decrease in this parameter.

In contrast with the aforementioned studies, our findings differ from those of other studies conducted in different socioeconomic contexts. The study by Verma et al.,18 conducted in India in 52 paediatric patients with T1D that did not use CGM/FGM data found that glycaemic control worsened during the confinement mainly due to shortages in insulin and glucose strips to measure capillary blood glucose levels. Similar problems with supply shortages were described in another study in children with T1D conducted in Jordan.19

One finding that may stand out in our study was that patients that had telemedicine appointments during the confinement exhibited poorer glycaemic control. It is worth noting that although routine appointments continued to be held at regular intervals, patients with poorer control are usually followed up more closely in our unit, independently of the epidemiological context. In this regard, the pandemic not only put our health care system to the test, but also has required adapting the traditional care delivery model to the new and changing circumstances. In this context, telemedicine is playing a crucial role.20 Its use has been increasing in recent years and has experienced a substantial growth in the current health crisis. Telemedicine facilitates the interaction between patients and health care professionals, helps improve adherence to treatment, saves the patient time and travel, decreases costs and is positively perceived by users21,22; in addition, it guarantees the safety of both patients and providers in the current context. However, it is still necessary to regulate and standardise this modality of care delivery, and allocate specific and sufficient time to it in provider schedules. In any case, the progressive and unstoppable integration of emerging technologies in the treatment of diabetes is developing a particularly well-suited framework for the follow-up of patients through telemedicine,23 as our findings illustrate.

The main limitations of our study are its design, which did not include a control group, the exclusion of patients not managed with CGM or FGM and the subjectivity of some of the variables collected through a questionnaire. Notwithstanding, we can assert that this sample of patients and caregivers had proven able to face an uncertain scenario successfully, achieving adequate management of the disease during confinement.

In conclusion, our study shows that glycaemic control in children and adolescents during the lockdown remained stable or improved modestly in patients that had previously exhibited adequate control, and that the improvement was particularly relevant in patients that had poorer control at the outset. In agreement with other published studies, the initial concern that glycaemic control could have deteriorated during the confinement not only was not confirmed, and we may even state that, if a similar situation were to present itself again, it would be possible to face it with less worry as concerns glycaemic control in children and adolescents with T1D. Furthermore, telemedicine has shown its considerable potential and is positioned as a modality of care delivery that should be promoted not only in the current epidemiological context, but even once it is over.

The authors have no conflicts of interest to declare.