The incidence of type 2 diabetes in children appears to have doubled during the COVID-19 pandemic, data from two new US studies suggest, with the lead investigator of one saying she was “surprised by the staggering increase in cases of type 2 diabetes…and the increase in severity of presentation.”
Findings from the two separate retrospective chart reviews — one conducted in Washington, DC, and the other in Baton Rouge, Louisiana — were presented June 25 at the virtual American Diabetes Association (ADA) 81st Scientific Sessions.
Although the two studies differed somewhat in the clinical parameters examined, both revealed a similar doubling of the rates of hospitalizations for type 2 diabetes among youth during 2020 compared with the same time period in 2019, as well as greater severity of metabolic disturbance.
And, as has been previously described with type 2 diabetes in youth, African American ethnicity predominated in both cohorts.
“Although we could not assess the cause of the increases in type 2 diabetes from our data, these disparities suggest that indirect effects of social distancing measures, including school closure and unemployment, are placing undue burden on underserved communities. Decreases in well-child care and fears of seeking medical care during the pandemic may have also contributed,” pediatric endocrinologist Brynn E. Marks, MD, Children’s National Hospital, Washington, DC, told Medscape Medical News.
More Hospitalizations, Racial Disparities Aggravated by COVID-19
Lead author Daniel S. Hsia, MD, Pennington Biomedical Research Center, Baton Rouge, Louisiana, told Medscape Medical News: “Since the pandemic, our data suggest that more children may be diagnosed with type 2 diabetes and may require hospitalization when they are diagnosed. Looking at both datasets, there appears to be a racial disparity in type 2 diabetes diagnoses that has only been exacerbated by the COVID-19 pandemic.”
Of concern, Hsia said, “The incidence rate of type 2 diabetes in children was already on the rise before the pandemic. While there may be a brief leveling off now that children are getting regular healthcare and going back to school in person, I believe these rates will continue to rise especially in light of the childhood obesity rates not improving.”
Their dataset captured all youth who were newly diagnosed with type 2 diabetes during the first full year of the COVID-19 pandemic, from March 11, 2020 to March 10, 2021, and compared those data to the time period March 11, 2019 to March 10, 2020.
During the pandemic, the number of cases of type 2 diabetes increased by 182%, from 50 in 2019 to 141 in 2020. The average age at diagnosis was about 14 years in both time periods.
In the pre-pandemic period, 18 (36%) diagnosed with type 2 diabetes required inpatient admission compared with 85 (60.3%) during the pandemic. At Children’s National, youth with suspected new-onset type 2 diabetes aren’t typically hospitalized unless they have severe hyperglycemia, ketosis, or are unable to schedule urgent outpatient follow-up, Marks noted.
The proportions of youth with new-onset type 2 diabetes who presented in diabetic ketoacidosis (DKA) rose from 2 (4%) pre-pandemic to 33 (23.4%) during the pandemic. Presentation with hyperosmolar DKA rose from 0 to 13 (9.2%).
However, during the pandemic only five youth were actively infected with SARS‑CoV‑2 at the time of type 2 diabetes diagnosis among the 90 tested.
Marks said, “We believe the increase in inpatient admissions was due to more severe presentation during the pandemic…We were surprised by the staggering increase in cases of type 2 diabetes…and the increase in severity of presentation.”
Shift in Diagnoses to Type 2 Diabetes
The pandemic also appears to have shifted the proportion of youth diagnosed with type 2 diabetes compared with type 1 diabetes. Whereas 24% of youth with new-onset diabetes pre-pandemic had type 2 diabetes and the rest had type 1 diabetes, during pandemic the proportion with type 2 diabetes rose to 44%.
“Rates of type 2 diabetes rose steadily at a rate of 1.45 cases per month throughout the course of the pandemic, suggesting a cumulative effect of the indirect effects of social distancing measures,” Marks said.
Furthermore, she added, whereas 60% of youth diagnosed with type 2 diabetes before the pandemic were female, the rate fell to 40% during the pandemic. This trend might be due to activity levels in that while male adolescents are typically more active, rates of exercise fell in both sexes during the pandemic but declined more sharply in males such that activity levels between the sexes became equal.
Although type 2 diabetes in youth has always been more common in ethnic minorities, the pandemic appears to have exacerbated these disparities.
While 58% of youth diagnosed with type 2 diabetes pre-pandemic identified as non-Hispanic Black, that proportion rose to 76.7% during the pandemic. Among Black youth with new-onset type 2 diabetes, 31 of 33 presented in DKA, and 12 of the 13 who presented in hyperosmolar DKA during the pandemic were Black.
“Strategies to promote health equity and address the undue burden of the COVID-19 pandemic on underserved communities must be developed to avoid worsening disparities and long-term health outcomes,” Marks said.
“A Microcosm“: Similar Findings in a Smaller Population
Hsia and colleagues looked at a smaller number of patients in a shorter time period. In March to December 2019, the hospitalization rate for new-onset type 2 diabetes was 0.27% (eight out of 2964 hospitalizations) compared with 0.62% (17 out of 2729 hospitalizations) during the same period in 2020 (P < .048) — also more than a doubling. Age at admission, sex, and body mass index didn’t differ between the two groups.
Criteria for DKA were met by three children in 2019 versus eight in 2020, and hyperosmolar hyperglycemic syndrome in zero versus two, respectively. Mean A1c on admission was 12.4% in 2019 versus 13.1% in 2020 (P = .59), and mean serum glucose was 441 mg/dL versus 669 mg/dL (P = .14), respectively. Serum osmolality on admission was 314 mmol/kg in 2019 versus 335 mmol/kg in 2020 (P = .19).
“Clinically speaking the differences in the lab values were significant, but we did not have enough numbers…to see a statistically significant difference. I think by looking at more centers, our site likely represents a microcosm of what is happening across the country,” Hsia said.
In 2019, seven of the eight children were African American as were 16 of the 17 children in 2020. The other single child in each group was White.
Hsia said, “Larger studies that include more patients are needed to confirm our initial findings. More research is needed to understand why this increasing trend of type 2 diabetes diagnoses in children may be occurring [and] to better understand how stay at home orders and other restrictions due to COVID-19 have worsened risk factors for type 2 diabetes.”
“These include decreased physical activity, more screen time, disturbed sleep, and increased intake of processed foods, which can all lead to weight gain,” he concluded.
Marks has reported receiving research support from Tandem, Dexcom, and the Cystic Fibrosis Foundation. Hsia has reported no relevant financial relationships.
ADA 2021. Presented June 25, 2021. Abstract 15-OR.