To the best of our knowledge, this was the first study comparing the impact of COVID-19 lockdown towards glycaemic control and lifestyle changes in children and adolescents with T1DM and T2DM. There was no similar study conducted in adolescents with T2DM to date. We reported overall deterioration in glycaemic control which was more apparent in patients with T2DM, male gender and pubertal adolescents. This cross sectional study also demonstrated marked lifestyle changes which occurred during the lockdown.
As illustrated in Table 2, T2DM patients, male gender and pubertal adolescents were the affected groups in term of the glycaemic control. In contrast, glycemic control in the younger pre-pubertal children with T1DM had significantly improved post-lockdown. This was likely due to more parental supervision of insulin injections and overall diabetes care in this young group of patients. Barbara Predieri et al  reported an overall improved glycemic control in Italian children and adolescents (n = 62, mean age 11.1 +/- 4.37 years) with T1DM using real-time continuous glucose monitoring (CGM) during lockdown with better improvement seen in the pre-pubertal children. They hypothesized that the improvement could result from more regular scheduled mealtimes without higher food intake and more attention on diabetes care by parents who were “forced” to stay at home. These findings in the pre-pubertal T1DM children were similar to ours. However, we did not observed an overall glycaemic improvement in our T1DM participants likely because of the different cohort of patients and methods of assessment of glycemic control. The Italian cohort consisted of patients who already had a relatively good baseline glycemic control and with sensor CGM use prior to inclusion of the study. They also had access to telemedicine during the lockdown. Hence the results may not be generalizable to patients with poorer control or who do not have access to technology. The vast majority of our patients are on self-monitoring blood glucose by finger-pricks. Only one patient who was on insulin pump therapy was using CGM. The usage of CGM and flash glucose monitoring is limited here due to cost issues. Most of our T1DM patients had virtual consultations in the form of phone calls from the paediatric endocrine team during the lockdown. Access to telemedicine was limited in our local setting due various factors which include a lack of human resources, a suitable app application and the lack to technology access by some patients. While there was no overall improvement, there was also no significant difference in the HbA1c of our T1DM patients before and post-lockdown (8.6% vs 8.7%) when analysed separately from other confounding factors. This was similar to the study by Wu XM et al  who reported no deterioration in glycaemic control in their cohort of Chinese children and teenagers (n = 43) using CGM.
In contrast to T1DM patients whom glycaemic control were not affected by the lockdown, there was a significant deterioration in HbA1c (8.5% pre-lockdown vs 9.9% post-lockdown) in T2DM patients. We hypothesized the reasons for this could be multifactorial. Firstly, lifestyle management is a cornerstone in T2DM which is related to excess weight and insulin resistance. While having a healthy lifestyle is also important for T1DM patients, the mainstay of treatment for T1DM is insulin. During the lockdown, there had been a reduction in physical activity levels and increment in screen time. Interestingly despite this, there was a reduction in the weight and BMI SDS of T2DM patients compared to T1DM patients who had gained weight. It is likely the significant worsening of glycemic control in T2DM patients with a mean HbA1c of 9.9% post lockdown, resulted in a catabolic state and weight loss.
The lockdown has had a worse glycemic effect on pubertal adolescents. Adolescence and teenage years are filled with physical, hormonal and emotional changes. There is also a shift in independence from the parents during this period and more reliance on peers support. All these may make adolescents more susceptible to major changes in routines during the lockdown resulting in depression, anxiety, boredom and a lack of motivation in diabetes management. In addition, most adolescents are already self-managing their diabetes and self-administering their insulin or medications and are less receptive to perceived adults’ interference. Hence, during the home confinement, it was likely there was not much extra benefit in terms of parental supervision for the adolescents as compared to the younger children. This was a reminder to us that our T2DM patients require equal or even more medical attention as compared to T1DM patients during this pandemic. Continued encouragement to maintain good diabetes self-care and access to professional mental health professionals for all patients and their families should also be provided if needed.
