**4. Discussion**

A properly balanced diet and appropriate dietary patterns are important at every stage of life, but in the case of young patients with T1DM, it is especially crucial since it can prevent or delay the symptoms of many diabetes-related conditions.

The survey was conducted in December 2020, and respondents were asked provide information regarding the previous month. The number of COVID-19 cases recorded in Poland on 1 November was 17,717, and on 23 December—12,358, which was the second peak of the pandemic [14].

Our study showed a high percentage of patients with T1DM who were overweight (32%) or obese (13%). Factors such as increased body weight, low physical activity, long screen time and exposure to stressful situations may lead to diabetic complications. Adherence to the MD has a crucial role in reducing the risk of health consequences.

The restrictions introduced due to the COVID-19 crisis affect various aspects of life. For instance, our research on a group of diabetics, assessing the health consequences of the first wave of the pandemic, showed that the body weight of 31% of respondents had increased by less than 5 kg, while in 11% of the cases—by more than 5 kg [12]. Another study conducted in Poland showed that during the first lockdown, 48.8% of overweight and 55.3% of obese people declared that they ate more, 55.3% and 61.7%, respectively, indicated that they ate more snacks, while 63.3% and 62.6%, respectively, said they cooked more [15]. The research conducted in this study, concerning the period of the second wave, showed BMI above the norm in as many as 45% of respondents with T1DM, which indicates a disturbing trend caused by restrictions on, for example, access to gyms. Research conducted among healthy population, during the first rise in COVID-19 incidence, also showed significant differences in the number of meals consumed. It was shown that during isolation there was an 11.2% increase in the percentage of people who ate five or more meals (from 19.9 to 31.1%) [16]. Being overweight or obese is an increasingly frequent risk factor among people with T1DM, not only in Poland, but also all over the world. It has been demonstrated that in Australia as many as 33% of adolescents under the age of 16 are overweight or obese, and among persons over 18 years of age: 38.3% and 17.2%, respectively [17,18]. Data from Sweden also indicate a large percentage of people over 18 years of age with excess body weight (35.1% of overweight people and 8.9% of obese people) [19]. Our study also showed significant differences in the number of meals consumed by healthy women and those with T1DM. Consumption of five or more meals was declared by 20% and 41%, respectively (*p* < 0.001). At its onset, the pandemic enforced certain social behaviors, such as excessive buying of food and hygiene products for the purpose of creating stocks. The resultant large amounts of products stored at home could be associated with excessive calorie consumption—it has been proven that the number of meals eaten at home increased by 38%. Stressful factors can trigger negative eating behavior, such as snacking between meals, leading to increased caloric value of the diet, and thus obesity [20].

Physical activity is another important element in the prevention of obesity and diabetes complications. Our previous study revealed that during the first wave of the COVID-19 pandemic, the percentage of respondents exercising one to two times a week had increased from 36% (before the pandemic) to 41%. On the other hand, the percentage of people exercising more often had decreased: three to four times a week—from 31% to 19%, more than five times a week—from 12% to 6%. The most common activities were walking and cycling [12]. Our current study found that walking was the physical activity that both people with T1DM (82%) and healthy ones (91%) chose most frequently. Patients with DM also chose cycling (43%) and exercising at home (35%). Regular physical activity improves, among others, sleep quality. There have been reports that during the lockdown period, physical activity, because of its numerous benefits, should be promoted in the same way as other public health related behaviors (including disinfection and distancing). Exercise can be a way to improve both physical and mental health [20,21].

Sleep duration was another factor that was analyzed. We showed that 46% of our respondents slept for more than 8 h—the differences between T1DM and healthy people were statistically significant (*p* < 0.001). Reduction of sleep time has been revealed to play a significant role in the pathogenesis of many chronic diseases. People have more flexibility as regards their sleep hours when they spend more time at home. Usually they fall asleep later and the quality of their sleep is worse: an increase in nocturnal awakenings is observed even when the length of nighttime rest is adequate. Sleep disorders may adversely affect homeostasis, consequently leading to disorders of mood, impaired well-being, worse eating habits, loss of motivation to take up physical activity, eventually resulting in hormonal disorders in obesity and DM [20,22–24].

As regards screen time, we have shown significant differences (*p* < 0.01) between patients with CSII and MDIs. It is a concern that as many as 40% of the diabetics involved in our study spent 5 to 7 h in front of a computer or TV, and 24%—8 h or more.

