At this point in the COVID-19 pandemic, there are a number of studies that clearly establish the increased risk people with diabetes face if they develop the viral infection. People with type 2 diabetes, in particular, are at higher risk for needing to be hospitalized for COVID-19, and they’re also more likely to experience poor outcomes during their hospitalization, including admission to the intensive care unit (ICU) and death.
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But there’s also evidence that people with type 1 diabetes may be at higher risk for poor outcomes related to COVID-19, especially if you adjust for other factors in COVID-19 outcomes such as age and obesity status. So while they may not face the magnitude of risk that the infection poses to those with type 2, people with type 1 should still be vigilant about precautions to avoid the virus due to their heightened risk of severe illness.
Now, a new study suggests that when it comes to at least one severe health threat related to COVID-19 and diabetes — developing diabetic ketoacidosis — Black people with type 1 face a much higher risk than their white counterparts.
Dangerous complication of COVID-19 and other infections
Diabetic ketoacidosis occurs when someone with diabetes is unable to use glucose in their blood for energy, due to a lack of available insulin or other factors. It’s typically seen in people with very high blood glucose levels. When your body can’t use glucose for energy, it uses stored fat instead, creating a byproduct called ketones. When these chemicals build up in your bloodstream too quickly, your entire body’s chemistry can become dangerously unbalanced, with symptoms that can include nausea, rapid breathing, dehydration, extreme thirst and frequent urination. Severe cases can cause coma and even death.
Since they don’t make much or any of their own insulin, people with type 1 diabetes are generally at the highest risk for diabetic ketoacidosis — especially when they get sick, due to metabolic changes that occur when your body is fighting an infection. But the new study makes clear that if they get COVID-19, people with type 1 aren’t all at the same risk level for ketoacidosis.
The study, published in the Journal of Clinical Endocrinology & Metabolism, included data from 52 different healthcare locations throughout the United States. A total of 180 people with type 1 diabetes developed COVID-19, as confirmed by a laboratory test, during the study period. The researchers were interested in comparing the rate of diabetic ketoacidosis in Black, white and Hispanic people with type 1 and COVID-19.
Overall, non-Hispanic Black and Hispanic patients with type 1 and COVID-19 were far more likely to develop ketoacidosis than their non-Hispanic white counterparts. The rate of ketoacidosis was 55% for Black patients and 33% for Hispanic patients, but only 13% for white patients. HbA1c levels (a measure of long-term blood glucose control) were also higher in Black and Hispanic patients, with an average of 11.7% for Black patients, 9.7% for Hispanic patients and 8.3% for white patients. These higher average HbA1c levels may help explain the higher rates of ketoacidosis seen in Black and Hispanic patients, but they may not be the whole story.
What explains the higher ketoacidosis risk?
As noted in a Healio article on the study, there were notable differences between the three groups — Black, Hispanic and white — beyond just HbA1c. Black and Hispanic patients were less likely to use diabetes technology such as insulin pumps and continuous glucose monitoring (CGM) systems. They were also far more likely to be covered by public insurance programs, with 78% of Black, 72% of Hispanic and 30% of white patients enrolled in them.
Taken together, these numbers paint a sadly predictable picture of limited access to quality healthcare for Black and Hispanic people with type 1 diabetes, compared with their white counterparts. Less access to wearable diabetes devices, in particular, may make it more difficult to become aware of elevated blood glucose levels quickly enough to prevent progression to ketoacidosis.
The study’s lead researcher urges doctors who treat people with type 1 to look out for potential disparities in access to care, including access to affordable insulin. They should also make sure all patients are aware of the signs of ketoacidosis and know what to do to help reverse it. And going forward, this study highlights the need for equitable access to COVID-19 vaccines among Black and Hispanic people with type 1 diabetes.