Those with diabetes confront their condition multiple times a day, every time they pick up a fork, and all the hours in between. Healthy habits are hard earned after many months of daily choices – a difficult but necessary step in managing or even reversing type 2 diabetes. But what happens when habits are disrupted? When disaster strikes, health may be pushed to the sidelines, and suitable foods and even medicine may be unavailable. Patients with diabetes should be encouraged to prepare for disasters to ensure that their diabetes can remain in control despite major disruptions.
As climate change progresses, personal preparedness and self-management of diabetes become even more critical. Regions of the world that traditionally did not have frequent heat waves or wildfires are now experiencing them annually. Areas that are used to hurricanes aren’t prepared for back-to-back storms or storms that are much stronger and longer lasting because of climate disruption.
Over 34 million people in the United States have diabetes. Millions more are pre-diabetic or have diabetes but are undiagnosed. And Latinx people have a higher risk of type 2 diabetes than non-Hispanic whites. But “Latinx” as a definition is very broad, encompassing diverse cultures and races from Puerto Rico to Mexico to Chile to Spain – and risks vary. Puerto Ricans in particular have a high risk of type 2 diabetes, with estimates that the Island has a prevalence rate about 50% higher than the general US population.1 The rates may be higher now, as disrupted health care and years of economic, social, and health destabilization from Hurricane Maria and earthquakes have left many unable to keep up with their health. Those disasters were followed by COVID-19, which further disrupted medical care as people feared attending medical appointments and hospital systems became overwhelmed.
To help patients with diabetes better prepare for the next disaster, Migrant Clinicians Network and the National Center for Health in Public Housing recently co-hosted Diabetes and Disasters, a four-part Spanish-language learning collaborative aimed at increasing Community Health Workers’ knowledge of diabetes to help prepare patients for disasters.
During the learning collaborative, co-presenter Lois Wessel, FNP, DNP, noted that a disaster can be environmental, such as a hurricane, tornado, or snowstorm, or it can be a public health disaster, like COVID-19. Disasters can be slow moving, taking place over several weeks, such as a heatwave or severe cold snap, or immediate, like a tornado. Indeed, disasters can be both immediate and slow -- a wildfire might prompt urgent evacuations, and then continue to burn for weeks. Many are influenced by climate change but not all. All disasters have one thing in common: disruption.
“The critical component is how the disaster affects the social structures we rely on to be able to do the basics to stay safe and healthy,” Wessel said. When transportation is disrupted or air quality drastically impaired, patients may not be able to get to the health center or to the pharmacy for insulin, or to a market that would have the right foods for a person with diabetes. When power is shut off, either disrupted by a disaster or turned off in the case of rolling blackouts, insulin may not be sufficiently chilled, or food may spoil. Credit cards won’t be accepted at grocery stores, if they are open at all during an outage. In all these situations, “the goal is to make sure that an ecological disaster doesn’t become a health disaster,” Wessel concluded.
The presenters outlined key areas to prepare for: nutrition, medicines, home monitoring and clinical concerns, and physical health.
After a disaster, vigilance must be heightened to ensure that nutrition needs are met. Preparation before disasters is key. During the first part of the learning collaborative, Wendy Shelly, RD, CDCES, CDN, reviewed the basics of diabetes nutrition, which is also covered in MCN’s Spanish-language diabetes comic book. Shelly recommended building an emergency food box that is regularly reviewed for expiration dates. For those with sufficient means to pay for the food up front, the box can serve as a critical way to keep diabetes in check even if a disaster strikes, whether the patient is stuck at home without resources, or if she must urgently flee. Some recommended components in the box:
- Whole grains that don’t need to be cooked, including plain oatmeal, low-sugar cereals, and biscuits – those low in sodium and low in sugar. Look for high fiber and whole grain.
- Proteins that don’t require refrigeration or cooking, including fat-free and low-sodium canned beans; nuts and nut butters (with no added salt); canned meats like chicken or tuna that are packed in water and not oil. Other less ideal options include dried meats, although most have a lot of salt, and powdered skim milk, which may not have excellent flavor but can provide protein in a disaster.
- Canned vegetables that are low in carbohydrates and low in added salt.
- Canned soups that are low in added salt.
- Glucose tablets and/or a few hard candies for low blood sugar emergencies. She cautions on the inclusion of the hard candies – there may be a temptation to snack when low blood sugar is not an issue. Make sure patients understand to only eat the candies when blood sugar dips dangerously low.
Shelly also provided some additional tips:
- If you include canned foods, be sure to pack a manual can opener.
- Avoid instant soups like instant ramen due to their very high amounts of sodium.
- If you include canned fruit, do not drink the juice in which it’s packed, as that can cause a spike in blood sugar.
- Avoid drinks that aren’t water. There are a few – like Zevia or Sparkling Ice – that are sugar free and low in sodium. With limited space, however, water is the best choice.