Stress is another factor that may exacerbate the course of many diseases, including T1DM, and trigger the development of long-term complications. The timing of the pandemic resulted in different patterns of coping with stress. Our previous research aiming to assess changes in social behavior among the DM population found that prior to the pandemic, none of the respondents had described their stress levels as 'very high'. At the beginning of the pandemic, the percentage of people who claimed to be highly stressed was around 32%, while during the study, 4% of respondents rated their stress levels as 'very high' and 17% as 'high' [12]. Our current results have revealed a tendency towards better control of negative emotions and greater capacity to learn to function in a changed reality. The highest percentage of people assessing their stress level as 'very high' was found among healthy people (13%), while among all diabetics, both in the CSII and MDIs groups, the figure was 7%. This may be due to the fact that having been exposed to stress for an extended period of time, they now perceive the new threats differently and are better equipped to face them.

None of the subjects included in our study received the maximum number of points on the MEDAS scale. The most frequent scores were the medium values: from six to nine. The highest percentage of people with MDIs obtained seven points (25%), while the highest percentage of patients with CSII: six points (24%). In the healthy group, 19% of respondents obtained six and eight points each, which proves the need for educational activities that must be carried out in the field of pro-health prophylaxis of patients with T1DM, but also among healthy people.

Metabolic syndrome (MetS) can be another consequence of an improper lifestyle, including inappropriate diet. The impact of cardiovascular disease (CVD) risk factors in adolescents with T1DM is not completely explained. Mayer-Davis et al. conducted a study on a group of 1198 diabetic patients at an average age of 14.83 ± 3.13 years. They showed that CVD risk factors were increased: blood pressure (incidence: 27%), obesity (21%) and high lipid level (18%). The authors concluded that there was little evidence that only a single factor underlay the pattern of CVD risk factors in adolescents with DM [25].

Vidal-Peracho et al. conducted a study to assess compliance with the MD among the inhabitants of Spain—also women with T1DM in the older age group (44.13 ± 12.0 years). The authors, similarly to our study, showed that the average index of the MD among those patients was medium (69%). Interestingly, among the subjects who strictly complied with the recommendations, women constituted a significantly lower percentage than men (22.4% vs. 30.2%). The smallest percentage of women (around 10%) did not follow the recommendation to drink more than seven servings of wine, while the largest proportion complied with the recommendation to use olive oil (around 90%) [26].

The specific components that should be present in the menu of patients following the MD are characterized by multidirectional prophylactic properties and have a positive effect on the parameters of the MetS.

In our study, 46% of healthy people, 52% of CSII and 58% of MDIs patients consumed more than three servings of nuts per week. Although for the majority of diabetic patients oil was the main fat (55% of CSII and 66% of MDIs users), only 22% and 34% of the respondents declared daily consumption of more than four tablespoons. It is worth emphasizing the statistically significant difference (17% vs. 28%, *p* < 0.01) in the frequency of consumption of olive oil between healthy people and those with T1DM. Studies by Grando-Casas et al. showed a positive tendency: patients with T1DM consumed significantly more fatty fish (36.2 vs. 29.2, *p* = 0.009) and nuts (14.7 vs. 9.0, *p* = 0.011) than healthy people [27]. The literature emphasizes the synergistic anti-inflammatory effect of nuts and olive oil, which helps to reduce the health consequences of diabetes. The consumption of fatty acids, including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), contributes to the reduction of inflammation and has cardioprotective action [28].

The main sources of dietary fiber in the MD are: whole grains, vegetables, fruits and nuts. In our study, consumption of three or more servings of legumes per week was reported by 28% of patients with CSII and 36% of patients with MDIs. Vegetables were consumed twice a day or more often by 68% of patients with CSII and MDIs, while fruit was eaten three or more times a day by a similar number of people: 67% of CSII and 69% of MDIs. In patients with T1DM, adherence to the guidelines of the MD has a beneficial effect on the intestinal microflora. This is an important mechanism because T1DM is an autoimmune disease. Proper microflora decreases the permeability of the intestines and modulates the immune system, whereas low consumption of fiber is related to the development of inflammatory diseases [29].

Products recommended by the MD, such as fruits (e.g., berries) and vegetables, are rich in polyphenolic compounds. Their supporting role is especially emphasized in the context of chronic diseases. Cocoa flavan-3-oils are associated with a reduction in the risk of insulin resistance, systemic inflammation, and DM, as well as improved lipid levels, endothelial blood flow, and blood pressure control. Resveratrol and quercetin also play an important part in cardiometabolic protection. Polyphenols can influence the composition of the intestinal microflora and can also be metabolized to bioactive compounds by intestinal bacteria [30]. The mechanism of action of polyphenols is based on inhibition of intestinal glucose absorption by sodium-dependent glucose transporter 1 (SGLT1), increasing insulin secretion and insulin-dependent glucose uptake, and decreasing hepatic glucose production [31]. There are also reports in the literature that it might be possible to treat DM with polyphenols influencing the AMP-activated protein kinase pathway [32].