Interestingly, the glycaemic control of our male patients were more adversely affected during this unprecedented time. We also observed that there was more changes in lifestyle in almost all aspects in boys compared to girls. This was not in keeping with previous reports that female gender was a risk factor for poorer glycaemic control [17, 18] attributed to greater psychological affect . Possible reasons for our findings are that boys tend to be more physically active and do not cope so well with prolonged periods indoors.
Both groups had exhibited marked sedentary lifestyle during the confinement at home. According to World Health Organization  and Malaysian Dietary Guidelines for Children and Adolescents , children and adolescents should practise at least 60 minutes of moderate or vigorous intensity physical activity daily. Unfortunately, the physical activity level of our patients were already low prior to lockdown and further reduced during the lockdown. Physical activity was found to be reduced from 540 minutes per week before COVID-10 pandemic to 105 minutes per week during the pandemic among children and adolescents aged 6–17 years old in Shanghai . For our T1DM patients, time spent for physical activities decreased from 226 minutes per week before to 213 minutes per week during the lockdown. The decline was more marked in our T2DM patients, in which it dropped from 229 minutes per week to 187 minutes per week. An Italian study involving a small cohort of 13 T1DM patients reported that glycaemic control improved in those who maintained physical activity during home confinement . While there is restriction in outdoor activities, innovative ways to maintain physical activity levels including appropriate indoor exercises should be encourage. For the adolescents and teenagers, following popular and credible online physical trainers who share various indoor exercise videos on channels such as YouTube could be beneficial. Short e.g. 10 minutes but multiple exercise sessions a day may also be more practical in an indoor setting. Different types of physical activities indoors and its impact on glycaemic control would need further evaluation.
Screen time which includes exposure to television, computers and hand phones in our patients had increased exponentially during the lockdown. This was expected with schools closure, introduction to online classrooms, boredom and restrictions of outdoor activities. During the lockdown period, only 6 of our patients (5.9%) fulfilled the recommendation by American Academy of Pediatrics  to limit daily screen time to less than 2 hours compared to 55 patients (44.7%) pre-lockdown. In Norway, increment in HbA1c was reported with every hour of watching television in their population-based study involving 538 children and adolescents with type 1 diabetes .
During the lockdown, there was modification of sleep wake rhythm among some of our children and adolescents. The American Academy of Sleep Medicine recommends that toddlers (aged 3–5 years) should obtain 10–13 hours of sleep, school-going children (ages 6–12 years) 9–12 hours and adolescents 8–10 hours . In our study, 70 (72.9%) T1DM patients and 26 (83.9%) T2DM patients had adequate sleep during the lockdown period. Most patients had increased sleep in the morning due to school closure. A shorter sleep duration was associated with poor glycaemic control. Jaser et al.  found that T1DM children who slept more than 9 hours per night had lower HbA1c (7.8%) compared to those who slept less than 9 hours per night (8%) (p = 0.02). However, we did not analysed this in our study. Our patients also had less meal frequency during the lockdown. 12% of participants skipped their breakfast attributed to waking up later in the morning with school closure.
There were a few limitations in our study. Firstly, assessment of glycaemic control was only based on HbA1c. Virtually all our patients were self-monitoring their home blood glucose by finger pricks with only patient using a CGM sensor. We were not able to analyse the home blood glucose levels of patients due to infrequent monitoring at home, lack of documentations in the glucose diary and forgetting to bring their glucometer on clinic follow-up. The poor compliance in monitoring blood glucose levels were likely to be multifactorial including lack of motivation, poor compliance, needle phobia and significant cost of glucose strips and needles. The other limitation was recall bias could exist as the lifestyle changes were recalled by patients and parents only after the lockdown has ended. The sample size of our T2DM participants was also relatively small.
The strength of our study was that the interviews were conducted by the same investigator to limit bias with the help of a standardised questionnaire which was filled up by the patients or parents. The overall sample size of our cohort was also larger than reported in previous studies involving children and adolescents with T1DM. Adequate and accurate clinical data of the participants were also readily available from our electronic medical records.