Exploring why kids who got COVID were more likely to develop Type 1 diabetes

Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

During the pandemic in 2020 and 2021, doctors saw a significant rise in the number of people, especially children, diagnosed with Type 1 diabetes, and now it looks like kids under age 18 are more likely to receive a new diabetes diagnosis within 30 days of a COVID-19 infection than their peers who were not infected.

Here to talk about the reasons for that is Dr. Roberto Izquierdo. He's a professor of medicine and of pediatrics at Upstate and also the chief of pediatric endocrine and diabetes. Welcome back to "The Informed Patient," Dr. Izquierdo.

Roberto Izquierdo, MD: Well, thank you for having me. Good morning.

Host Amber Smith: You and your colleagues from six other hospitals looked back at your data about new patients with Type 1 diabetes from 2019, before the pandemic, and 2020, during the pandemic. What did you find?

Roberto Izquierdo, MD: Well, we found that there was an increase in the number of children with Type 1 diabetes that were newly diagnosed with the condition. We also found that there was also an increased proportion of those children that presented with diabetic ketoacidosis, which is a life-threatening complication of Type 1 diabetes in which your blood sugars reach a very high level, and you also start to see the appearance of these chemicals called ketones. Ketones are produced when there's not enough insulin, and as you know, Type 1 diabetes is an autoimmune condition, or disease, in which,the cells that produce insulin in the pancreas are destroyed or damaged, and they cannot produce insulin.

So this lack of insulin does not allow the sugars in the blood to enter the cells because insulin actslike a key that opens the door for sugar in the blood to enter the cells to be converted into energy

So somehow the body has to try to get around this, and it starts burning fat, and part of fat metabolism is the production of these ketones, which are, in small amounts, very useful; they're helpful when you're fasting, for example, because they could be utilized by the heart, the brain, as energy, as an alternative fuel.

But without insulin, that process is not regulated, and the ketones accumulate in the blood drop the pH in the blood, and then that makes you acidic. And that could lead to all sorts of problems, like lethargy, coma, nausea, vomiting, abdominal pain.

So if you're seeing children who have diabetic ketoacidosis when they're diagnosed, does that indicate that it's a more advanced form of Type 1 diabetes or that they've had a more severe case?Well, I would classify it as a more severe presentation because we also see patients that are early on in their diagnosis, that are referred, and those patients are not admitted to the hospital and we could treat as an outpatient.

Host Amber Smith: I see. Now help us understand, because in recent years we've heard about a surge in the numbers of people being diagnosed with Type 2 diabetes, but that's entirely different from Type 1. Is that right?

Roberto Izquierdo, MD: That's correct. Yeah. Type 2 diabetes is another form of diabetes, in which the body is able to produce insulin, but the tissues, like the muscle cells, for example, are not responsive to the insulin. So we call that insulin resistance; the cells in the pancreas, the beta cells, have to produce more insulin to keep up with that insulin resistance.

Roberto Izquierdo, MD: But when it cannot keep up with that amount of insulin resistance, then you develop Type 2 diabetes. Now Type 2 diabetes is highly familial, so if your brother or sister or parent have Type 2 diabetes, then you are at increased risk for Type 2 diabetes also -- significant. So it's genetics, but also the environment, so eating high-fat foods, sedentary lifestyle, weight gain can increase your risk of developing Type 2 diabetes.

There's reports also of an increase in incidents of Type 2 diabetes during the pandemic. Because many of us were more sedentary, less active, eating more at home, and that led to weight gain, and we've seen an upsurge, too, of Type 2 diabetes.

Host Amber Smith: I see. So in Type 2, the pancreas might still be functioning or making insulin, but in the patients that you're seeing with the Type 1 diabetes who are recovering from COVID, their pancreas is not producing insulin anymore. Is that right?

Roberto Izquierdo, MD: Yes, that's correct.

Host Amber Smith: Is that permanent, or is it reversible?

Roberto Izquierdo, MD: Unfortunately it's not reversible, so it is permanent. So at this time, the only way to treat it is through multiple daily injections of insulin. So we give a combination of a long-acting insulin that keeps the sugar from rising overnight and between meals, and a fast-acting insulin that,treats the rise in blood sugar after a meal that contains carbohydrates.

Host Amber Smith: Now, I understand more research needs to be done. But what do you think might be the connection between Type 1 diabetes and COVID-19 or the coronavirus?

Roberto Izquierdo, MD: We need more research to understand the mechanism. The cells in the pancreas, the beta cells, do have the ACE, or angiotensin-converting enzyme, in receptor 2 on their surface, so it could be that those cells are directly damaged by the COVID virus. The other possibility is our body's immune response to the COVID infection creates a whole host of chemicals called cytokines, and these cytokines help the immune system fight off the infection, but as a byproduct, they could also damage the beta cells.

