January 20, 2022, 2:38 p.m. Michael Devitt — According to the CDC, diabetes is one of several underlying medical conditions that put adults at any age at higher risk for severe illness from COVID-19. In fact, more than two years after SARS-CoV-2, the virus that causes COVID-19, was first identified, there is strong evidence to suggest that COVID-19 has had an overwhelmingly negative effect on people with diabetes.
While much of the research regarding COVID-19 and diabetes has been conducted in adults, a recent analysis of health data suggests there may be an association between SARS-CoV-2 infection and diabetes risk in individuals younger than 18. The analysis, published as a Morbidity and Mortality Early Release earlier this month, found that young patients diagnosed with COVID-19 were at a significantly increased risk of developing diabetes compared with patients who did not have COVID-19, or with patients diagnosed with other acute respiratory infections.
“The mechanism of how SARS-CoV-2 might lead to incident diabetes is likely complex and could differ by type 1 and type 2 diabetes,” the authors wrote. “Monitoring for long-term consequences, including signs of new diabetes, following SARS-CoV-2 infection is important in this age group.”
To estimate the risk of diabetes following SARS-CoV-2 infection, researchers from the CDC’s COVID-19 Emergency Response Team and the National Center for Chronic Disease Prevention and Health Promotion built a retrospective patient cohort using health information from two large commercial databases: IQVIA and HealthVerity.
In the IQVIA database, health claims data on nearly 81,000 individuals younger than 18 years who were diagnosed with COVID-19 between March 1, 2020, and Feb. 26, 2021, were compared with three age- and sex-matched groups: one group that was not diagnosed with COVID-19 during the same period, and two groups with and without a diagnosis of acute respiratory illness between March 1, 2017, and Feb. 26, 2018.
In the HealthVerity database, health claims data on more than 439,000 patients younger than 18 years who were diagnosed with COVID-19 between March 1, 2020, and June 28, 2021, were compared with individuals who had a negative SARS-CoV-2 PCR test result and no record of COVID-19 diagnosis or positive test results during the same period.
For both databases, incident diabetes was defined as the presence of one or more health care claims with a diagnosis of diabetes occurring at least 30 days after the patient’s index encounter date.
The analysis found that the incidence of diabetes was significantly higher among patients diagnosed with COVID-19.
Compared with patients that did not have a COVID-19 diagnosis, patients in the IQVIA and HealthVerity databases with COVID-19 were 31% and 166% more likely, respectively, to have a new diagnosis of diabetes.
In addition, those in the IQVIA database with a COVID-19 diagnosis were 116% more likely to have a diagnosis of diabetes than patients who had been diagnosed with a non-COVID-19 acute respiratory infection prior to the pandemic.
There was no association between a non-SARS-CoV-2 respiratory infection and diabetes of any type.
In both databases, diabetic ketoacidosis was more common at the onset of diabetes in patients who were also diagnosed with COVID-19. Diabetic ketoacidosis was reported in more than 48% of patients in the IQVIA database, and more than 40% of patients in the HealthVerity database, who had COVID-19 and diabetes. In comparison, diabetic ketoacidosis was reported in only 13.6% of IQVIA patients with diabetes without COVID-19, and only 29.7% of HealthVerity patients with diabetes without COVID-19.
The authors stressed that their findings did not mean that COVID-19 directly caused diabetes in children and adolescents. They offered a number of potential explanations, including the effects of COVID-19 on organ systems already known to play a role in diabetes risk; the use of steroids during hospitalization, which could lead to transient hyperglycemia; and pandemic-associated weight gain.
“Although this study can provide information on the risk for diabetes following SARS-CoV-2 infection, additional data are needed to understand underlying pathogenic mechanisms, either those caused by SARS-CoV-2 infection itself or resulting from treatments, and whether a COVID-19-associated diabetes diagnosis is transient or leads to a chronic condition,” they wrote.
The authors acknowledged several study limitations, as well. In particular, the definition of diabetes used a single ICD-10 code, did not include laboratory data at the time of diagnosis, and could not reliably distinguish between type 1 and type 2 diabetes, which led the authors to state that the definition might have low specificity.
Other limitations included
In addition, there was no mention in the analysis on the impact of social determinants of health on diabetes risk, even though there is widespread evidence to indicate that diabetes has disproportionately affected racial and ethnic minorities and economically disadvantaged populations, and emerging evidence that the COVID-19 pandemic has had a similarly negative effect.
Despite these limitations, the authors noted that their findings have been supported by results from studies in adult patients, and that they highlight the importance of taking steps to prevent COVID-19 in patients of all ages, including the use of COVID-19 vaccines and booster shots in eligible patients. They called for additional efforts to draw attention to the risks associated with COVID-19 in children and adolescents, and suggested that clinicians be made aware of long-term consequences and monitor patients for diabetes in the months following SARS-CoV-2 infection.
“Family physicians are a trusted source of information for patients and their families, and keeping abreast of new data helps ensure that we are able to have timely, appropriate discussions with our patients,” said Alexis “Alex” Vosooney, M.D., of West St. Paul, Minn., chair of the Academy’s Commission on Health of the Public and Science. “This report highlighted that we’re still learning what the short- and long-term risks of COVID-19 infection may be in children.”
Vosooney told AAFP News the findings could lead to a slight change in the way FPs discuss COVID-19 infection risks for young patients.
“The findings are another point we can include with families when talking about unknown risks with COVID-19 infection so that we can emphasize the need for mitigation strategies and vaccination,” Vosooney said.
Asked how she would monitor a young patient who was diagnosed with COVID-19, Vosooney said, “I would continue to watch for any signs or symptoms that would cause concern for diabetes, and test if and when the clinical situation was appropriate, but I would not start to routinely order screening labs on patients just because they had COVID-19.”
Vosooney said that she reviews CDC.gov and her state department of health’s webpage on a regular basis, along with the COVID-19 webpages at AAFP.org and familydoctor.org.
It should be noted that the AAFP also has a vast expanse of resources on diabetes. For example, the Academy recently added a Diabetes: Clinical Guidance and Practice Resources section to its collection of clinical recommendations, which includes an updated screening recommendation for diabetes that differs from that of the USPSTF. Familydoctor.org, meanwhile, contains more than a dozen pages on diabetes and related topics such as nutrition and healthy eating.