|Year : 2021 | Volume
| Issue : 3 | Page : 155-160
Impact of lockdown period on chronic diseases
Rajashree Khot, Amol H Dube, Bharatsing D Rathod, Prashant P Joshi, Sunita D Kumbhalkar
Department of General Medicine, All India Institute of Medical Sciences, Nagpur, Maharashtra, India
|Date of Submission||09-Feb-2021|
|Date of Decision||28-Feb-2021|
|Date of Acceptance||07-Mar-2021|
|Date of Web Publication||23-Jul-2021|
Dr. Rajashree Khot
Plot No. 52 Jayneeta, New Ramdaspeth, Nagpur - 440 010, Maharashtra
Source of Support: None, Conflict of Interest: None
Objectives: In the wake of COVID-19 pandemic, strict lockdown measures posed many challenges in managing chronic diseases such as hypertension and diabetes. The impact of lockdown on physical and biochemical parameters along with contributing factors was assessed. Design: Cross-sectional analytical study. Materials and Methods: One hundred and fifty consecutive patients with chronic illnesses attending medicine outpatient department during unlock down phase I were enrolled. A 5 point Likert scale was used to determine the effect on diet, exercise, pain, physical and psychological symptoms, and a personal interview to assess the contributing factors. Clinical examination and laboratory investigations were done to compare between pre and post lockdown status and appropriate statistical tests were used. Results: The mean age of the patients was 48.53 ± 6.4 years with a female preponderance. Mean duration of illness was 8.93 ± 2.4 years and majority had hypertension (21%), diabetes (19%) or both (12%), hypothyroidism (18%), and gastroesophageal reflux disease (8%). While physical symptoms and pain did not show a significant change, 41.3% had worsening of psychological symptoms, 53.3% diet, and 70.6% exercise noncompliance. Weight, blood pressure, lipids, serum thyroid-stimulating hormone showed little change. Glycemic control was deranged in 72.5% with HbA1c increasing from 6.47 ± 1.9 to 8.1 ± 2.4 (P = 0.007). Contributing factors, 52.3% reported lack of exercise, 40% financial problems, 36% transport difficulties, and 30% unavailability of medicines. Conclusion: Lockdown negatively affected the management of chronic diseases with significant worsening of psychological symptoms, diet, and exercise adherence. Glycemic control worsened in diabetics. Lack of transport and unavailability of medicines were the significant contributing factors.
Keywords: Chronic diseases, COVID-19, lockdown period, non-communicable diseases
|How to cite this article:|
Khot R, Dube AH, Rathod BD, Joshi PP, Kumbhalkar SD. Impact of lockdown period on chronic diseases. Indian J Med Spec 2021;12:155-60
|How to cite this URL:|
Khot R, Dube AH, Rathod BD, Joshi PP, Kumbhalkar SD. Impact of lockdown period on chronic diseases. Indian J Med Spec [serial online] 2021 [cited 2021 Sep 19];12:155-60. Available from: http://www.ijms.in/text.asp?2021/12/3/155/322213
| Introduction|| |
The recent COVID-19 pandemic has caused increased burden on healthcare systems all over the world. When the pandemic started to spread like fire from country to country, different strategies were conceived to ward off the pandemic and protect the population at large.
The first case was detected in India on January 27, 2020, in Thrissur in Kerala, a 20-year-old female student who returned from Wuhan University, China. India implemented lockdown measures immediately from March 25, 2020. All the businesses, schools, colleges, theatres, malls, and religious places were closed down and movement of the people was restricted. The travel was curtailed with closing down of interdistrict, interstate, and international boundaries. Only the pharmaceutical and health-care facilities were allowed to function and that too with restrictions.
