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Dr Rayzel Shulman
The incidence of type 1 diabetes has risen during the COVID-19 pandemic, according to a recent meta-analysis.
The review compared 2 years of data from during the pandemic to data from a prepandemic period, and showed a higher incidence of type 1 diabetes in the first year (incidence rate ratio [IRR], 1.14) and second year (IRR, 1.27) of the pandemic. The investigators also found an increase in the incidence of diabetic ketoacidosis (DKA; IRR, 1.26).
The meta-analysis included 17 studies of 38,149 children and adolescents with newly diagnosed type 1 diabetes. "Putting them all together really gave us more confidence to say this is something that we think is real," study author Rayzel Shulman, MD, PhD, an endocrinologist at The Hospital for Sick Children in Toronto and associate professor of pediatrics at the University of Toronto, Ontario, Canada, told Medscape Medical News.
The study was published June 30 in JAMA Network Open.
Increased Incidence
The investigators reviewed 42 studies, including 17 that examined rates of type 1 diabetes incidence, 10 on type 2 diabetes, and 15 on DKA. The included studies all had a minimum observation period of 12 months during the pandemic and at least 12 months before it. Relative to the prepandemic period, the meta-analysis found higher rates of type 1 diabetes and DKA during the pandemic.
The review was conducted in response to questions about the methodology of study results suggesting an association between the COVID-19 pandemic and the incidence of diabetes, according to Shulman.
Although this is not the first review of studies on the connection between diabetes and COVID-19, it adds to the literature by extending the study period to 2 years of the pandemic. The longer time frame helps address potential seasonal differences in incidence and increases confidence in the results.
The investigators also sought to look at the incidence of type 2 diabetes in children but found few studies that met the study criteria. Although some studies reported rates of type 2 diabetes, most lacked information about the population, specifically, the "denominator" needed for findings regarding any association with the COVID-19 pandemic.
With greater confidence in the increased incidence of type 1 diabetes, Shulman emphasized a need to ensure sufficient resources to care for newly diagnosed patients, including education and support for families.
The study's secondary outcome was the change in incidence rate of DKA among children with newly diagnosed diabetes. Data reported in 15 studies showed a 26% increase in DKA incidence during the first year of the pandemic.
"DKA is a serious and life-threatening condition that is preventable," said Shulman. Symptoms of type 1 diabetes include increased thirst and urination, weight loss, and fatigue. If parents or caregivers notice these signs, Shulman advises them to seek care immediately to reduce the risk of DKA.
Possible Mechanisms
Commenting on the findings for Medscape, Elizabeth Sellers, MD, an endocrinologist at the Children's Hospital Research Institute of Manitoba and associate professor of pediatrics at the University of Manitoba in Winnipeg, said the study's findings on DKA are an important reminder to be attentive to symptoms of diabetes. Sellers did not participate in the meta-analysis.
One possible explanation for the increase is a hesitancy to seek care among parents and caregivers during the pandemic. "I think we use that information and turn it into a positive," said Sellers, by increasing recognition of the symptoms. Sellers, whose research is included in the review, is part of an initiative by the Canadian Pediatric Endocrine Group to increase diabetes awareness.
The study provides important findings, particularly the second-year results, but is not designed to answer why there has been an increase in diabetes incidence, said Sellers. "You have to identify the problem first and then you can go back and look at mechanisms."
The meta-analysis did not seek to draw conclusions about the underlying mechanisms that would explain changes in diabetes incidence but rather indicates a need for further studies to seek a better understanding of the connection. Several theories may be considered, writes Clemens Kamrath, MD, of the Centre of Child and Adolescent Medicine at Justus Liebig University in Giessen, Germany, and colleagues in an accompanying editorial.
Studies have suggested a direct effect of infections such as COVID-19, whereby the virus damages insulin-producing beta cells. However, the commentary notes these studies do not account for asymptomatic infections among children.
Kamrath and colleagues also considered the indirect effects of the COVID-19 pandemic, which they indicate may be more likely than direct effects. These indirect effects include autoimmunity and environmental changes that occurred during the pandemic.
Researchers will need to continue monitoring the data to see if the trend persists and continue working to determine the mechanisms, said Schulman. "I don't think this is the end of the story."
The study was supported in part by grant funding from the Department of Pediatrics at The Hospital for Sick Children. Shulman, Sellers, and Kamrath have reported no relevant financial relationships.
JAMA Netw Open. Published June 30, 2023. Full text, Editorial
Gwendolyn Rak is a health reporter for Medscape and Univadis based in Brooklyn, New York.
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