New cases of childhood diabetes rose during pandemic news and research
The little girl felt unwell, but both she and her mother thought they knew the cause. Aliyah Davis, just nine years old, fought against covid. Exhausted, repeatedly stomach ache, with no sense of smell or taste and some shortness of breath, she seemed to have an almost textbook case of the virus.
Aliyah had a history of asthma, so her mother, Christina Ortiz, took her to the emergency room, where she was told that the symptoms were probably covid-related. But two and a half weeks later, Aliyah became ill again in the middle of the night, and Christina noted that her daughter had experienced insatiable thirst and frequent urination since the first emergency visit. This time, a urine dip tested positive for ketones. Further evaluation revealed the problem: Aliyah had newly started diabetes.
Her diagnosis in the summer of 2020 was the cutting edge of what has become a worrying and sometimes puzzling development. Although researchers are still struggling to understand why, it seems that covid-19 and diabetes have formed an intricate – and dangerous – partnership.
It is also two-way, says Francesco Rubino, a pioneer in diabetes surgery at King’s College London. “The relationship works not just in one way, but in two ways,” Rubino tells me.
On the one hand, diabetes is an important risk factor for developing serious illness or dying after suffering from covid. But we now also have several reports of patients getting covid-19 and then developing newly started diabetes and sometimes severe blood sugar imbalances, such as diabetic ketoacidosis (DKA). In fact, a large diabetes study of adults published last month in the journal Lancet Diabetes and Endocrinology showed that individuals who recovered from COVID-19 in the past year had a 40 percent greater chance of being diagnosed with diabetes than the uninfected.
At this point, the evidence is more limited in children, and there is much we do not know. “While we are concerned that covid may cause diabetes, we must rule out other reasonable causes for this connection. [are] not necessarily the one that links the virus to the disease, says Rubino.
Aliyah’s blood sugar was sky high even though he had no immediate family history of diabetes, was not overweight and had no other obvious comorbidities. Her DKA diagnosis prompted a four-day hospital stay. Such diagnoses are also becoming more common.
Hospitalizations of children broke records during the rise of the Omicron variant of the SARS-CoV-2 virus. As of March 31, more than 12.8 million pediatric cases of covid-19 had been reported in the United States since the pandemic began. Comparatively few children are hospitalized for covid, but even a small proportion of a large number can be significant.
A new diabetes diagnosis is a serious problem with the potential to change a person’s life. As a chronic condition, it affects how the body uses blood sugar (or glucose), and it can cause devastation for years to come. Possible complications include kidney failure, heart attack, stroke, nerve damage, macular degeneration, blindness, vascular problems and even amputations.
With type 1 diabetes, which is usually diagnosed in children and young adults, it is believed that the immune system accidentally attacks insulin-producing cells in the pancreas, so that the body has little or no insulin and blood sugar levels rise. With type 2, mainly diagnosed in adulthood and much more commonly, even cells become resistant to insulin, leading to similar peaks in blood sugar levels. New cases of both types have been reported during the pandemic, says Rubino, chief investigator for CoviDIAB, a global registry that collects detailed information on the subject.
Researchers at the Centers for Disease Control and Prevention (CDC), which analyzed two large databases of insurance claims on people under the age of 18, found that children with a previous covid infection were 31 to 166 percent more likely to develop diabetes than those who had not. covid-19 (or who had another, non-SARS-CoV-2 respiratory infection). Compared to the other acute respiratory infections in particular, the probability of a new diabetes diagnosis was 116 percent higher in those who had a covid-19 infection.
One of the earliest reports of this development came from London 2020, where researchers found an 80% increase in new-onset type 1 diabetes in children during the pandemic. A study at Rady Children’s Hospital in San Diego also noted an increase of 57 percent in children admitted with newly started type 1 diabetes during the pandemic from March 2020 to March 2021. This study also found a higher proportion of children receiving DKA, indicating a greater severity of the disease at the time of diagnosis, according to Jane Kim, a study author and pediatric endocrinologist at the University of California, San Diego.
Reports of increasing diabetes rates in children are “in line” with several new observations internationally, says Paolo Fiorina, diabetes expert and research assistant at Boston Children’s Hospital-Harvard Medical School. Finnish, Romanian, Italian, German and Australian researchers have all found that more children were diagnosed with new-onset type one diabetes during the pandemic than the pre-pandemic. At the Children’s Medical Center in Dallas, pediatric endocrinologist Abha Choudhary says type 2 cases are on the rise and “these patients are sicker at presentation.”