The entire focus was on COVID-positive patients and most of the hospitals were converted into COVID hospitals or COVID care centers. Patients with chronic diseases were allowed to seek only emergency treatment. Patients having hypertension, diabetes mellitus, coronary artery disease (CAD), etc., are at a higher risk of developing the infection and also at a risk of worsening, as regular checkups, medication review, and adherence is a part of the disease management.<sup></sup>
Whether the lockdown had a positive or negative impact on these illnesses? This study was planned to assess the impact of lockdown period on chronic diseases in terms of lifestyle changes, symptomatic outcomes as well as effect on morphological, clinical, and biochemical parameters. Factors contributing to these changes were also studied.
| Materials and Methods|| |
In this cross-sectional analytical study carried out in the post lockdown period of 1 month during unlockdown phase 1 when patients with chronic illnesses started attending the Medicine outpatient department (OPD) of a tertiary care center in Central India, 150 consecutive patients with chronic illnesses such as hypertension, diabetes mellitus and CAD, were enrolled. As this was a time-bound study, patients attending the OPD and satisfying inclusion criteria were enrolled. Chronic diseases were defined broadly as conditions that existed for the past 1 year or more and require ongoing medical attention or limit activities of daily living or both (Centers for Disease Control definition).
Lockdown period from March 25, 2020, to June 30 (official announcement of release of lockdown period by the state government).
Post lockdown period one month after release of lockdown period.
After approval from the Institutional Ethics committee, 150 patients with chronic diseases who gave written informed consent were included in the study. The type of chronic disease was determined based on previous medical records of the patient, laboratory investigations, and treatment. Patients were excluded if they were not willing to give informed consent, or were critically ill requiring intensive care management or had acute infecions including COVID 19. They were interviewed on one-to-one basis and given a questionnaire to identify the factors responsible for change in their symptoms and/or laboratory parameters. A 5-point Likert scale was used to determine the change in diet, exercise, preexisting symptoms; pain, physical and psychological symptoms. Clinical examination and appropriate laboratory investigations were done. For example, blood sugar and HbA1c in diabetics, C-reactive protein in rheumatoid arthritis, electrocardiogram in ischemic heart disease.
A 5-point Likert scale was used to determine symptomatic outcomes. Biochemical parameters were compared between lockdown and postlockdown period.
Data were analyzed using the Microsoft Excel program. All values were expressed in percentages and as mean ± standard deviation. For Likert scale data analysis, Mann–Whitney test was used as it is an ordinal, discrete, and limited range data. To find out significant change in continuous variables, a 2 paired student t-test was used and for noncontiguous variables Chi-square test was used. The difference was considered to be statistically significant with P < 0.05.
| Results|| |
In the month following unlockdown 150 patients with chronic illnesses, satisfying the inclusion criteria were enrolled in the study. The mean age of the patients was 48.53 ± 6.4 years and there was a female preponderance with a Male: Female = 1: 1.6. The mean duration of illness was 8.93 ± 2.4 years and majority (50.7%) belonged to middle class. Most of the patients (60%) had visited their physician within a period of 3 months before lockdown. The baseline characteristics of patients are shown in [Table 1].
The types of chronic illnesses varied from common lifestyle diseases such as diabetes and hypertension to noncommunicable diseases (NCDs) such as hypothyroidism and chronic kidney disease (CKD). Majority of patients had hypertension (21%), diabetes (19%), or both (12%). Multiple comorbidities were present in 14.8% of patients. Many patients (8%) with GERD experienced severe dyspeptic symptoms during lockdown period. The distribution of chronic diseases is shown in [Figure 1].
Patients were asked to assess the effect of lockdown period on change in their physical symptoms, psychological symptoms in those with preexisting psychiatric illness or psychological well-being in those without any psychiatric illness, pain, diet control, and adherence to exercise on a 5 point Likert scale. As perceived by the patients it was observed that majority of the patients did not perceive a major change in their physical symptoms, including pain [Figure 2].
However, psychological well-being was negatively affected; 32% of patients had slight worsening of their symptoms and 9.3% had significant worsening of their symptoms. The difference was not statistically significant. However, four patients developed significant depression and had to undertake psychiatric consult and treatment. Most of the patients complained of changes in their routine diet and exercise schedule. Worsening of dietary control was reported by 53.3% of patients and nonadherence to exercise was reported by 70.6% of patients. This reflects a drastic change in lifestyle caused during lockdown period. The results were highly significant for diet and exercise; P < 0.005 [Table 2].