So I think with time, we'll be able to figure this out a little bit more and to see what the exact causes are.

Host Amber Smith: Do we know yet if the kids who are fully vaccinated have a lower risk of developing Type 1 diabetes after COVID-19 than the kids who were not vaccinated?

Roberto Izquierdo, MD: I have not seen reports of that, but I'm sure that there will be, but we do know that, vaccines prevent the COVID infection.

And I think as a result, that incidence of and prevalence of diabetes should decrease in these children once they're vaccinated. For example, kids that get vaccinated have less of the systemic inflammatory response that we see in some children weeks after the COVID infection. So I would expect that the vaccine would prevent COVID, and as a result, you have less incidence of Type 1 diabetes.

Host Amber Smith: But just to be clear, you're seeing kids with new-onset Type 1 diabetes who don't have any sort of family history of diabetes and don't really have any risk factors per se for diabetes, but they've had COVID-19.

Roberto Izquierdo, MD: That's correct. Yes.

Host Amber Smith: That's a little scary.

Roberto Izquierdo, MD: It is very scary. In our own population here, the patients with newly diagnosed Type 1 diabetes have increased by 30%. In some places, like a report from a hospital in San Diego, it increased by 57%. So that's very alarming.

Host Amber Smith: I want to ask you about the symptoms of new-onset Type 1 diabetes. What would these children, in your case, since you focus mostly on pediatrics, what would they be experiencing that would send them to the doctor?

Roberto Izquierdo, MD: The symptoms to look out for are frequent urination, thirst -- so, drinking a lot of water, unintentional weight loss, fatigue. We see a number of children that previously could make it through the night without bedwetting, and then they start wetting the bed.

Roberto Izquierdo, MD: Those are some of the signs that could trigger the parents to bring them to the pediatrician or the family doctor to have them checked.

Host Amber Smith: Are doctors looking at this as part of long COVID, because we hear about people who survive COVID, but then they're dealing with symptoms, lingering symptoms or new symptoms, fatigue mainly, months after?

Roberto Izquierdo, MD: Not to my knowledge. No, I think this is more like an acute event than like the long COVID that has been described.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. And I'm talking with Dr. Roberto Izquierdo about children who are developing diabetes after COVID-19 infection. He's Upstate's chief of pediatric endocrine and diabetes.

I'd like to have you walk us through how Type 1 diabetes is diagnosed. So if you have a patient who comes in, who's had frequent urination and increased thirst, and they've lost weight, how do you test to see what's going on?

Roberto Izquierdo, MD: We draw a blood test for blood sugar. There's another test called the hemoglobin A1C, that we use to monitor patients long-term. The A1C measures the amount of sugar attached to the red blood cells, and the red blood cells circulate in the blood for about three months. So if your blood sugar's high, that A1C will be high. So the normal sugar, no matter what you eat, in the blood, in someone without diabetes, between 70 and 126. If you get a fasting blood sugar on two occasions in which the blood sugars over 126, that's considered diabetes. Or if you have a blood sugar over 200 with symptoms like drinking, a lot of water, urinating a lot, weight loss -- that's also just on one blood test, you could diagnose Type 1 or Type 2 diabetes.

Normally the A1C in someone without diabetes is less than 5.7. So if the A1C is greater than 6.5, we diagnose also Type 2 diabetes. So those are the two main tests, the blood sugar and then the A1C. We also check the electrolytes because, for example, someone has a child who's sick with fatigue, dehydration, lethargy, they may be in diabetic ketoacidosis. In that situation, we check the electrolytes, we check the bicarb, which is the buffer, and we also check the pH, the blood pH, and that helps us diagnose if the patient is in diabetic ketoacidosis. In that situation, then, you need more emergent treatment, so, if the patient's not in the emergency room, we do send them there to get hydration, and these patients then need to be admitted to provide fluids by vein and to provide insulin by vein to stop the ketones from being produced. And usually that could take, depending on the severity, eight to 12 hours.

Host Amber Smith: Would a regular pediatrician, because I'm imagining most people would go to their primary care provider first, would that person order those tests, or at what point might someone be referred to someone like yourself, who specializes in endocrinology?

Roberto Izquierdo, MD: Yeah, usually the pediatricians do, and the families are well aware of diabetes, so they can draw those diagnostic tests initially. Usually for patients with Type 1, especially children, we do get a referral in this area, for management, with insulin long-term.

Host Amber Smith: So someone who is sent to the hospital immediately to be regulated or stabilized, how long might they be in the hospital, and then what happens after that?

Roberto Izquierdo, MD: We're very lucky to have an excellent team here of diabetes care and education specialists, dietitians, and also the inpatient hospital nurses that are well versed with the treatment. So most patients that need admission only stay for a day or so, and they go home the next day.