- Pack a water filter, like a Brita filter, in the case of evacuation to a place (like a hotel or campground) where the taste of the water may discourage intake.
- Avoid protein bars, granola bars, and fruit bars. While they are labeled as healthy, most are high in sugar and carbohydrates.
Treatment and medicines
In the second part of the learning collaborative, José Rodriguez, MD, Chief Medical Officer at Hospital General Castañer in Puerto Rico, emphasized the value of evaluating the patient and the medicines they are using, before any disaster strikes. “It’s important to discuss every detail related to diabetes,” he noted. “After we do that, we can talk about medicines. But, as you can see, you can’t depend on the medicines,” when disaster strikes. Regular monitoring of blood sugar, proper nutrition and exercise, check-ups on A1c levels every three months in a clinic, and other key strategies must be implemented concurrently with medication. After a new medication is prescribed, extra care must be given to ensure that, over a 24-hour period, the patient is able to maintain control of their diabetes. Those who are unable to maintain their diabetes over time are at high risk of serious complications, from ocular degeneration, to chronic kidney disease, to periodontal disease.
“Diabetes is often one problem that a patient may experience” in combination with other health concerns, Dr. Rodriguez also emphasized. Diet and lifestyle may lead to obesity, hypertension, and high cholesterol, which increase the risk of diabetes. For treatments, care must be taken to determine all of the medicines and supplements that a patient may be taking for their various conditions, as they may affect a patient’s blood sugar or the effectiveness of their medication.
This also includes over-the-counter medication. If a patient has the flu, for example, he may take a cough syrup regularly over a period of several days, and then be confused when his blood sugar is out of control, but the patient hadn’t accounted for the extra sugars in the cough syrup. Herbal remedies and home medicines should also be reviewed.
The health center must work diligently ahead of a disaster – to equip patients with solid education on their diabetes, how it affects their body, and how their medications work; to plan around where the most vulnerable live in the community, both those who need the most care and those most likely to be cut off from care; to review emergency protocols around medicine, envisioning multi-week cut-off from supplies and electricity and prepare accordingly.
Patients must also work to be prepared. Before an emergency, patients should have documentation of their diabetes and how they are monitoring and controlling it. A written list of medications is essential in case their medication is damaged during the disaster.
In Puerto Rico, emergency plans were tested during several recent disasters. Puerto Rico had several days’ head start before Hurricane Maria approached. At Hospital General Castañer, clinicians went into the community to get additional medication into the hands of those most at risk. Unfortunately, a lot of medicine was damaged during the hurricane. When the power went out, many people threw away their insulin, fearing that it had gotten warm, and headed back to the hospital for a new prescription, but their health plans would not cover the insulin as they had just refilled their prescription – a concern that health centers should prepare for. In this emergency, the hospital advised patients to keep their insulin vials in cool clean water to maintain a low temperature, and to keep it out of direct sunlight, when refrigeration was unavailable. Dr. Rodriguez noted that the hospital was without regular electricity for six months. When infrastructure is destroyed, the disruption becomes a long-term concern, and medication and storage of medication should be considered when patients develop their personal plan.
Home monitoring and clinical concerns
Patients may need to practice self-management of their diabetes for extended periods, and consequently should be well informed of their health concerns and how to monitor their diabetes. Patients should also be aware of the signs and symptoms when their diabetes requires immediate clinical attention. Stress, illnesses, exercise, and other medications can all affect control of diabetes.
Of course, going into an emergency with controlled diabetes is much safer than with uncontrolled, and patients should be encouraged to take diabetes care seriously and urgently. After a disaster, with no electricity, patients need to have written instructions to refer to on how to monitor their diabetes, Dr. Rodriguez recommended, and power supplies to keep their home monitoring systems working properly. He emphasized the importance of FDA-approved monitors, and working with patients to troubleshoot potential issues to make sure readings are correct. Many newer home monitoring devices monitor blood sugar throughout the day, and allow patients to send blood sugar graphs to their clinicians for review. Understanding blood sugar dips and spikes throughout the day, what causes them, and how to adjust medication and lifestyle to prevent unhealthy ones, is important for patients with diabetes to understand before a disaster strikes.
Patients must understand the signs and symptoms of hypo- and hyperglycemia, in the case that home monitoring systems fail. For hypoglycemia, when blood sugar is too low, symptoms include sweating, disorientation, confusion, irritability, tremors, faster or irregular heartbeat, dizziness, imbalance, convulsions. Hypoglycemia can lead to a coma if not treated. Hyperglycemia, when blood sugar is too high, has some overlapping symptoms, including dizziness, irregular heartbeat, sweating, confusion, and a general feeling of being unwell. However, hyperglycemia frequently presents with thirst and frequent urination, hunger, and blurred vision. In the case of an emergency, where equipment is unavailable and emergency services are hard to reach, a patient can test with food. If food improves your low blood sugar within 15 to 30 minutes, then the patient was experiencing an episode of hypoglycemia. If it does not improve, emergency services are warranted.
