If you’ve been keeping up with federal guidance on who’s at a higher risk for complications from COVID-19, you know that people with diabetes are among the affected groups.

People older than 60, along with those who have underlying health conditions such as respiratory problems, high blood pressure, heart disease, obesity, and cancer are also at a higher risk for serious illness from the novel coronavirus, notes the Centers for Disease Control and Prevention (CDC). Furthermore, non-Hispanic Black Americans, Hispanics, and Asian Americans, all of whom have higher rates of both diagnosed and undiagnosed diabetes than white Americans, per the National Diabetes Statistics Report, are also at higher risk for serious COVID-19 disease, including complications and death, as has been widely reported.

Yet it’s still unclear whether diabetes can leave a person at an elevated risk of getting infected in the first place, notes the American Diabetes Association (ADA). This is apparently true despite research, including a review published in the Indian Journal of Endocrinology and Metabolism, showing that the immune systems of people with persistent hyperglycemia (higher than normal blood glucose, or sugar) are impaired.

Scientific Research Linking Diabetes and COVID-19 Complications

People with type 1 and type 2 diabetes are both three to four times more likely to develop serious COVID-19 disease and be hospitalized than those who don’t have diabetes, according to a study published online in December 2020 in Diabetes Care. A small preliminary study published in the March 2020 issue of Diabetes Metabolism Research and Reviews provides more insight into what’s affecting the severity. It looked at 174 people in Wuhan, China, and concluded that people with COVID-19 and diabetes but without other comorbidities were at a higher risk for severe pneumonia and the inflammation that contributes to an accelerated progression of COVID-19 and a worse prognosis.

Another study, which was published in April 2020 the Journal of Diabetes Science and Technology, analyzed 1,122 people at 88 hospitals in 11 U.S. states, and drew a link between diabetes and a fourfold increased risk of dying from COVID-19. Glytec, a provider of insulin software management, funded the research.

A study published online in May 2020 in Cell Metabolism supports these findings. For this cohort study, researchers analyzed the health data of 7,337 people in Wuhan with and without type 2 diabetes. They observed an association between having diabetes and an increased risk of dying from COVID-19. Those with stable blood sugar levels had a better prognosis than those with diabetes whose blood sugar control was poor. In fact, the survival rate for those with good blood sugar control was nearly 99 percent, compared with an 11 percent death rate among those whose control was considered poor. Participants’ blood sugar levels were measured using postprandial and fasting blood glucose tests. The authors defined poor blood sugar control as tending to exceed 180 milligrams per deciliter (mg/dL), and well-controlled blood sugar as ranging from 70 to 180 mg/dL.

Diabetes Complications Can Increase Risk of Severe Illness From COVID-19

Still, having complications related to diabetes, along with increasing age, may matter more than blood sugar control, suggested a study published in April 2020 in Diabetologia, which analyzed 1,317 people admitted to 53 French hospitals during a three-week period in March 2020. Study authors concluded that 10 percent of people with diabetes admitted to a hospital died within 10 days, and that men were more likely to die than women. The main contributing factors to death were having complications including neuropathy and heart disease, having a high body mass index (BMI) —indicating obesity — and being older. Patients between ages 65 and 74 were three times more likely to die than individuals younger than 55.

People with type 2 diabetes are definitely at higher risk of COVID-19 complications and death, but those with type 1 or gestational diabetes may also be at higher risk, according to recent guidance by the CDC. In the French study, 3 percent of admitted patients had type 1 diabetes, while 89 percent had type 2 diabetes. The remainder of diabetes patients had other types of the disease.

Black people who have type 1 diabetes and COVID-19 may be especially vulnerable to worse outcomes because they are more likely to present with diabetic ketoacidosis (DKA), a condition that causes the blood to become acidic and that can be life-threatening in its own right. A study published in the Journal of Clinical Endocrinology and Metabolism in December 2020 found that 55 percent of Black clinic patients and 33 percent of Hispanic patients presented with DKA, compared with only 13 percent of white patients. “The shared risk of COVID-19 and DKA in type 1 diabetes worsens the short-term and long-term prognosis for Black and Hispanic patients,” said the study authors, also noting that “previous studies have demonstrated an increased risk of DKA among minority populations with type 1 diabetes.”