“I think covid-19 causes an increase” in new diabetes cases, says Fiorina. “This is clearly demonstrated now … and it is much higher than what is observed in other viral infections such as SARS-CoV-1 and hepatitis.” Others, including Rubino, are wary of attributing causation. “At the moment we can say that there is a connection between new cases of diabetes and covid-19,” he says. “I think it’s pretty stable.” (The American Diabetes Association says a direct link is not yet complete.)
Researchers are still trying to learn the mechanisms behind a potential link. In addition, the long-term link between SARS-CoV-2 and diabetes is not well established. For that matter, type 1 and type 2 diabetes are different disease processes, says Kim. “We want to be careful about extrapolating type 1 findings [to] type 2 and vice versa, she says.
It is possible, experts say, that the pandemic’s effect on our healthcare systems plays a role here. Past delays in seeking care, for example, may justify some of the increase in new diabetes cases. Says Rubino, “Is this really new diabetes, or just newly diagnosed but pre-existing diabetes?”
Some researchers have a theory that covid-19 can lead to diabetes through a direct attack of pancreatic cells. Research has shown that the coronavirus can infect insulin-producing cells in the pancreas, the so-called beta cells. Autopsy results of COVID-19 victims have confirmed the presence of viral antigen and even damage to some of these beta cells.
“When New York City was in the middle of the April 2020 pandemic, we learned that it was very challenging to control the blood sugar level of some covid-19 patients,” said Shuibing Chen, director of the diabetes program at Weill Cornell Medical College and an NIH-funded team. examining the issue. “Then we tested different cells for their permeability to SARS-CoV-2. Very surprisingly, we discovered that beta cells from the pancreas may be infected.” These cells appeared to have been transformed during the process, making them unable to function properly.
Another NIH-funded team, led by Peter Jackson at Stanford University School of Medicine, used mass spectrometry to see that beta cells were “heavily reprogrammed by the virus to cause cell death,” Jackson said. That process, he says, can lead to new diabetes in some patients or a worsening of the condition in others. “The effects we see in vitro are so strong,” Jackson adds.
And researchers are considering other possibilities. It has long been known that in severe illness or infection, a stress reaction in the body can lead to high blood sugar, so-called hyperglycemia. The virus can also induce a cytokine storm – a whirlwind of inflammation and an overzealous immune response – that can lead to insulin resistance and beta cell dysfunction or provoke an autoimmune reaction, where one’s own defense system attacks the pancreas and makes it dysfunctional.
Another potential factor: “Children have gained weight during the covid pandemic, probably due to lack of exercise, increased food intake and psychosocial stress,” says Choudhary. It can increase childhood obesity, which is associated with a higher risk of developing type 2 diabetes. Some patients may also have had prediabetes, which occurs in one in five teenagers, according to the CDC. In susceptible individuals, it is possible that the infection will tip that scale to the point where they develop diabetes. “Viral infections can potentially be a trigger in a patient who has a predisposition,” says Choudhary.
There is a fairly exhaustive list of options – even steroid medications used to treat covid temporarily raise blood sugar levels – but the frequency of vaccinations is part of the equation. Fiorina says that some parents’ reluctance to vaccinate their children may be a factor in this increase in pediatric diabetes cases, “reinforced by their erroneous thinking that there is an obvious limit where younger ages reduce the increased risk of covid-19.” Kim adds, “As a physician dedicated to the health of all children, whether they have diabetes or not, I recommend COVID-19 vaccination and the flu for those who do not have contraindications.”
The vast majority of people who get covid will not develop diabetes, says Rubino, and that context is important. However, with treatments that are often not available and researchers are still trying to understand the underlying causes, families need to be vigilant and aware of the symptoms on behalf of their children. Constant thirst, increased urination, extreme fatigue and unexpected weight loss are special red flags.
And positive life changes can make a big difference. Since her hospital stay, Aliyah, now 11, is feeling much better. She has an insulin regimen and she and her mother are closely monitoring what she is eating. Although a vaccine was not available when she got the virus, she is now fully vaccinated, says her mother.
She is also back to doing what other children her age do, “playing with my friends,” Aliyah says. Given the difficult journey she has made, it is a small joy that should not be underestimated.