Q&A: Climate change presents special concerns for people with diabetes
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Climate change and air pollution may be having a substantial influence on adverse outcomes and mortality for people living with diabetes.
In a review article published in Clinical Diabetology, researchers examined 42 studies that analyzed the impact of climate change and other environmental hazards for people living with diabetes. The authors grouped the studies into three topics: extreme temperatures, natural disasters and air pollution.
In the review, researchers found people with diabetes had a higher hospitalization risk and worse glycemic control during temperature extremes compared with normal temperatures. Some studies showed that during natural disasters, people with diabetes were often unprepared and lacked emergency access to supplies, medications or care. Four studies showed that people with diabetes exposed to more pollution, particularly small particulate matter, had an increased risk for hospitalization.
Osagie Ebekozien, MD, MPH, CPHQ, chief medical officer at T1D Exchange and co-author of the review, said his organization wanted to explore the impact of climate change on people with diabetes because of how big a factor the weather and environment are becoming in people’s everyday lives.
“In a lot of the centers that we work with now, they’re dealing every day with the impact of climate change,” Ebekozien told Healio. “As we’re trying to improve outcomes for people with diabetes, it became obvious to us that where people live, where they go to school, where they go to work, all of that is changing rapidly [with climate change]. For us, as a population-based collaboration, we wanted to answer that question, what does the science tell us today? What do we know, as of 2023, about the impact of rapidly changing environmental conditions for people with diabetes?”
Healio spoke with Ebekozien and review co-author Emma Ospelt, MPH, population health data analyst at T1D Exchange, about their findings, what policy changes and interventions could help people with diabetes and what further research is needed.
Healio: Are there any specific reasons extreme temperatures are causing worse outcomes for people with diabetes?
Ospelt: Extreme temperatures was [the subject of] the largest portion of the studies that we found, so we were able to dive a bit deeper into this topic. The majority of these studies said exposure to hot temperatures would increase risk for hospitalization, especially for elderly populations. Some of these studies speculated and looked deeper into why. They showed that people with diabetes are more sensitive to extreme temperatures because of impaired thermal regulatory control and capacity. The capacity for them [to handle heat] is not as high as it should be, so they’re living in that heat state. Also, some studies said that the medications that are used to treat diabetes, especially those that treat fluid balance, can also exacerbate the risk of heat-related illness. Researchers stated that this is not a very well-studied area, but from previous knowledge on biology, this is what they’ve gathered so far.
Healio: With natural disasters, there are a bunch of different implications. When there’s a big weather disaster, people with diabetes could have trouble getting supplies, food and medications. Why is this such a critical problem, and are there ways to better prepare people with diabetes for these events?
Ebekozien: One of the reasons I wanted to put out this paper is to create more awareness around this issue, specifically as it relates to diabetes. We want to help people with diabetes understand that these weather changes impact them differently than those without diabetes and understand how adverse outcomes really impact their blood glucose levels and their hydration and dehydration. All of those are critical things.
Getting the knowledge out there is one of the first ways to prepare. The second piece is helping our hospital systems to be better, where we can provide optimal care for people with diabetes when we see weather-related challenges or concerns. At some of our centers now, we are trying to promote this message. We need to think about other community partners, cooling stations, food banks, other nonprofit organizations that can help with insulin supplies or that can help with coolers or cooling bags for insulin. When you think about other chronic conditions, you have medications that can have a long enough shelf life and can be out on the shelf for years and not have any issue. You don’t have that same luxury with insulin — insulin needs to be kept at a cool temperature.
We’re trying to promote that more hospital systems have those kinds of supplies and to raise awareness that with ongoing climate change, we’re going to be seeing more [extreme weather events]. We need to have more supplies for people with diabetes, even in the midst of rapidly changing weather. Local partnerships are one big component and then national advocacy as well. We want states, regional and national bodies to start to think about climate change and how we prioritize this specifically for people with diabetes. It’s going to be critical that we have a national strategy on how we address this.
Healio: How does air pollution adversely affect people with diabetes? Also, this was a topic where there weren’t a lot of studies to begin with. Do we need to explore this more, especially with what we’ve seen this year with wildfire smoke?
Ospelt: When we were doing this review months ago, I hadn’t really had experience with wildfire smoke exposure. I’m looking back now at the articles, and one was on Canada and wildfire smoke. It just seems so relevant. Every week or so, we’re getting another bout of the smoke in upstate New York. It’s not going anywhere.
This section was pretty limited in the available studies and research. The ones that we did find discussed wildfire smoke exposure as well as particulate matter 2.5 exposure. Exposure, even short term to particulate matter, can lead to increased risks for hospitalization and all-cause mortality, especially for those who have been previously hospitalized for something diabetes-related. In one study, smoke led to elevated glucose levels in adults. The biological pathway of this is similar to cardiovascular effects, causing inflammation in the body and oxidative stress. It’s not something that they’ve fully studied, but it’s similar pathways and why it’s leading to increased hospitalization risk.
For interventions, this is again not something that was really talked about, but from reading all of this literature, I would think reducing your immediate exposure to air pollution if you are someone who is susceptible and living with diabetes [is important]. You get these alerts on your phone that say, don’t go outside. But maybe someone who is living with diabetes doesn’t even know that exposing themselves to air pollution could be harmful. Education is really important, but start with limiting that exposure and making sure you have the proper supplies and medication you need in your house. If someone doesn’t have a 3-day supply [of medications], that could also be an issue.
Healio: Can this review be used to help develop interventions for people with diabetes? Do you think this review will help to spur more action to raise awareness about climate change?
Ebekozien: I think a little bit of both. The education piece for providers, for patients, for stakeholders [is important]. This is the place for us to think about policy interventions, create that awareness, see where we have good evidence, where we have somewhat mixed evidence and the need for us to have even stronger evidence moving forward.
Ospelt: [This review] will definitely shed light into both of those avenues. We have the opportunity to use our resources to combat climate change. It’s almost an impossible task at some point, but we can help people with diabetes by providing them with education and resources while the wider community is helping to combat climate change.
Healio: What areas of research need the most focus? What kind of studies do we need on climate change and people with diabetes?
Ebekozien: We’re living in the U.S. where different parts of the country are experiencing different kinds of adverse weather conditions. There’s some opportunity for us to look at those naturally occurring experiments. We can learn, for example, from what’s happening with people with diabetes living in Phoenix [during extremely high temperatures] compared to those not exposed to high temperatures. We need to be creative in how we study these issues, using naturally occurring events to further shed light into opportunities or solutions. That also relates to testing the impact of policy changes and how those policy changes can help reduce adverse effects.
The impact of climate change is going to be different based on people’s individual privileges and their individual class as well. We need to think about solutions that will be tailored to address the marginalized and the vulnerable. There will be some in our community who will be able to deal with some of these impacts, and there might be others that are already marginalized or vulnerable, where some of the impact of this adversely changing weather might be more severe for them. We need to consider those people when thinking about our research studies and interventions to make sure we don’t leave anybody behind in trying to defeat this important issue.
Ospelt: A lot of studies that we encountered were very short term and would compare [before and after] 6 months of a natural disaster or look at a 10-day heat index. Looking at long-term impacts, are these adverse outcomes something that are going to stay with these people for years and years, or is it just a short-term impact? Having long-term data is really important as well.
Reference:
- Ospelt E, et al. Clinical Diabetology. 2023;doi:10.5603/DK.a2023.0012.
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