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Pediatric Diabetes, DKA Rates Increased During Early COVID-19 Pandemic


Type 1 diabetes incidence was 1.14 times higher in the first year and 1.27 times higher in the second year of the COVID-19 pandemic, compared with the 12 months before the pandemic.

Among children and adolescents, incidence rates of type 1 diabetes (T1D) and diabetic ketoacidosis (DKA) were substantially higher after the beginning of the COVID-19 pandemic than before, according to a review published today in JAMA Network Open.1

Specifically, T1D incidence was 1.14 times higher in the first year and 1.27 times higher in the second year of the COVID-19 pandemic, compared with the 12 months before the pandemic.

The review included data from 42 studies, comprising 102,984 incident diabetes cases. The selected studies reported differences in incident diabetes cases among individuals younger than 19 years, with a minimum observation period of 12 months during and 12 months before the pandemic.

The meta-analysis focused on T1D incidence rates and included 17 studies involving 38,149 youths. The results revealed a higher incidence rate of T1D during the first year of the pandemic compared with the year prior (incidence rate ratio [IRR], 1.14; 95% CI, 1.08-1.21). Diabetes incidence in general also continued to rise during months 13 to 24 of the pandemic (IRR, 1.27; 95% CI, 1.18-1.37).

Among the 42 studies, 10 reported incident cases of type 2 diabetes (T2D) both before and during the pandemic, but the lack of incidence rates provided prevented the results from being pooled. Additionally, 15 studies reported the incidence of DKA and found a 1.26 times higher rate during the COVID-19 pandemic compared with the prepandemic period, (IRR, 1.26; 95% CI, 1.17-1.36).

According to the review authors, these findings support those of a July 2022 meta-analysis evaluating T1D and DKA incidence in children during 2019 and 2020.2

Potential explanations for the link between new-onset diabetes and prior infection with SARS-CoV-2 include several proposed direct mechanisms, the authors said. These include the presence of ACE2—the receptor for SARS-CoV-2—on insulin-producing β cells, which may make them susceptible to viral entry. Additionally, SARS-CoV-2 infection has been found to contribute to the disruption of glucose metabolism, further exacerbating the risk of diabetes. Individuals who are already predisposed to diabetes may be particularly vulnerable to developing it following SARS-CoV-2 infection due to the combination of dysregulated glucose metabolism and direct damage to β cells, which impairs their ability to compensate and may lead to β-cell exhaustion.

However, despite these hypotheses, the exact underlying mechanism explaining the association between SARS-CoV-2 infection and the subsequent increased risk of incident diabetes remains unclear, according to the authors.

They also noted that data on changes in T2D incidence during the COVID-19 pandemic are limited.

“The studies included in this systematic review and meta-analysis described an increase in the number of incident type 2 diabetes cases between periods but had insufficient data reported to assess whether there was also an increase in the incidence rate of childhood type 2 diabetes after the onset of the pandemic,” the authors said. “Population-based studies that can measure the size of the study population (denominator) and therefore determine whether there has been a change in the incidence rate of type 2 diabetes in children and adolescents since the onset of the COVID-19 pandemic are needed.”

The results of this study highlight the importance of allocating resources to address the immediate rise in demand for pediatric diabetes care, which is likely to extend into young adulthood. It also emphasizes the significance of implementing strategies aimed at preventing DKA in patients who have recently been diagnosed with diabetes.

“Although prospective data examining whether this trend has persisted are needed, our findings suggest the need to elucidate possible underlying direct and indirect mechanisms to explain this increase,” the authors concluded. “Furthermore, there is a paucity of data about socioeconomic, racial, and ethnic disparities in the incidence rate of diabetes during the COVID-19 pandemic; this gap must be filled to inform equitable strategies for intervention.”


1. D’Souza D, Empringham J, Pechlivanoglou P, Uleryk EM, Cohen E, Shulman R. Incidence of diabetes in children and adolescents during the COVID-19 pandemic: a systematic review and meta-analysis. JAMA Netw Open. Published online June 30, 2023. doi:10.1001/jamanetworkopen.2023.21281

2. Rahmati M, Keshvari M, Mirnasuri S, et al. The global impact of COVID-19 pandemic on the incidence of pediatric new-onset type 1 diabetes and ketoacidosis: a systematic review and meta-analysis. J Med Virol. 2022;94(11):5112-5127. doi:10.1002/jmv.27996

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