|Table 2: Changes in symptoms perceived by patients during lockdown period|
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Clinical examination and morphological parameters were assessed in all patients. Most of the patients were concerned about their weight. It was observed that majority, i.e., 68% did not have any change in weight. Twenty-nine patients (19.3%) had a weight gain of more than 3 kgs in 3 months. This could be due to nonadherence to diet and exercise. The difference was not significant statistically. There was increase in mean systolic blood pressure from 128.07 ± 22.20 to 133.65 ± 20 and diastolic blood pressure from 78.68 ± 11.47 to 82.25 ± 10.79 in hypertensive patients. More patients had uncontrolled blood pressure in post lockdown period but the difference was not statistically significant. Again this could be due to adverse effect of lifestyle changes and also nonavailability of medications. Investigations were done on follow-up of the patients according to their individual problems and their check-up plans. Patients with hypothyroidism did not have a significant change in Thyroid-stimulating hormone levels. Similarly, the lipid profile of the patients also remained unaltered. The most significant effect was seen on diabetes control. Number of uncontrolled diabetics increased from 55% to 72.5% in post lockdown period. It worsened significantly after assessing categorically as well as by comparison of mean HbA1c levels, pre and post lockdown [Table 3].
|Table 3: Effect on morphological and biochemical parameters during lockdown|
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A one-on-one interview of the patients was taken to determine the factors responsible for problems or improvement in the management of the chronic diseases. They were classified as favorable and unfavorable factors. About 52.3% reported lack of exercise, 40% reported financial problems, and 36% had difficulty in getting transport to hospital. About 10.3% of patients reported increased stress and workload due to absenteeism of household help and other supportive staff [Figure 3].
Many patients skipped their medicine doses as they could not get their medicines due to lack of prescription from registered doctors. Many patients also complained of lack of medical help as most of the doctors had kept their private clinics closed during lockdown. Transport to hospitals was also a major issue as the public transport was unavailable. The police and security allowed only emergency medical patients to be taken to hospital. Forty percent of the patients had financial problems affecting compliance with medicines and causing stress and psychological problems. Only 10% of patients could avail the telemedicine facility. Three patients of CKD were deprived of their routine maintenance dialysis due to strict quarantine measures. Patients with malignancy had to defer their chemotherapy cycles as the hospitals were managing only COVID patients. Overall the patients felt that there should have been some arrangement for access or delivery of healthcare to patients with noncovid chronic diseases.
| Discussion|| |
COVID-19 pandemic has taken toll of all health as well as economic resources, globally. In order to combat the pandemic and implement protective measures for its population A morning-to-evening 14-h “Janata Curfew”–a Curfew of the People–was announced for March 22. This preceded a full lockdown that was announced on March 24 for a period of 3 weeks, till April 14. On April 14, the lockdown was extended for another 19 days, till May 3, and then extended again till May 18, with provision for relaxation of the shutdown for selected agricultural businesses, cargo transportation, and sale of farming supplies. A mammoth population of 1.3 billion people had been restricted to their homes, and transport services, schools, factories, and business establishments had been closed.<sup></sup>
Our health facilities and workforce were inundated by a plethora of activities related to controlling the pandemic. In doing so, there was a risk that essential health services which communities expect from the health system, would be compromised. The health-seeking was deferred because of social/physical distancing requirements or community reluctance owing to perceptions that health facilities may be infected. The WHO<sup></sup> had already issued guidelines for the management of chronic diseases during lockdown.
Our government also issued guidelines for those with regular care and those with new medical needs,<sup></sup> people were unsure where/how to seek medical care services. In reality, those with chronic diseases, especially the middle and low-income groups faced a lot of problems.
As soon as the lockdown period was over patients with chronic diseases attended in large numbers in our non-COVID facility. The 1<sup>st</sup> month saw around 180 patients attending the medicine OPD of which 150 consecutive patients were included in our study.
