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February 13th, 2021 
Awake Goy Written by Prabhu Dutta Shaw, Dr. Arathi P Rao
COVID-19 is a disease that has indiscriminately affected individuals with unequal vulnerability. While the world is still suffering because of the ongoing COVID-19 pandemic, the risk of the emergence of a diabetes epidemic has started looming into view. On the one hand, it is seen that hyperglycaemia tends to increase morbidity and mortality related to COVID-19. On the other hand, recent studies are now showing that COVID-19 itself can induce or worsen hyperglycaemia in the infected individuals, culminating in a vicious cycle. Therefore, a bidirectional relationship has been established between COVID-19 and diabetes.[1]
Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the virus responsible for the ongoing COVID-19 pandemic, has spike proteins on its surface, which bind to the angiotensin-converting enzyme 2 (ACE2) receptors in the host cells. Thus, the virus enters the islet cells present in the pancreas via ACE-2 receptors and causes reversible damage to the beta cells that produce insulin. The virus-induced beta cell damage can be either due to the lytic effects of viral replication and/or inflammatory response mediated damage in the host cells, leading to autoimmunity.[1] This damage caused to the beta cells triggers hyperglycaemia. Without enough insulin, the body can’t use glucose properly for energy. Thus, hormones are released by the body that breaks down fat to produce ketones (chemicals produced in the liver when there is insufficient insulin for energy). The use of ketones in the body can signal the production of acids, leading to a potentially fatal condition called ketoacidosis.
A multicentre study conducted in the UK reports an increase in new-onset of type 1 diabetes mellitus (T1DM) in children, with evidence of COVID-19 infection or exposure to SARS-CoV-2 in some of these. The report states that 70% of the children presented with diabetic ketoacidosis (DKA), and 52% had severe DKA (pH 6.82-7.05).[2] A multicentre study from the USA has published a preliminary report stating that out of 64 patients with T1DM who were confirmed or suspected COVID-19 patients, more than 50% of them had hyperglycaemia and, nearly one-third had DKA.[3]
As this new-onset of diabetes is transient in nature, insulin may be administered to patients for a brief period until the condition is reversed. Research needs to be carried out in order to gain insights so that patients who have new-onset diabetes due to COVID-19 can be treated effectively. In order to prevent a diabetes epidemic, the government needs to develop and implement effective policies by taking the help of public health experts and epidemiologists. Awareness needs to be created among people regarding the symptoms of diabetes, especially among prediabetic individuals. The insulin, glucose, and glycated hemoglobin (HbA1c) level in the COVID-19 patients, who are admitted in hospitals, should be tested frequently in order to diagnose and treat the new-onset of diabetes among them as early as possible. The healthcare providers also need to follow-up and monitor the affected patients even after they have recovered from COVID-19.
An international group of diabetes researchers has come together to establish a global registry as part of the CoviDIAB Project for patients with COVID-19 related diabetes (https://covidiab.e-dendrite.com/). The registry aims to establish the phenotype and extent of new-onset diabetes that is defined by hyperglycaemia, negative history of diabetes, confirmed COVID-19, and a history of a normal HbA1c level.[4] With public health initiatives like this, in-depth understanding of the epidemiology of COVID-19 induced diabetes can be achieved and we can have enhanced preparedness to tackle non-communicable diseases induced by communicable diseases in the future.
References
- Boddu SK, Aurangabadkar G, Kuchay MS. New onset diabetes, type 1 diabetes and COVID-19. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2020 Nov 17.
- Unsworth R, Wallace S, Oliver NS, Yeung S, Kshirsagar A, Naidu H, Kwong RM, Kumar P, Logan KM. New-onset type 1 diabetes in children during COVID-19: multicentre regional findings in the UK. Diabetes Care. 2020 Nov 1;43(11):e170-1.
- Ebekozien OA, Noor N, Gallagher MP, Alonso GT. Type 1 diabetes and COVID-19: preliminary findings from a multicentre surveillance study in the US. Diabetes Care. 2020 Aug 1;43(8):e83-5.
- Rubino F, Amiel SA, Zimmet P. New-onset diabetes in covid-19 [published online ahead of print July 6, 2020]. N Engl J Med. 2020.
Prabhu Dutta Shaw has a bachelor’s degree in Cardiac Technology from CMC, Vellore, following which he completed his MBA in Hospital and Healthcare Management from Amity University Online. He is currently a postgraduate student, pursuing Master of Public Health (Epidemiology) at Prasanna School of Public Health, Manipal Academy of Higher Education (MAHE), Manipal, India.
Dr. Arathi P Rao ( MBBS, DGO, MPH, Ph.D.) is the Coordinator of MPH Programme and the Head of Manipal Health Literacy Unit at the Prasanna School of Public Health, Manipal Academy of Higher Education (MAHE), Manipal, India. She is also the MAHE Coordinator for Global Health & Humanitarian Medicine course, South Asia.
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