Why Climate Change Is Different for People With Diabetes

How to help patients with chronic conditions prepare to evacuate safely during natural disasters

With Mark Molitch MD and Mihail Zilbermint MD

How to safely evacuate with diabetesHow can a patient keep their insulin refrigerated when fleeing a fire?

It has been a season of fires, floods, and hurricanes that have seen millions of people fleeing their homes with what they can carry, often with just minutes of notice. While it’s frightening and tragic for everyone, for those with chronic illnesses like diabetes, it can be doubly troublesome. Do they have access to their medications? And if they take insulin and it needs refrigeration, what happens if the electricity is out for an extended period? Will they have access to food when they need it to keep their blood sugar levels stable? What if their hospital is inaccessible?

These are some of the issues that Mihail Zilbermint MD, an endocrinologist at Johns Hopkins University’s Suburban Hospital, looked at in a new literature review examining the impact of climate change on diabetes care. Among his findings:

  • Extreme heat episodes can be especially dangerous for those with diabetes, causing dehydration and a spike in cardiovascular events among those with the disease. A study from Brazil looking at heat-related hospitalizations among those with diabetes found that older patients were particularly at risk, even from short term heat events.
  • There may be medical supply and food shortages.
  • Hospitals themselves are subject to the whims of flooding and fires, eliminating some of the potential safety net for people who have been evacuated from their homes during climate-related disasters.

While some of the concerns are exacerbated in developing countries, they exist here too, Zilbermint says. In his report, he noted that during Hurricane Harvey in 2017, a major regional medical center in Houston was flooded. People with diabetes have more hospitalizations and longer stays during any given year as their counterparts, which makes access an issue.

After Hurricane Maria in Puerto Rico that same year, the Baxter pharmaceutical plant went offline as the island struggled to restore power for months. Limited drug supplies were also a factor after Hurricane Katrina. Food supplies – particularly fresh food – can also be disrupted, causing those with diabetes to rely more on processed foods, which can negatively impact their condition.

There are more than 34 million Americans with diabetes, and according to the American Diabetes Association, about 7.4 million of those use some form of insulin. While it can work if it isn’t refrigerated, it needs to be kept at temperatures under 80 degrees Fahrenheit to maintain efficacy. In heat events that coincide with prolonged electricity outages, that can be an issue.

What this means for patients and providers is the need to identify the patients most at risk of detrimental impacts from climate related events and ensure that they have a good plan for what to do in case of one.

The Diabetes Disaster Response Coalition has resources for patients (diabetesdisasterresponse.org), including a checklist that those with diabetes can use to create an emergency kit. Among the items they suggest be put into a waterproof insulated bag:

  • Copies of all prescriptions, health insurance cards, and emergency contact information including physicians and endocrinologists
  • A record of basal rates, insulin-to-carbohydrate ratios, and insulin sensitivity factor (a calculation of how much one unit of insulin lowers your blood glucose levels)
  • Insulin and a cooling pack to maintain a safe temperature
  • Syringes or an insulin pen and needles
  • All prescribed and over-the-counter medications commonly taken
  • Glucose monitor, lancets, test strips, pump (with extra batteries or charger) and other supplies
  • Low blood sugar supplies such as glucose tabs, gels, fruit snacks, or juice boxes, etc.

“The climate crisis has largely been ignored by physicians,” Zilbermint says. “We often pretend it won’t affect us, but our kids or our grandkids. But it will happen to us. It is happening to us.”

Physicians need to proactively advocate to patients about being prepared, especially those with insulin needs. “They have to know what to do if the power goes out, have a plan to transport insulin, and have an extra glucometer.”

During the Hurricane Maria aftermath in Puerto Rico, Zilbermint says his physician peers there told him people were “running around trying to figure out where their next meal was coming from, and who might have electricity to store insulin.” With the power out for months there, the safety of insulin stored at ambient room temperature was in question, as there is no data on safety after 28 days stored without refrigeration.

Should there ever be an affordable pill form of insulin, Zilbermint says the refrigeration problem would go away. But for now, it remains an issue of concern. Glucagon also needs to be refrigerated, although there is a version that can be at room temperature for several days, he notes.

“In America, we are a little spoiled by our access to regular power, but in underdeveloped areas – and even in some of the most poverty stricken areas of this country – there is not always access to refrigeration.”

It’s not just about checking in annually on your patients’ preparedness plans, he notes, but on recognizing that diabetes and climate change are related. “Then you can determine which patients are at higher risk, such as those who are elderly or have a comorbidity or live in a remote rural area or one that is at a higher risk of an event.”

He’d like to see the pharmaceutical industry step up more, and physicians should agitate for those companies to create medications that are effective and can work in situations that climate change is increasingly bringing. 

Mark Molitch MD, a professor emeritus in the endocrinology, metabolism, and molecular medicine department at Northwestern University Feinberg School of Medicine, says that given that emergency events are happening with increasing frequency, it makes sense that patients should think about what might happen and how to prepare for it. Insurance companies, during this time of COVID-19, are allowing patients to get an extra month of medications to have on hand. It’s a good time to add them to your emergency kit.

“Anything can happen at any time,” Molitch says. “So you need to be ready.”

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