Pandemic Disruption Adversely Affected People With Diabetes

For people with diabetes, disruption from the COVID-19 pandemic led to higher rates of death and other adverse outcomes, particularly diabetic ketoacidosis (DKA) in children, new research found.

The data came from what was believed to be the first systematic review of evidence related to the clinical impact of the disruptions caused by the COVID-19 pandemic and delays in seeking care among people with diabetes, rather than illness from the virus itself. The review was commissioned by the World Health Organization (WHO) and included a total of 138 studies. The majority (39 each) were from North America and Western Europe, but some were from Eastern Europe, Asia, South America, Australia, and Egypt. Overall, they included more than 100,000 people.

Despite a great deal of heterogeneity across the studies, there were some consistent patterns. Both all-cause and diabetes-related mortality were consistently increased during, compared to prior to, the pandemic, and most studies showed increases in major amputations and sight loss. While there were no differences in overall amputations or DKA in adults, there were significantly higher rates of DKA hospitalizations in children and adolescents, both with new-onset and preexisting type 1 diabetes.

The findings were published on January 23, 2024, in The Lancet Diabetes & Endocrinology by Jamie Hartmann-Boyce, PhD, of the Department of Health Promotion and Policy at the University of Massachusetts Amherst, and colleagues. The same team had conducted a previous similar WHO-commissioned review of the effects of the SARS-CoV-2 virus itself on people with diabetes.

‘It’s Important to Think About Who Is Most at Risk From These Disruptions’

The findings hold lessons for future pandemics or other types of emergency situations, Hartmann-Boyle told Medscape Medical News.

“It’s important to think about who is most at risk from these disruptions and targeting care to them. Also, just having plans in place for people for access to medications and supplies. In the US, it can be difficult to get backup supplies through insurance, but I think this tells us again how important that is, that there needs to be some sort of safety net.”

With children in particular, she advised, “keep in mind the warning signs to look out for in terms of new-onset diabetes and why it’s important not to wait to seek care.”

She cautioned that although the data came from around the world, most of the studies were done in higher-income areas. “There’s an inherent bias. These are people with access to healthcare. Our review is of evidence available globally, but the reality is that certain countries produce a lot more data than others.”

Even within the United States, “probably you’re getting people with more healthcare access and more socioeconomic advantage contributing their data to these studies than those struggling to access insulin, which was a problem before and during the pandemic.”

Several studies reported that people with type 1 diabetes with access to continuous glucose monitoring were likely to do well, or have even better A1c levels, during pandemic lockdown, whereas the opposite was true for those who didn’t. “We saw that technology really came in handy and helped a lot of people, but that can deepen already-existing inequalities,” she noted.

The Data: Deaths, DKA Were Consistent

Of six studies examining all-cause mortality among people with diabetes during the pandemic, just one excluded deaths due to COVID-19. That one found an increase in non-COVID–related deaths from 2019 to 2021 of 11%. The difference remained significant after adjustment for age, sex, socioeconomic deprivation, diabetes type, and other potential confounders. The mortality rates were higher among people who didn’t receive care processes during the pandemic.

Of 13 studies comparing diabetes-related mortality during 2020-2021 to pre-pandemic time periods, all found increases during vs prior. This increase was especially high, nearly threefold, among Hispanic individuals.

Four systematic reviews evaluated associations between the pandemic and DKA, of which three found 30%-40% increases in DKA and severe DKA among children with new-onset type 1 diabetes compared to before the pandemic.

“There are still ongoing questions about whether COVID increases the risk for new-onset diabetes. If new-onset type 1 diabetes is caught early on, it doesn’t result in DKA and ICU admission at diagnosis. But we know that during the pandemic, a lot of people waited until they were really sick before they sought medical care. I think that’s quite possibly part of the picture we’re seeing,” Hartmann-Boyle noted.

Among 12 studies of major amputations, nine showed a significant increase during the pandemic. However, the pattern was reversed for minor amputations, with three of four studies showing a decrease. Findings for diabetes-related hospitalizations in 30 studies were also mixed, with some showing increases and others decreases.

“It’s difficult to interpret the data on hospital admissions because we know that a lot of people were avoiding hospitals. So, how we interpret that is challenging. And the same goes for things like amputation and diabetic foot ulcer presentation. The studies that showed decreases in those, was it real or because they weren’t presenting at their doctors? It’s a challenge,” Hartmann-Boyle said.

As for vision, one systematic review found that delays in receipt of antivascular endothelial growth factor injections for various retinal diseases including diabetic vascular edema resulted in significant reductions in visual acuity across all diseases and specifically diabetic macular edema.

“The vision is a major concern. The studies suggested vision worsening more than we would have expected had there not been a pandemic. Anecdotally, eye screening rates really plummeted. If you have background retinopathy or preproliferative retinopathy, you’re not noticing that on a day-to-day basis, and it will only get picked up at screening. By the time you notice a change in your vision, you’ve lost the opportunity to intervene.”

The review was commissioned and financially supported by the WHO. Funding also came from the UK National Institute for Health Research. Hartmann-Boyle had no further disclosures.

Miriam E. Tucker is a freelance journalist based in the Washington, DC, area. She is a regular contributor to Medscape Medical News, with other work appearing in the Washington Post, NPR’s Shots blog, and Diatribe. She is on X: @MiriamETucker.

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