If they're very young, and the parents feel a little bit uncomfortable, we may keep them an extra day because they do have to learn a lot, and I'm always amazed how well the parents do, and the kids, too, because within 24 hours, they go from not checking the blood sugar and not administering insulin to checking blood sugars, administering insulin, learning how to treat low blood sugars, how to check ketones, how to count carbohydrates, because the dose of insulin is based on the carbohydrate content of the meal as well as the blood sugar before the meal. It does take a team to do that.Our diabetes care and education specialists spend, for patients with new diagnosis, approximately three hours, you know, sometimes a little less and sometimes more, and then they meet with a dietitian to review carb counting.

Now, some kids that are not as sick, they just come to the office. And again, we're fortunate to have the DCES and the dietitian. So we see them within 24 hours and start insulin as an outpatient, and most families are able to do that. And then we also provide support after the diagnosis, once they go home. There's somebody on call 24/7, and the parents call for various issues.

Host Amber Smith: We also provide information to them, like the "CalorieKing" book, where you count carbs, and the apps. And there's some basic diabetes books that are very useful, like the "Pink Panther" (for children), so we provide that. I'm thanking the Upstate Foundation for that, for contributions. Now you used the term DCES?

Roberto Izquierdo, MD: That's the diabetes care and education specialist.

Host Amber Smith: I see.

Roberto Izquierdo, MD: In the past, it was called diabetes educator, but they do more than education because they adjust insulin and other things.

Host Amber Smith: Well, because this is a lifelong thing, a change in a child's life, but it's going to be with them for the rest of their lives.

So there is, I assume, a lot of learning to get right from the beginning, hopefully.

Roberto Izquierdo, MD: Yeah. And we do have a large population of patients, so we have close to about 1,200 children with diabetes in Central New York in more than 25 counties. And in this area, the proportion of Type 2 is much less, but we have like 500 patients over the past two years. We share that care; along with the doctors, we also have a team of nurse practitioners and PAs, physician assistants, that participate in their care. And fortunately, we do have a social worker and a child life specialist.

Host Amber Smith: Let me ask you: If a child, develops Type 1 diabetes and doesn't get care, is this a life-threatening condition for them, or what would happen?

Roberto Izquierdo, MD: Oh, it could be disastrous. If you don't treat the Type 1 diabetes, eventually you pass away because of lack of energy, you lose weight, you lose energy. So, before insulin was invented, patients with Type 1 diabetes would pass away. That was in the 1920s, so we have come a long way.

Host Amber Smith: It sounds like it.

Roberto Izquierdo, MD: Yeah.

Host Amber Smith: Earlier you mentioned that treatment usually is a combination of long-acting and short-acting insulin. I'm assuming that might be tailored individually to each person.

Roberto Izquierdo, MD: Right. Initially we base it on the patient's weight and the patient's age, but then we follow the pattern from day to day and day to week, and we make adjustments. Parents also learn how to do this. And over the past several years, there've been some great advances in the management of Type 1 diabetes, because now we have those continuous glucose sensors, like you see advertised, the FreeStyle Libre and the Dexcom, and then patients can also progress to a pump, which is the size of a small cellphone, which you fill with insulin and you program it to give a small amount of insulin every hour. And then when, you need to eat, you tell the pump how much insulin to give just by pressing a button like you do on your cellphone. What's great now, over the past couple of years, that you have these automated systems, so it's really making a large difference in which the pump and the sensor, they communicate with each other. So it's automated. The drawback is that you have to have two sites, a pump site and a sensor, but, it does adjust the basal rate of the insulin given. So if your sugar is going low, it'll decrease the insulin administration or stop it temporarily, or if the sugars are going high, it'll increase the basal rates or give you a small bolus (dose of insulin) to bring the sugar down. So that's making a dramatic improvement in the management of these patients, as we've seen by improved quality of life, less low blood sugars, less high blood sugars.

Roberto Izquierdo, MD: So it's very exciting. There's more research being done in which we're looking into insulins that work faster. You might not even have to count carbs once that's developed. So I've seen dramatic improvement with those automated systems. I encourage all patients and families, but it's a personal decision, you know, for the family and the patient. I mean, some patients just do great with injections. Now we have insulin pens with very tiny needles, and some patients just prefer that, and they do just as well.

Host Amber Smith: I'd like to ask you how Type 1 diabetes affects a person's life in terms of, well, they're always going to be taking the insulin medication, but does this mean that they're restricted with their physical activities?

Roberto Izquierdo, MD: No, actually we encourage physical activity, and with good health care and taking care of yourself, like not smoking, eating a healthy diet, and as you get older, controlling your blood pressure and so on, you could live a very healthy life. I have had a couple of patients, one patient passed when they were 95 and the other one 90. So they had diabetes for many, many years. So I think with good health care, and good personal care, you can prevent a lot of the complications of diabetes, so no longer do you lose a toe or anything like that, with the current advances. Patients that had diabetes when they were diagnosed in, like, say, 1960, they may have complications, unfortunately.