We have observed high figures as regards to consumption of sweet beverages of more than one serving per day in 87% of diabetics with CSII and in 92% of diabetics with MDIs. Consuming less than three servings of sweets in a week was reported by 50% of the members of the CSII group and 47% of patients with MDIs. Granado-Casas et al. assessed the compliance with the MD recommendations among patients with T1DM and healthy subjects and showed that diabetic patients consumed significantly fewer sweets (17.4 g vs. 38.5 g, *p* < 0.001) [27]. Patients with insulin resistance and DM are aware of the health consequences of consuming sweet snacks, i.e., excessive body weight and increased insulin resistance, leading to glucotoxicity and accelerated apoptosis of B lymphocytes. Subsequently, immunogenicity is increased, and then symptomatic diabetes develops. In insulin resistance, there is an overload of β cells, which accelerates apoptosis and immune damage [33–36]. It has been shown that obesity and deteriorated self-management that occur in patients with T1DM are significantly associated with the risk of hospitalization for heart failure, as well as retinopathies and macrovascular diseases [17,19,37]. Obese people have three times higher incidence of lowcholesterol high-density lipoprotein (HDL-C) hypolipidemia and four times higher incidence of hypertension compared to normal body weight [38].

The recommendations of the MD include drinking good-quality red wine in moderate amounts. Valerio et al. assessed the relationship between alcohol consumption as well as cigarette smoking and CVD risk factors in adolescents with T1DM. It was shown that 10% of respondents consumed alcohol and smoked cigarettes. Adolescents who drank alcohol and smoked had higher triglyceride levels compared to those who did not (86.9 vs. 63.9 mg/dL, *p* = 0.01) and lower compliance to MD (6 vs. 7) [39].

Other authors who studied adherence to the MD recommendations among people with T1DM also assessed anthropometric and biochemical parameters. Fortin et al. conducted a 6-month nutritional intervention based on the use of an MD and a low-fat diet in patients with T1DM. Changes in anthropometric parameters were observed in the MD group: waist circumference decreased by 1.5 cm and BMI by 0.7 kg/m2. There was also a reduction in systolic blood pressure (from 137 ± 20 to 134 ± 17 mmHg), diastolic blood pressure (from 79 ± 9 to 77 ± 10 mmHg), LDL-cholesterol (from 1.92 ± 0.67 to 1.81 ± 0.61 mmol/L) and triglycerides (from 1.14 ± 0.069 to 0.93 ± 0.44 mmol/L), but these differences were not statistically significant. The need for long-term use of the above-mentioned diet is emphasized in order to obtain greater improvement in parameters [40].

The study by Zhong et al. was designed to determine the relationship between adherence to the MD and glycemic control in adolescents (<20 years of age) with T1DM. It should be stressed that at the beginning of the study only 3% of the 793 participants obtained a high result (score ≥ 8) regarding the compliance with the MD, 46%—a medium (score from 4 to 7) result, and 51.5%—a low result. People with a high index of the quality of the MD had significantly lower total cholesterol compared to those with a low and medium index (143.6 vs. 161.6 and 157.7 mg/dL) and LDL cholesterol (77.1 vs. 95.5 and 91.8 mg/dL) [41].

One of the consequences of DM is cognitive impairment, especially in terms of verbal memory. Kössler et al. assessed the impact of adherence to the MD in patients with T1DM and T2DM. A beneficial effect on cognitive functions was found in patients with T2DM only, which requires further research [42].

Our study has several limitations. Being retrospective, like many studies from the COVID-19 pandemic period, we left it to the patients to estimate the portions consumed, and they may have been biased. Our survey was conducted only among the inhabitants of northeast Poland; therefore, subsequent studies should be based on a broader population sample from other regions of the country with a large number of cases. The study was conducted among women because they are willing to take part in various types of research far more often than men. Moreover, in Poland the percentage of young women with T1DM is much higher than that of men [43]. However, this can be considered an advantage of this study because we had a group that was homogeneous in terms of age and gender (only women) and resided in neighboring provinces, which provided an overview of a larger region—northeast Poland.