Understanding COVID-19 and Its Symptoms

According to the World Health Organization (WHO), coronaviruses are a large family of viruses that cause diseases including the common cold, but also more severe illnesses, such as Middle East respiratory syndrome (MERS); severe acute respiratory syndrome ( SARS); and COVID-19, which first became known at the end of 2019 during an outbreak in the city of Wuhan in China’s Hubei province and has since developed into a global pandemic.

According to the WHO, common symptoms of COVID-19 include:

Fever
Tiredness
Dry cough
Aches and pains
Nasal congestion
Runny nose
Sore throat
Loss of taste or smell
Skin rashes
Pain in the muscles or joints
Discolored fingers or toes
Diarrhea

Some infected people have no symptoms at all, but they can still spread the virus.

The CDC describes the emergency warning signs for COVID-19 in adults as:

Difficulty breathing or shortness of breath
Persistent pain or pressure in the chest
New confusion or inability to wake up or stay awake
Bluish lips or face
Inability to rouse or stay awake

If you are experiencing these symptoms, call 911 or call ahead to the hospital and let them know you are seeking care for COVID-19 or may have it, the CDC advises.

If you are interested in getting a test and want to know how to proceed, contact your local or state health department. The CDC lists state and territorial departments, and the National Association of County and City Health Officials has a directory you can use to find your local department.

For most people, the disease is mild, and many don’t develop symptoms at all. A South Korean study published in August 2020 in JAMA Internal Medicine looked at young people, the vast majority of whom were healthy, and found that 30 percent of those infected with the virus causing COVID-19 never developed symptoms at all. COVID-19 symptoms are mild for most others, although 10–15 percent of infected people do become seriously ill, and 5 percent become critically ill, according to WHO. Mortality estimates vary, but a New York–based study published in October 2020 in the Journal of Hospital Medicine found that 7.6 percent of hospitalizations resulted in death in August, down from 25.6 percent in March, when infection began to spread in the United States.

It’s important to note that the risk of death from COVID-19 is far greater than from influenza (flu), a disease it is frequently compared with. More than 340,000 people died of COVID-19 in the United States in 2020, according to CDC data. In contrast, the nation loses between 12,000 and 61,000 people per year to influenza, reports the CDC.

Vaccines: How They Work and When You Can Expect to Get One

Two vaccines against COVID-19 illness are available in the United States under emergency use authorization by the U.S. Food and Drug Administration (FDA):

Pfizer and BioNTech’s vaccine, available to people 16 and older
Moderna’s vaccine, available to people 18 and older

Both vaccines rely on mRNA technology, which instructs cells to make a protein fragment that will trigger an immune response that protects from disease if a person is exposed and infected, according to the CDC. Both are also administered as two shots given several weeks apart, the agency explains.

Vaccinations began in the United States on December 14, 2020, as several news outlets reported, and are being given in phases according to the risks different groups face for COVID-19 infection and illness. For many with type 2 diabetes, the vaccinations can’t come soon enough. Nearly 4 in 10 people with diabetes surveyed by the ADA in December 2020 said they plan to get vaccinated as soon as possible. This is compared with under 3 in 10 adults age 50 to 64 and about 4 in 10 adults age 65 and older in the general population, according to a separate Axios-Ipsos poll that month.

“As many as 40 percent of the COVID fatalities — 120,000 Americans — have been people with diabetes, and more in our community may be at risk of the worst of the virus’s effects because so many are now unable to manage their diabetes effectively,” said Tracey D. Brown, CEO of the ADA, in a statement released December 23, 2020. She added that because the diabetes community disproportionately includes people of color and those with low incomes, it should have prioritized access to the COVID-19 vaccine along with pandemic relief resources.

Each state decides on its own which groups to prioritize and when, though the CDC has recommended that people age 16–64 with underlying health conditions that raise the risk of life-threatening complications, including type 2 diabetes, be among the first. Type 1 diabetes is not currently mentioned in this guidance.

