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The State of Diabetes Post-COVID: Q&A with CDC Chief Giuseppina Imperatore, MD, PhD

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Dr. Giuseppina Imperatore, MD, PhD, is chief of the Surveillance, Epidemiology, Economics, and Statistics Branch of the Division of Diabetes Translation in the Centers for Disease Control and Prevention. She provides leadership and strategic direction in the conduct of public health research to better understand factors contributing to the development and complications of diabetes, and the health disparities associated with these outcomes.

Doximity spoke with Dr. Imperatore on the state of diabetes diagnosis and care since the start of the COVID-19 pandemic. CDC research suggests that people might have higher risk of developing diabetes after an acute COVID-19 illness. Here, the CDC discusses which populations are most at risk of diabetes and shares resources for diagnosis and management of diabetes.  

Are there any chronic illnesses we have seen an uptick in since the pandemic began? 

Although there isn’t data on a significant uptick in chronic illnesses post pandemic, CDC research shows that one in five adults aged 18 to 64 years and one in four adults aged 65 and older experienced at least one health condition that might be attributable to a previous COVID-19 infection. The health conditions include cardiovascular disease, chronic kidney disease, Type 1 (T1D) and Type 2 diabetes (T2D), among others. 

More specifically, about 1.26 million and 1.22 million American adults were newly diagnosed with diabetes in 2020 and 2021, respectively. While the decreasing trend in diabetes incidence among adults continues post-COVID-19 pandemic, CDC research supports that adults might have higher risk of developing diabetes after an acute COVID-19 illness.

Additionally, recent CDC research shows that people younger than 18 who had had COVID-19 were up to 2.5 times more likely to be newly diagnosed with diabetes in the months after infection than those without COVID-19 and those who had other respiratory infections before the pandemic. If the rate of new cases continues to trend upward in this younger population, T1D cases would increase about 65%, and T2D cases would increase about 700% from 2017 to 2060, according to this recent study.

It is also worth noting that these estimates depend on self-reporting of diagnosed diabetes. The pandemic temporarily disrupted the health care system, possibly leading to decreased screening or detection of diabetes.

How does COVID-19 lead to diabetes? 

Research suggests that the SARS-CoV-2 virus can affect the pancreas and complicate the management of preexisting diabetes or increase the risk of developing diabetes. The virus can damage pancreatic beta cells, the cells that produce insulin to regulate glucose levels, causing them to produce less insulin to keep glucose within an optimal range. Loss of functional beta cells can lead to T1D and T2D. The viral infection can also increase stress hormones such as cortisol and adrenaline, increasing the risk of hyperglycemia and diabetes during the acute phase of the infection. 

Which groups are most affected by diabetes post-COVID pandemic? 

We are not seeing an overall increase in diabetes among adults post pandemic. However, CDC’s surveillance data show that adult subgroups with a higher age-adjusted incidence rate of diabetes prior to COVID-19 still had a higher risk of newly diagnosed diabetes in 2021. Compared with white non-Hispanic adults (4.4 per 1000), Black non-Hispanic adults (7.4 per 1000) and Hispanic or Latino adults (6.8 per 1000) had higher incidences of diabetes in 2021. Incidence also varied significantly by education level, which is an indicator of socioeconomic status. Specifically, 7.5 per 1000 adults with less than a high school education were newly diagnosed with diabetes in 2021 versus 5.8 per 1000 adults with a high school education and 4.4 per 1000 adults with more than a high school education. 

Do any pre-existing conditions increase the risk of Type 2 diabetes post-COVID infection? 

The risk factors of T2D include having prediabetes, being overweight or obese, being physically inactive, and other nonmodifiable factors such as age, race or ethnicity, family history of diabetes, and diabetes during pregnancy.

We see that the COVID-19 pandemic disrupted access to healthy, affordable food and safe spaces for physical activity for some people, potentially creating barriers to T2D prevention. 2022 CDC Adult Obesity Prevalence Maps show that 22 states currently have an obesity prevalence at or above 35%, compared with nine states in 2018. A CDC study also found that the rate of body mass index (BMI) increase approximately doubled among people aged 2 to 19 years in the early pandemic (March to December 2020) compared with a pre-pandemic period (January 2018 to February 2020). Accelerated weight gain can cause long-lasting metabolic changes that put people at higher risk for T2D.

What can health care clinicians do to better diagnose and treat newly acquired or worsened diabetes after a COVID-19 infection?

About 98 million American adults — more than one in three — have prediabetes. Of those with prediabetes, more than 80% don’t know they have it. With proven lifestyle changes, people can prevent or delay prediabetes from turning into T2D. Therefore, it is critically important for clinicians to refer patients at risk of developing T2D to the National Diabetes Prevention Program. This CDC-recognized lifestyle change program is proven by research to cut participants’ risk of T2D by more than half. 

Early screening and diagnosis are also important to improve patients’ health outcomes. It is recommended that clinicians screen for: 

  • Prediabetes or T2D in adults starting at age 35 to align with the American Diabetes Association guidelines.
  • Prediabetes or T2D in adults at any age who are overweight or obese and with at least one risk factor for T2D. 
  • Diabetes symptoms in people under 18 with a history of COVID-19 infection.

Clinicians can refer patients with diabetes for diabetes self-management education and support (DSMES) services. DSMES can help improve patients’ hemoglobin A1C, prevent or delay diabetes complications, reduce hospitalizations for acute conditions, and improve their healthy coping skills and quality of life. 

Where can health care clinicians get up-to-date guidance on diagnosing and managing diabetes?

Clinicians can stay up to date on the latest Standards of Care in Diabetes to ensure their patients are receiving timely, equitable, and high-quality care. These guidelines include screenings and management for diabetes and related comorbidities such as cardiovascular disease and chronic kidney disease. 

Image by Net Vector / Shutterstock

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