Was there a change in the incidence of diabetes in children and adolescents after the onset of the COVID-19 pandemic?

In a recent study published in JAMA Network Open, researchers performed a meta-analysis to compare the incidence rates of pediatric diabetes of types 1 (T1D) and 2 (T2D) during and before the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic.Study: Incidence of Diabetes in Children and Adolescents During the COVID-19 Pandemic. Image Credit: AfricaStudio/Shutterstock

Background

Diabetes is a chronic illness among children, and coronavirus disease 2019 (COVID-19) has reportedly increased T1D and T2D incidence among pediatric individuals.

A few studies have indicated that COVID-19 may be associated with incident diabetes; however, the validity of the study findings is uncertain. Diabetes pathophysiology and the biological pathways of the association between COVID-19 and diabetes are distinct, making it crucial to assess T1D and T2D incidence.

COVID-19 has also contributed to a previously observed increase in yearly T1D incidence in the European Union, periodicity, and variation in estimated incidence between the initial and subsequent months.

It is critical to evaluate if the observed elevated incidence of recently diagnosed diabetes among children is greater and more persistent or if it is a consequence of an ongoing catch-up impact following a lower incidence rate earlier in the SARS-CoV-2 pandemic.

The rise in sedentary habits during COVID-19 may be linked to increased pediatric obesity, an established T2D risk factor. Furthermore, persistent observations regarding an elevated diabetic ketoacidosis (DKA) risk during diabetes development in children during COVID-19 underscore the necessity for more studies on diabetes incidence and its impact on youth.

About the study

In the present meta-analysis, researchers evaluated the impact of COVID-19 on diabetes incidence among pediatric individuals.

The team searched studies published in English between 1 January 2020 and 28 March 2023 on databases such as Cochrane Library, Embase, Medline, Web of Science, and Scopus; additionally, the references of all included studies were reviewed, and gray literature was searched for relevant studies published on government websites.

Studies analyzing T2D and T2D cases in individuals under 19.0 years one year before and one year into the pandemic were included. Two researchers independently screened the data, and disagreements were resolved by consensus or by a third researcher when required.

Bias risks in the included studies were assessed using the Risk of Bias in Non-randomized Studies of Exposure (ROBINS-E) tool. Studies that did not report diabetes incidence for at least 12 months before and 12 months during COVID-19 were excluded from the quantitative evaluation (meta-analysis).

Random effects modeling was performed for the quantitative assessment (meta-analysis), and the incidence rate ratios (IRR) were determined. The primary study outcome was an alteration in the diabetes incidence among pediatric individuals during COVID-19 compared to the pre-pandemic period. The secondary study outcome was an alteration in diabetes ketoacidosis (DKA) incidence among the youth with diabetes during COVID-19.

Results

In total, 10,757 studies were initially identified, from which 4,353 duplicates were eliminated, and after reviewing the abstracts, the entire text of 81 studies was screened for eligibility. As a result, 42 studies, consisting of 102,984 pediatric diabetes patients, satisfied the inclusion criteria and were considered for the qualitative review, whereas 17 studies, including 38,149 patients, were considered for the quantitative assessment.

The references of the included studies did not yield additional relevant records. The meta-analysis findings indicated a higher pediatric diabetes incidence during the initial COVID-19 wave than during pre-pandemic times (IRR, 1.1). Diabetes incidence increased between months 13 and 24 of COVID-19 compared to pre-COVID-19 times (IRR. 1.3).

In total, 10 studies (24%) documented new-onset T2D cases before and during COVID-19; however, the incidence rate of diabetes was not documented in the study’s-incidence, and therefore, the findings were not considered to derive the pooled estimates.

A total of 15 studies (36%) reported diabetes ketoacidosis incidence, which was higher during COVID-19 than in the pre-pandemic period (IRR, 1.3). There was considerable heterogeneity in the meta-analysis of diabetes incidence but not in that of DKA.

Diabetes is linked to the SARS-CoV-2 pandemic, with changes in glucose metabolism and insulin-producing beta cells being affected. Previous studies have reported that the angiotensin-converting enzyme 2 (ACE2) receptor, essential for SARS-CoV-2 entry into the host, is expressed in insulin-producing beta cells.

COVID-19 contributes to the dysregulation of glucose metabolism, making individuals with increased susceptibility vulnerable.

In addition, the pandemic has indirect effects, such as lifestyle changes, pediatric non-COVID-19 infections, increased stress, and social isolation. Hesitancy to seek care may also contribute to the increased risk of DKA during the pandemic.

Conclusions

Overall, the study findings showed that T1D incidence increased by 1.1-fold during the initial COVID-19 wave and 1.3-fold during the subsequent wave compared to the pre-pandemic period among children and adolescents.

The increase was higher than the expected 3.0% to 4.0% yearly increase based on pre-pandemic temporal alterations in Europe.

Increased health resources and facilities may be required to cater to the increasing pediatric diabetes count globally. Further research is needed to investigate the trend and elucidate the mechanisms underlying the temporal alterations.

The increased prevalence of DKA at the time of diabetes diagnosis highlights the need to identify gaps in the pathway from diabetes development to diagnosis.