Those with type 2 diabetes are in phase 1c, along with people age 65–74 and some essential workers. Groups in the phases that precede them include 1a: healthcare workers and residents or workers in long-term care facilities, such as nursing homes; and 1b: people age 75 and over and frontline essential workers who are not in healthcare, such as teachers, police officers, grocery store workers, and others. Check with your state to find out how it is prioritizing vaccine distribution and when you will be eligible for vaccination. This CDC page is a good place to start if you’re not sure how.

Given all that, if you have diabetes and wish to stay in the best health possible during this pandemic, experts including Katherine Araque, MD, the director of endocrinology at the Pacific Neuroscience Institute at Providence Saint John’s Health Center in Santa Monica, California, have some advice.

1. Follow the CDC Guidelines — They’re for Everyone

“We know that we should follow the CDC guidelines with regard to symptoms and when to test, regardless of the underlying diagnosis of diabetes,” says Dr. Araque.

Those guidelines include:

Clean your hands often with soap and hot water for at least 20 seconds, or use sanitizer that is at least 60 percent alcohol.
Avoid touching your eyes, nose, and mouth with unwashed hands.
Avoid close contact and practice social distancing (staying at least six feet apart).
Cover coughs and sneezes with a tissue. (Then clean your hands!)
Clean and disinfect frequently touched surfaces daily, and dirty ones immediately.
Stay home if you’re sick.
Separate yourself from others if you have been diagnosed with COVID-19 or think you have it.
Wear a face mask covering your mouth and nose outside of your home and when you're around people who don’t live in your household, particularly in settings where social distancing is hard to maintain.
Call ahead about medical attention unless you are having a medical emergency.

Of course, in this fast-moving pandemic, local, state, and federal regulations and guidelines are constantly shifting regarding meetings, gatherings, travel, working, and when you should stay at home. Follow the latest ones; they are meant to slow the spread of the virus.

2. Keep Your Diabetes Treatment Supplies and Equipment Clean and Disinfected

“We advise our patients to please keep up hygiene at home, to keep washing their hands,” says Araque. “For patients with diabetes, it is important to wash their hands thoroughly before administering insulin or injectable medications.” They should also use soap and water to clean the areas on their body where they inject their medication. She further cautions patients not to share needles or pens, and to dispose of needles safely.

3. Keep Your Prescriptions Filled and Stock Up on Extra Supplies

“We want to ensure that those patients have all their medications — not only the medications to treat diabetes but the medications to treat hypoglycemia,” says Araque. She advises having extra glucagon or glucose tablets in case your blood sugar drops too low. People who take insulin should have backup insulin pens (or syringes and vials) if needed, and extra ketone strips.

“Contact your insurer or diabetes supplier about increasing your allotment of supplies,” advises Melissa Young, PharmD, CDCES, a pharmacist at University of Utah School of Medicine in Salt Lake City and a spokesperson for the Association of Diabetes Care and Education Specialists. “You do not want to run out of continuous glucose monitoring sensors or pump tubing. If your pump malfunctions, calling the manufacturer will usually be the first step. If a glucometer malfunctions, there is an 800 number on the back of the glucometer; try that first. Typically, manufacturer support is available to assist with glucometer questions.”

As for how much you should stock up on: The CDC recommends a 14-day self-quarantine period for anyone exposed to the coronavirus, starting from the date of last contact. “So to be safe, at least several weeks' to a month’s supply of medications on hand is recommended,” says Dr. Young.

4. Check for Measures That Make It Easier to Get Those Extra Supplies

If you are worried about the possibility that your prescription coverage won’t allow early refills, check with your pharmacy benefit provider or insurance provider. “Now that a national emergency has been declared, many insurers have increased allowances for [number of] days' supplies or early refills for chronic care, noncontrolled — such as nonopioid — medications for underlying medical conditions such as diabetes and high blood pressure,” says Young.

For instance, the large pharmacy benefit manager CVS Caremark says that “select clients” have waived early refill limits on 30-day prescription maintenance medication, and that Aetna will offer early refills on 30- to 90-day supplies of maintenance medication prescriptions for insured and Medicare members. The latest guidance on early refills and 90-day maintenance medication is in CVS Caremark’s FAQ.

