Trends in Type 1 Diabetic Ketoacidosis During COVID-19 Surges at 7 US Centers: Highest Burden on non-Hispanic Black Patients

Abstract

Objective We examined United States (US) trends in diabetic ketoacidosis (DKA) among individuals with type 1 diabetes (T1D) during the COVID-19 pandemic at seven large US medical centers and factors associated with these trends. Methods We compared DKA events among children and adults with T1D during COVID-19 surge 1 (March-May 2020) and COVID-19 surge 2 (August-October 2020) to the same periods in 2019. Analysis was performed using descriptive statistics and Chi-square tests. Results We found no difference in the absolute number of T1D patients experiencing DKA in 2019 vs 2020. However, a higher proportion of non-Hispanic Blacks (NHB) experienced DKA in 2019 than non-Hispanic Whites (NHW) (44.6% vs 16.0%; p<0.001), and this disparity persisted during the COVID-19 pandemic (48.6% vs 18.6%; p<0.001). DKA was less common among patients on continuous glucose monitor (CGM) or insulin pump in 2020 compared to 2019 (CGM: 13.2% vs 15.0%, p<0.001; insulin pump: 8.0% vs 10.6%, p<0.001). In contrast to annual DKA totals, a higher proportion of patients had DKA during COVID-19 surges 1 and 2 compared to the same months in 2019 (surge 1: 7.1% vs 5.4%, p<0.001; surge 2: 6.6% vs 5.7%, p=0.001). Conclusions DKA frequency increased among T1D patients during COVID-19 surges with highest frequency among NHB. DKA was less common among patients using CGM or insulin pumps. These findings highlight the urgent need for improved strategies to prevent DKA among patients with T1D—not only under pandemic conditions, but under all conditions—especially among populations most affected by health inequities.

COVID-19 and diabetes in children

“…38) Interestingly, American studies highlight a significant association between ethnicity and DKA proportion, with more DKA diagnoses in nonwhite children (Black, American Indian and Alaskan Native patients). 37,38) Increase in DKA severity in T2D was also described during the pandemic among nonwhite children (Black or African America, Hispanic, Latino). These adolescents had worse glycemic and metabolic control overall even before the pandemic, mostly as a consequence of socioeconomic status factors and higher BMI.…”

“…During the first (March-May 2020) and second (August-October 2020) COVID-19 waves, higher proportions of patients had DKA compared to the same periods in the previous year (first wave: 7.1% vs. 5.4%, P<0.001; second wave: 6.6% vs. 5.7%, P=0.001). 37) In another study of 615 children admitted with new-onset diabetes in a tertiary care children' s hospital between March 2018 and December 2020, children admitted to the hospital with new-onset diabetes in the pandemic and post-pandemic period were more likely to present with DKA compared to those in the pre-pandemic period. 38) Interestingly, American studies highlight a significant association between ethnicity and DKA proportion, with more DKA diagnoses in nonwhite children (Black, American Indian and Alaskan Native patients).…”

Diabetes Population Health Innovations in the Age of COVID-19: Insights From the T1D Exchange Quality Improvement Collaborative

“…The existing health collaborative served as a springboard for robust surveillance study, documenting numerous works on the effects of COVID-19. 3,4,[20][21][22][23][24][25][26][27][28] Other investigators also embraced the power of real-world surveillance and real-world data. 29,30 Big Data, Machine Learning, and Artificial Intelligence…”

Commentary on CDC data showing an increased risk for pediatric diabetes with COVID‐19 infection

“…It is well established that the risk for both types of diabetes varies significantly between different racial and ethnic groups and that COVID-19 has disproportionately affected disadvantaged groups. 6 Unfortunately, important details addressing race, ethnicity, presence of comorbid conditions, socioeconomic factors, and body mass index (BMI) were not reported. Several studies have shown an alarming rise in childhood obesity and BMI since the beginning of the pandemic, attributable to various factors such as limited physical activity, virtual schooling, disrupted routines, and food insecurity.…”

“…Patients were only followed for limited periods of time and longer‐term follow up would be required to assess whether diabetes was transient or persistent. It is well established that the risk for both types of diabetes varies significantly between different racial and ethnic groups and that COVID‐19 has disproportionately affected disadvantaged groups 6 . Unfortunately, important details addressing race, ethnicity, presence of comorbid conditions, socioeconomic factors, and body mass index (BMI) were not reported.…”