The mean age of the patients was 48.53 ± 6.4 years with a female preponderance. This indicated that the elderly population was still confined to homes. The patients were regular in their follow-up and checkup during prelockdown period and 80% were compliant to their medications. A spectrum of chronic illnesses was observed. More than 50% of patients had diabetes and/or hypertension. A complete clinical and biochemical assessment was done. On symptomatic assessment using the Likert scale, it was observed that 41.9% of patients had worsening psychological symptoms with new symptoms such as stress and anxiety, related to financial well-being. Many patients reported new-onset of insomnia. Majority of the patients experienced psychological stress and anxiety during lockdown. The major mental health issues that have been reported to be associated with the COVID-19 pandemic are stress, anxiety, depressive symptoms, insomnia, denial, anger, and fear globally.<sup></sup>
The physical symptoms varied with equal frequencies on the scale. Pain in patients showed no significant change. Joint pains worsened as household help was unavailable in lockdown, leading to increased physical exertion.
A significant number of patients reported worsening dietary control and exercise adherence due to lockdown. This was commonly seen with diabetic patients. These findings were significant in patients having lifestyle-related NCDs. Similar observations were reported by Ruiz-Roso et al. in their study where they did a detailed assessment using food frequency questionnaire, and physical activity questionnaire. Their data also showed a high percentage of physical inactivity before the COVID-19 lockdown, which was exacerbated during the home confinement.<sup></sup>
The diet of the patients was also affected by “Food and Grocery” concern. Food security is a major issue which needs to be addressed during lockdown period. Food supply chain is affected due to a number of factors during lockdown.<sup></sup>
The derangement in biochemical parameters in chronic illnesses such as hypothyroidism, chronic liver disease, rheumatoid arthritis, failed to show a statistically significant change. Worsening of glycemic control was seen in significant number of diabetic patients, as assessed by HbA1c levels. Majority of diabetic patients reported loss of dietary control, noncompliance with exercise, inability to get a consult, and problem with procurement of drugs as factors responsible for inadequate control. Our findings were similar to most of the studies where authors observed impaired glycemic control in lockdown period.<sup></sup> Poorly controlled diabetic patients would be at risk of development of severe COVID-19 infection and worse outcomes including increased mortality. Even well-controlled diabetics with increased glycemic variability had worsened outcomes due to COVID-19 infection as reported in studies from China.<sup></sup>
Few patients did home blood glucose monitoring and followed up with their physicians, telephonically. They maintained their glycemic control. A study by Rastogi et al. found that glycaemic control was better during lockdown period due to less work stress and improved self-management of diabetes, but the study was carried out on a well-educated urban population.<sup></sup>
Patients also had uncontrolled hypertension but no major complications during lockdown period. The pre and post lockdown readings did not change significantly.
When factors responsible for the management of chronic illnesses were analyzed it was observed that around 30% of patients were not able to procure medicines for their chronic diseases. They also reported that many pharmacies were closed or were open for a very short period. They had difficulty in getting prescriptions from their routine physicians due to closure of clinics. Only 10% of patients availed of the telemedicine facility. Unavailability of public transport was another major reason cited for nonadherence to treatment. In a cross-sectional survey, Nwoke Emmanuel Awucha et al. reported that in Nigeria, the COVID-19 pandemic had minimal impact on consumers' ability to access essential medicines. However, important challenges identified were poor availability of means of transportation, reduced income, and high cost of medicines, as well as fear of contracting the virus.<sup></sup>
In a study from Pakistan, 98% reported effect of lockdown on their routine living, whereas 45% reported an effect on their health. The key challenges due to lockdown were to do daily exercise, missed routine checkup/laboratory testing, and daily health care.<sup></sup>
| Conclusion|| |
The lockdown period for prevention and control of Novel severe acute respiratory syndrome CoV2 infection also posed new challenges in the management of chronic diseases. The diet and exercise adherence were significantly affected. Diabetes control also worsened significantly. Lack of physical exercise, financial problems, and nonavailability of medications were cited as major problems.
It is important that the management of chronic diseases should not be affected during lockdown period. Services that are traditionally delivered through outreach such as immunization, antenatal care, and screening for common NCDs/communicable diseases should be re-organized during the period of lockdown/restriction. With occurrence of new strains of the virus a new lockdown may be imposed. If patients with chronic illnesses worsen, they will add to the burden of vulnerable population.
We are grateful to the Director and CEO of our Institute Major Gen Dr Vibha Dutta SM for continuous support, inspiration, and encouragement even in difficult times of COVID 19.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]