Mental health and wellness
Mental health is an oft-overlooked concern that people with diabetes must prepare for in the case of a disaster. Any disaster can affect an individual’s mental health.
“Stress is a physiological response to an external event,” Wessel said. “This can start a cycle of stress, that whenever there are external circumstances beyond your control, you can begin to feel stress. For diabetes, all this stress can increase blood sugar.” Stress causes the release of adrenaline and cortisol, hormones that disrupt the body’s usage of insulin, which is itself a type of hormone.
Wessel emphasized teaching strategies to reduce stress as part of the health plan for people with diabetes, and for others in communities that are at risk of a disaster – which, with climate change, are all communities. Primary strategies include recognition and separation of what one can control after a disaster from that which is out of one’s control. After a disaster, there are many unknowns, as communication is cut off and situations remain unstable. Releasing control of the situation and focusing instead on what is controllable – how to spend time, how to help others in ways that are safe, how to take care of one’s body with food and care – will reduce stress.
Anxiety is a combination of stress and worry that can have a serious impact on physical well-being. “I say that anxiety is like the biggest stress, stress that can’t be calmed down,” Wessel said. “It’s a stress that’s so strong that it causes anxiety. But the solution to anxiety is similar.” Uncertainty during a disaster can be addressed similarly, as individuals, with care to one’s health and well-being; or as a community, coming together to release negative reactions through a shared mass, a community art or singing project, or other community-level outlets. Health care workers, for their part, must be prepared for how they are going to maintain communication with the community to provide clear messages over the clinic’s activities and limitations in the wake of a disaster.
Stress eating and drinking are two more concerns that people with diabetes must take care to avoid, as well as other personal responses to stress that can cause diabetes to get out of control. “It’s important that we remind people that it’s better to have limited sugar, alcohol, and caffeine. All of these… can calm someone down in the short term, but symptoms of stress and anxiety will return and often will be worse.” She recommended teaching patients simple awareness exercises that are backed by research to help prepare people to respond when they are experiencing stress and anxiety, including breathing exercises or focusing attention on one body part like wiggling toes to recenter and reground into the body. A doctor in Colorado, for example, provided very simple “tapping” techniques to his community during wildfires. This technique, drawing from acupressure, has the patient tap lightly on key points across the body, which brings attention back to the body, and can help relieve stress and anxiety. The doctor, upon following up with patients after the fires, found that the patients continued to use the technique in stressful situations including when waiting for COVID test results.
Wessel also noted that exercise can have a positive long-term effect on mental health, as well as diabetes. “If you go out even just to walk or jog, you’ll feel better,” Wessel noted. “Exercise touches all parts the body – but it’s particularly helpful for people with diabetes.” Beyond mental health, engaging in a daily exercise plan can help the pancreas function better, releasing more insulin naturally and allowing for better usage of insulin, for those with type 2 diabetes. It may help reduce blood sugar, hemoglobin A1c, blood pressure, and cholesterol. Exercise does not have to be push-ups at the gym or running on a track; dancing, movement, play, and games like soccer with friends can all move the body in positive and healthy ways.
Exercise can also have short-term effects that can buffer the mental health stress of disasters. “After a traumatic event, it’s important to remember there are ways to exercise, even if you’re in a refugee camp or in the outskirts of a village,” that can improve health, Wessel emphasized. In refugee camps in Iraq, researchers discovered that children who continued to actively play managed their health better than those who did not. Wessel encourages children – and adults – to continue to play in safe ways after a disaster.
Finally, having a safe place to speak about disaster experiences can help survivors begin to heal from the experience. While many wish to avoid talking about it, “not talking about it is going to cost in the long run,” in terms of their mental health, Wessel said.
In Puerto Rico, patients were just beginning to recover from Hurricane Maria when frequent earthquakes shook the island. Shortly thereafter, COVID began to circulate. Compounding emergencies make mental health ever more important to address in an ongoing manner. “Many people don’t accept that they have a behavioral health concern,” Dr. Rodriguez admitted. “People come with complaints that are difficult to explain – constant headaches on one side of the head, a pain in the left side -- and the patient doesn’t believe they are connected, but he doesn’t realize that [those pains] are from stress.”
Even in a stable and supported environment, managing diabetes can be challenging. After a disaster, a patient with diabetes needs extra support. Here are some additional resources to aid clinicians in helping patients with diabetes prepare:
Migrant Clinicians Network offers several diabetes-specific resources in English and Spanish that can be adapted for use in preparation for a disaster on the MCN Diabetes page: https://www.migrantclinician.org/issues/diabetes
MCN is committed to helping communities to prepare for disasters as the climate crisis continues. Sign up for our active blog, Clinician to Clinician, to hear more about our initiatives and access new resources: www.migrantclinician.org/blog.
MCN’s Witness to Witness offers extensive resources on managing stress and anxiety: http://migrantclinician.org/w2w.
Read this article in the Spring 2022 issue of Streamline here!
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