Worsening glycemic control in youth with type 2 diabetes during COVID-19

Introduction: The COVID-19 pandemic has disproportionately affected minority and lower socioeconomic populations, who also have higher rates of type 2 diabetes (T2D). The impact of virtual school, decreased activity level, and worsening food insecurity on pediatric T2D is unknown. The goal of this study was to evaluate weight trends and glycemic control in youth with existing T2D during the COVID-19 pandemic.

Methods: A retrospective study of youth <21 years of age diagnosed with T2D prior to March 11, 2020 was conducted at an academic pediatric diabetes center to compare glycemic control, weight, and BMI in the year prior to the COVID-19 pandemic (March 2019-2020) to during COVID-19 (March 2020-2021). Paired t-tests and linear mixed effects models were used to analyze changes during this period.

Results: A total of 63 youth with T2D were included (median age 15.0 (IQR 14-16) years, 59% female, 74.6% black, 14.3% Hispanic, 77.8% with Medicaid insurance). Median duration of diabetes was 0.8 (IQR 0.2-2.0) years. There was no difference in weight or BMI from the pre-COVID-19 period compared to during COVID-19 (Weight: 101.5 v 102.9 kg, p=0.18; BMI: 36.0 v 36.1 kg/m2, p=0.72). Hemoglobin A1c significantly increased during COVID-19 (7.6% vs 8.6%, p=0.0002)

Conclusion: While hemoglobin A1c increased significantly in youth with T2D during the COVID-19 pandemic, there was no significant change in weight or BMI possibly due to glucosuria associated with hyperglycemia. Youth with T2D are at high risk for diabetes complications, and the worsening glycemic control in this population highlights the need to prioritize close follow-up and disease management to prevent further metabolic decompensation.

Introduction
The COVID-19 pandemic resulted in a worldwide lockdown, during which time most children and adolescents attended school virtually (1). Rates of overweight and obesity among children and adolescents during this time have increased significantly worldwide, owing to an increase in higher calorie processed foods, decreased activity level, increasing food insecurity and increased rates of stress and anxiety due to the pandemic (2, 3). Moreover, the COVID-19 pandemic has disproportionately affected minority and lower socioeconomic status populations (4), who have higher rates of obesity, type 2 diabetes (T2D), and associated complications (5, 6).

The obesity epidemic over the last 20 years has led to an increase in youth onset T2D, most notably in non-Hispanic black, Asian/Pacific Islanders and American Indians (5–9). Almost half of new-onset diabetes presenting in adolescents is attributed to type 2 diabetes (10, 11), and youth onset type 2 diabetes is often characterized by a more rapidly progressive decline in B-cell function compared to adults (12). Studies have also demonstrated a high rate of diabetes-related complications in the majority of youth onset type 2 diabetes that is present by young adulthood (13). Management of pediatric T2D is aided by adherence to schedules and parental support (14), and negatively affected by depression, sedentary behavior, and a diet rich in processed foods (15). These are all factors which have been severely disrupted during the COVID-19 pandemic.

The impact of virtual school, decreased activity level, and worsening food insecurity on pediatric T2D has not been thoroughly analyzed, but there is concern for worsening pediatric obesity, thereby exacerbating T2D and worsening glycemic control. A recent study demonstrated an increased incidence of diabetic ketoacidosis (DKA) at initial T2D presentation during the COVID-19 pandemic (16), however there is little data regarding changes in glycemic control among adolescents with known T2D during the COVID-19 pandemic. Among youth with known type 1 diabetes (T1D), studies have shown an increase in DKA with maintenance of overall glycemic control during the COVID-19 pandemic (17, 18). Clinical experience during the COVID-19 pandemic suggested an increase in overweight and obesity with worsening glycemic control in patients with T2D diagnosed prior to the COVID-19 pandemic. This study sought to evaluate weight trends and glycemic control in youth with known T2D during the COVID-19 pandemic compared to the prior year.