Walgreens and CVS have also announced that they're waiving fees for home delivery of eligible medications.

“Contact your regular pharmacy or diabetes supplier as soon as possible,” Young advises. “Your prescription information is on file, and they are aware of your insurance plan allowances on medications and supplies to be received per prescription.” Call the toll-free number on the back of your health insurance card for benefit details, she says. Take advantage of mail-order delivery if you are instructed to stay at home or are taking self-isolation measures.

If you are worried about the cost of extra medication and lack adequate coverage, you are not alone. Fifteen percent of people surveyed by the ADA who have diabetes and use a continuous glucose monitor or insulin pump said that during the pandemic they have delayed refilling supplies — in 70 percent of those cases, it's because of financial hardship or other financial constraints. Check the JDRF resource page for help with diabetes medication costs. JDRF is a nonprofit dedicated to type 1 diabetes advocacy and research.

In general, know that several pharmaceutical companies have patient assistance programs (PAPs) that are designed to help people with diabetes better afford their insulin and oral medication. For example, Novo Nordisk and Dexcom have PAPs to serve individuals affected by job loss or insurance coverage related to COVID-19. Other pharmaceutical companies have existing PAPs that may help you in your specific situation. Ask your healthcare team if a PAP can help you better afford, and thus adhere to, your diabetes treatment plan.

5. Don’t Worry Yet About the Medication or Insulin Supply Chain

You may be wondering if measures to slow the spread of the coronavirus that causes COVID-19 will affect your ability to get your medication and medical supplies on time.

As of January 8, 2021, a JDRF webpage on type 1 diabetes and COVID-19 stated that the organization is in touch with drug and diabetes supply manufacturers and is also unaware of any manufacturing or distribution disruptions. But "because of increased orders in recent weeks, some suppliers are telling [type 1 diabetes] customers that they may be delayed in immediately refilling orders. We are told that these are delays, not longer-term issues and not due to shortages in the supply chain," the JDRF says. They advise people to keep checking their page for the latest developments.

6. Know That Some Over-the-Counter Medication Can Affect Blood Glucose

Some over-the-counter drugs used to treat cold and flu symptoms may affect your blood sugar levels, the JDRF warns. These include:

Cough syrups, except those that are labeled sugar-free
Pills that contain the same ingredients as syrups and do not have carbohydrates
Decongestantssuch as phenylephrine and pseudoephedrine
Aspirinin large doses
Advil (ibuprofen), which can increase the hypoglycemiceffect of insulin

Ask your healthcare provider if you are not sure about the effects of an over-the-counter medication.

7. Be Vigilant for Signs of Unstable Blood Sugar or DKA, Especially if Insulin or Other Drugs Run Low

People with type 1 diabetes, and, in rare cases, long-standing type 2 diabetes, are vulnerable to developing a potentially life-threatening condition known as diabetic ketoacidosis (DKA), notes Araque. When the body doesn’t have enough insulin to convert glucose into energy, it begins to break down fat to use as fuel. The result is a buildup of acids in the bloodstream known as ketones.

As reported in the journal Diabetic Medicine in May , an “unusually high” number of COVID-19 hospitalized patients with diabetes in the United Kingdom developed DKA.

“We advise patients to check their ketones at home if they are experiencing persistent hyperglycemia to make sure they don’t go into DKA, regardless of whether they have any symptoms. This can happen in patients that miss injections or that have failures in their pumps or any problems getting access to insulin. They need to go to the hospital, separate of any symptoms of COVID-19.”

Given how the COVID-19 pandemic has changed daily life and increased stress for many people, you may also need to be checking your blood sugar more regularly, according to guidelines released by the JDRF–Beyond Type 1 Alliance. Ask your doctor about the right frequency for you.

8. Do Your Best to Maintain a Healthy Diet and Wellness Routine

Eating right has become progressively harder for many with diabetes during the pandemic, as incomes have shrunk — and with them, food budgets. According to the ADA, more than one-quarter of survey recipients with diabetes reported disrupted access to healthy food during the pandemic. Feeding America reported in October that nearly 16 percent of people in America were food insecure in 2020. Further, the ADA reported, nearly 1 in 5 people with diabetes say they now rely on nutrition assistance of some kind, including food banks. Nearly half of those say the food they are getting isn’t as good for managing their blood sugar, and 1 in 5 say they can’t eat as often as they should to effectively manage their health.

