Black Americans With T1D, COVID-19 Have Increased Risk of Hospitalization for DKA

Non-Hispanic Black individuals with type 1 diabetes and coronavirus disease 2019 infections may be more likely to be hospitalized for diabetic ketoacidosis (DKA) compared with non-Hispanic White patients.

A cross-sectional study of patients from over 50 clinical sites in the United States found non-Hispanic Black (NHB) individuals with type 1 diabetes (T1D) and coronavirus disease 2019 (COVID-19) infections were more likely to be hospitalized for diabetic ketoacidosis (DKA) compared with non-Hispanic White (NHW) patients. Results were published in the Journal of Clinical Endocrinology & Metabolism.

In the United Sates, racial and ethnic minorities are more likely to be infected with and die from COVID-19 compared with NHW individuals. “Racial-ethnic minorities also have increased odds of hospitalization compared with Whites after adjusting for age, sex, comorbidities, and income,” the researchers wrote.

As of August 2020, data showed that although NHB individuals “comprise 13% of the US population, they contribute up to 34% of the US mortality from COVID-19. These data underscore the reality that social and health inequities predispose NH Blacks and Hispanics to adverse outcomes of the COVID-19 pandemic,” the authors said.

Diabetes is one of the most prevalent comorbidities disproportionately affecting these populations. The risk of a diabetes diagnosis is 77% higher for African Americans and 66% higher among Hispanics compared with White Americans.

Although there is a relative abundance of data on the intersection of type 2 diabetes and COVID-19, there is limited research on T1D despite these patients suffering unique complications. To determine whether NHB and Hispanic patients with T1D and COVID-19 had a higher incidence of DKA compared with NHW patients, the researchers analyzed data from a national registry representing 52 T1D Exchange clinical sites.

T1D Exchange is a Boston-based population health research organization made up of a clinical network of endocrinology centers. As part of the surveillance study, participating clinics completed a retrospective chart review and submitted information on all patients with T1D who tested positive for COVID-19 via an online questionnaire created by T1D Exchange. Data collection took place between April 7, 2020, and August 30, 2020.

Patient medical charts were reviewed to confirm DKA status, defined as “blood glucose greater than 200 mg/dL (11 mmol/L), venous pH less than 7.3 or bicarbonate less than 15 mmol/L, ketonemia, and ketonuria.”

A total of 180 individuals were included in the final analysis. Most patients (n = 62) were NHW, while 44 were NHB and 36 were Hispanic. The investigators found more NHB and Hispanic patients were publicly insured compared with NHW patients. NHB and Hispanic patients also exhibited higher glycated hemoglobin (A1c) levels, were less likely to be using an insulin pump or continuous glucose monitor, and were more likely to be hospitalized for COVID-19 treatment compared with NHW patients.

Data also showed:

  • NHB patients were more likely to present with DKA (55% vs 13%; P = .001); all patients with DKA were hospitalized
  • There were more cases of new-diagnosis T1D in the NHB and Hispanic patients versus NHW patients (13% and 12% vs 1%, respectively; P = .001)
  • NHB patients had almost 4 times greater odds (HR, 3.7; 95% CI, 1.4-10.6) of presenting with DKA than NHW, after adjusting for age, sex, A1c, and insurance

Previous studies have shown NHB and Hispanic individuals have a greater risk of DKA and associated mortality, compounding COVID-19 risks in these populations. Therefore, the combined risk of COVID-19 and DKA in those with T1D worsens the short-term and long-term prognosis for Black and Hispanic patients.

“Our findings demonstrate that NHB patients with COVID-19 and T1D have an additional risk of DKA beyond the risk already conferred from having longstanding diabetes or being of minority status,” the researchers wrote.

Social determinants of health, including income level, education, and inadequate health care access for NHB and Hispanic communities, likely contributed to the study’s findings, they hypothesized.

The cross-sectional nature of the study precludes any generalizing of findings. In addition, the study’s relatively small sample size and lack of data on timing of DKA in relation to COVID-19 diagnosis mark limitations.

However, “The evidence of an increased risk of DKA among Black patients with T1D and COVID-19 supports the case for restructuring health care systems to cater to the needs of under-privileged communities, and also to develop awareness programs for DKA recognition and treatment for the T1D patient population,” the authors concluded.


Ebekozien O, Agarwal S, Noor N, et al. Full inequities in diabetic ketoacidosis among patients with type 1 diabetes and COVID-19: data from 52 US clinical centers. J Clin Endocrinol Metab. Published online January 7, 2021. doi:10.1210/clinem/dgaa920