Commentary on "New-onset diabetes in children during the COVID-19 Pandemic: an assessment of biomarkers and psychosocial risk factors at play in Mississippi"

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Ann Pediatr Endocrinol Metab. 2024;29(4):209-210
Publication date (electronic) : 2024 August 31
doi : https://doi.org/10.6065/apem.24223091edi04
Division of Pediatric Endocrinology, Department of Pediatrics, Bundang Jesaeng Hospital, Daejin Medical Center, Seongnam, Korea
Address for correspondence: Se Young Kim Division of Pediatric Endocrinology, Department of Pediatrics, Bundang Jesaeng Hospital, Daejin Medical Center, 20 Seohyeon-ro 180beon-gil, Bundang-gu, Seongnam 13590, Korea Email: smuf67@naver.com

During the coronavirus disease 2019 (COVID-19) pandemic, adults with type 1 (T1D) and type 2 (T2D) diabetes showed vulnerability to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, resulting in high morbidity and mortality. After the pandemic, increased development of acute diabetes and severity of the initial presentation was observed in adults. Choi et al. [1] reported that the incidence and severity of COVID-19 contribute to this increased risk of T2D in adults. They showed that the higher incidence of T2D in hospitalized patients could be related to changes in the counterregulatory hormones of insulin, catecholamine, or cortisol during the acute phase of COVID-19 or in drugs such as glucocorticoids used to prevent acute exacerbation of SARS-CoV-2 infection. However, there also was a significantly increased risk of T2D in asymptomatic or mild COVID-19 patients who were not hospitalized. They suggested long-term follow-up for T2D in patients who experienced any severity of COVID-19 in the acute phase [1]. Their findings inspired us to investigate the incidence and prognosis of T1D and T2D in children during and after the COVID-19 pandemic comparing to those before the pandemic.

Reports about the relation of SARS-CoV-2 infection and diabetes in children have showed consistent results. Davoodi et al. [2] reported a significantly higher rate of new T1D in children during the pandemic, as well as increased number of cases of diabetic ketoacidosis (DKA). Studies also have shown higher severity of DKA and the need for higher doses of insulin in such patients [2]. These changes likely were caused by increased damage to the pancreatic beta cells by SARS-CoV-2 infection. However, they did not investigate COVID-19 status of the patients prior to progression into T1D.

Ho et al. [3] also reported significant increases in DKA and severe DKA in children presenting with new-onset T1D during the COVID-19 pandemic.

Rahmati et al. [4] performed a systematic review and meta-analysis of the risk of pediatric T1D and DKA before and after the pandemic. Compared with the pre-COVID-19 era, the number of worldwide new-onset pediatric T1D, DKA, and severe DKA cases during the first year of the COVID-19 pandemic increased by 9.5%, 25%, and 19.5%, respectively. Compared with pre-COVID-19 pandemic levels, the median glucose and HbA1c values in newly diagnosed T1D children after the COVID-19 pandemic increased by 6.43% and 6.42%, respectively. The COVID-19 pandemic significantly increased the risk of global pediatric new-onset T1D, DKA, and severe DKA. Related public mandates targeted measures to raise public and physician awareness of these relationships [4]. Gullu et al. [5] evaluated the presentation patterns, severity, autoantibody status, and seasonal variability of newly diagnosed T1D patients during two years of the pandemic compared to those in the pre-pandemic period. Number of patients presenting with DKA was significantly higher during the pandemic period, and the number of patients presenting with severe DKA was significantly higher during the pandemic period. Islet-cell antibody (ICA) positivity was significantly higher in patients admitted during the pandemic, especially in its second year. Anti-glutamic-acid-decarboxylase-antibody-ICA copositivity was significantly higher in patients admitted during the pandemic period, especially those admitted in the second year of the pandemic [5]. This study by Stout et al. [6] reported increased incidence of new-onset diabetes among children in Mississippi and assessed the relationships of changes in inflammatory biomarkers including psychosocial risk factors and new-onset diabetes during the pandemic. Surprisingly, they reported that 33% of new-onset T1D cases had positive SARS-CoV-2 IgG antibody (Ab), and 62% of those with T2D had positive IgG Ab. More than half (54%) of their new-onset diabetes patients were experiencing DKA [6]. Their T2D patients showed higher body mass index (BMI), lower vitamin D levels, and higher leptin and C-reactive protein levels compared to those of T1D patients. There was no significant difference in psychosocial factors, interleukin-6 level, or SARS-CoV-2 Ab status in T1D and T2D patients [6]. In addition, they were unable to demonstrate significant correlations between COVID-19 infectious biomarkers and new-onset diabetes, although they did show a correlation between increased BMI and T2D in Mississippi during the pandemic. Lee et al. [7] retrospectively reviewed 73 children with T1D and 50 children with T2D diagnosed with SARS-CoV-2 infection. They reported that all children with diabetes and COVID-19 had mild clinical features due to low disease severity, high vaccination rates, uninterrupted access to medical care, and continuous glucose monitoring.

Notes

Conflicts of interest

No potential conflict of interest relevant to this article was reported

References

1. Choi JH, Kim KM, Song K, Seo GH. Risk for newly diagnosed type 2 diabetes mellitus after COVID-19 among Korean adults: a nationwide matched cohort study. Endocrinol Metab 2023;38:245–52.
2. Davoodi MA, Zamanian M, Balali Bl. Increased incidence of the type 1 diabetes and diabetic ketoacidosis severity in children during COVID-19 pandemic. Diabetol Metab Syndr 2024;16:121.
3. Ho J, Rosolowsky E, Pacaud D, Huang C, Lemay JA, Brockman N, et al. Diabetic ketoacidosis at type 1 diabetes diagnosis in children during the COVID-19 pandemic. Pediatr Diabetes 2021;22:552–7.
4. Rahmati M, Keshvari M, Mirnasuri S, Yon DK, Lee SW Shin JI, 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;94:5112–27.
5. Gullu E, Akin L, Gokler ME, Aydin M. Increased severity of presentation signs in children with newly diagnosed type 1 diabetes during the COVID-19 pandemic: a tertiary center experience. Ann Nutr Metab 2024;80:161–70.
6. Stout J, Dixit N, Pasha S, Sukumaran A, Topaloglu AK, Armstrong MK, et al. New-onset diabetes in children during the COVID-19 Pandemic: an assessment of biomarkers and psychosocial risk factors at play in Mississippi. Ann Pediatr Endocr Metab 2024;29:234–41.
7. Lee NW, Kim YM, Kim YH, Kang SJ, Jang KM, Kim HS, et al. Clinical charateristics and outcome of COVID-19 in children and adolescents with diabetes in Daegu, South Korea. Ann Pediatr Endocr Metab 2024;29:167–73.

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