“This is a struggle for many,” says Vandana Sheth, RDN, CDCES, a Los Angeles–based spokesperson for the Association of Diabetes Care and Education Specialists (ADCES). She offers the following suggestions for eating in a diabetes-friendly way on a budget.

Shop at your local dollar store. “Many have a large selection of food choices at a very cost-effective price,” she says.

Keep in mind the diabetes plate method for maintaining a balanced diet when shopping. The following lower-cost suggestions can fit into that plan, says Sheth: Eggs, beans, lentils, nut butter, seeds, canned fish, frozen produce, whole grain tortillas or bread, cheese, oatmeal, and yogurt.

Buy in bulk, if you can, and freeze extra portions. Nonfat yogurt, for example, is a diabetes-friendly food that may be less costly when bought in large portions. “When you buy Greek or Icelandic yogurt, get the 32-ounce container, as this will be cheaper than buying individual cartons.” The same goes for whole-grain bread, which people with diabetes can safely eat in moderation. “When you buy bread, put it in the freezer and take out individual slices as you need them,” Sheth adds.

Look for discount services. Sheth suggests Imperfect Foods, which provides cosmetically defective but otherwise fine produce and groceries at a discount.

Connect with a registered dietitian nutritionist who specializes in diabetes. The ADCES has a locator to find one in your area. “They can provide customized ideas and share community resources,” she says.

With gyms closed in a number of states and many sports activities postponed, it can be a challenge to stay on the healthy regimen you established before the pandemic. “In my experience, some patients become sedentary when they stay at home,” notes Araque. If you are not under quarantine or otherwise advised to stay at home, go for a walk outside in the park (while maintaining the recommended social distance). If you are homebound, watch an exercise video. There are plenty of free resources to help you exercise online as well.

“Have a friend join you as you work out from home, so that you have an accountability partner and can see each other via your phone or computer,” suggests Sheth, noting this can combat feelings of isolation.

Per the JDRF, continue to manage stress and prioritize sleep — two other essentials for managing your blood sugar.

9. Lean on Peers With Diabetes for Support

In its guidelines, the JDRF–Beyond Type 1 Alliance recommends reaching out to others living with diabetes for support. "None of these behaviors are easy, and we all need support," the organizations comment in their guidelines.

A study published in October 2018 in Diabetes Care suggests that people with type 2 diabetes who participate in peer support programs are able to better manage depression and their blood sugar than those who don't. These results may lower overall healthcare costs, researchers say.

Meanwhile, participation in a diabetes online community is associated with increased self-care habits, notes a study published in July 2018 in Future Science OA. These habits include eating a healthy diet, exercising, and sticking to your medication regimen.

There are plenty of online resources for finding peer support, including Facebook groups and the ADA's peer support directory.

10. If You Call the Doctor, Keep Both COVID-19 and Diabetes in Mind

If you are sick, don't hesitate to reach out to your healthcare team, say the JDRF–Beyond Type 1 Alliance guidelines. But be sure to call first and have your health information ready.

“When people with diabetes call their doctor’s office for advice, they should be prepared to report blood sugar values, medication doses taken or missed, severity of respiratory symptoms, any nausea or vomiting, and how much they are able to eat or drink,” says Julie Adkison, PharmD, CDCES, a pharmacist and certified diabetes educator in Houston, who runs the blog My Diabetes Village. “Be aware of the signs and symptoms of DKA so that you know when to check for ketones, and seek care immediately if needed.”

And don’t be afraid to voice your concerns to your healthcare team. “This is not the time to not ask questions,” says Araque. “This is the time to ask questions and call your provider. It’s better to ask them than to delay care.”

For more information on how COVID-19 is affecting those living with diabetes, check out a study from Diabetes Daily.

Coronavirus: Must-Know Info

10 Diabetes Care Tips During the Coronavirus Pandemic