Host Amber Smith: Do most of your Type 1 diabetic patients come to see you annually or more frequently than that?

Roberto Izquierdo, MD: We try to see them every three months, so we alternate with the nurse practitioner or the physician assistant and the doctor, and then use a diabetes care and education specialist as needed and the dietitian as needed.

Initially we see them more frequently, so once you're diagnosed, we see the person about two weeks later. And then after that two-week visit, we see them a month later. And then usually it's three to four months.

Host Amber Smith: You've mentioned dietitian a few times, too. So does having diabetes mean that you're not going to be able to eat birthday cake or other sweets?

Roberto Izquierdo, MD: No, no. Nowadays, because we count the carbs in the food, you could eat all those sorts of foods. We just recommend for children a healthy diet. Just like I wouldn't want my children to be eating Snickers all day. That's not healthy for anybody. So they could eat cake, ice cream, they just have to give more insulin, so when they're going to do that, you count the carbs, which they learn how to do, and get the insulin dose via the pump or via an injection.

Host Amber Smith: You called Type 1 diabetes an autoimmune disease. And I wanted to have you explore that a little more. What does that mean to the person who's got the disease?

Roberto Izquierdo, MD: So autoimmune is like, it's the person's immune system attacks the cells, those beta cells. Now we don't completely understand that.

We know that certain viruses can trigger that immune response, and some viruses have been found in the beta cells. For example, you could get a virus infection, and then that immune response then kills the virus, but also kills those beta cells. Now, why does this happen?

Roberto Izquierdo, MD: Some individuals are more predisposed to it, so they have a predisposition. So it's not strictly genetic, but there is a predisposition. So most patients that have Type 1 diabetes don't have a sibling that has Type 1 or parents, but there is an increased risk. So, if you have a child with Type 1, then maybe the risk goes up four times that their brother or sister may have it.

Now there are research studies trying to identify those patients because we could detectmarkers for in the blood that we check for, certain antibodies. If we see those antibodies, then they could possibly participate in some research studies to try to prevent progression. There's a lot of research in that area, though it's still in the research investigational field, but at some point maybe we could even prevent the disease.

Host Amber Smith: Does having Type 1 diabetes put a person at risk for developing other diseases?

Roberto Izquierdo, MD: Type 1 does increase that risk because once you have an autoimmune disease, you may have another autoimmune disease.

So in those situations, we routinely check for thyroid disease; it's very common, underactive or overactive, mostly underactive disease. So we do that through a blood test every two years. Celiac disease is very common, so we check for that too, especially in the first two years after diagnosis.

And then some other conditions. We want to monitor the cholesterol and triglycerides to make sure they're OK. We monitor blood pressure, because as you get older, managing all those comorbidities, what we call other conditions, keeps the complications at bay.

Roberto Izquierdo, MD: I always tell the residents (doctors in training), the ABCs of diabetes: A1C, blood pressure, cholesterol. But there's other conditions that we monitor; patients with diabetes do tend to have a higher incidence of depression. So we would routinely screen for depression.

Now we're also monitoring for the determinants of health, the social determinants of health, the SDOH, because we know that non-Hispanic Blacks tend to have a higher incidence of diabetic ketoacidosis,compared to other groups, and so, by screening for those conditions, we can try to help them, help the family. If you screen positive for a certain social determinant of health, like, say, maybe food insecurity, then our social worker can give them some resources to look into. If it's transportation, we could try to work to clear that because patients also that live in rural areas are at higher risk for diabetic ketoacidosis. And those that lack insurance are also at higher risk for diabetic ketoacidosis. So, we're trying to develop strategies to prevent diabetic ketoacidosis and also improve their blood sugars, so they have a lower A1C, for example.

Host Amber Smith: This has been a lot of information. So let me kind of recap: You're seeing, and endocrinologists like you across the country are seeing, an increase in the number of children who are diagnosed with Type 1 diabetes after having been infected with COVID-19. And this is a lifelong illness, if they're diagnosed with it, that takes some careful management, and the children who are vaccinated, that may offer some protection toward this, but that's kind of unknown because it hasn't really been explored entirely.

So there's more research to come, likely. If someone is diagnosed, a child is diagnosed, and they come to see you as a pediatric endocrinologist, do they stay with you throughout their life, or once they turn 21, do they get an adult doctor?

Roberto Izquierdo, MD: Usually they get an adult doctor. With me, I'm a pediatric and adult, so they stay with me as long as they want to stay. In our practice, once they reach 21, they get transitioned to the adult practice. So that may be our practice here, or they may decide to see another local physician. So we have developed a transition program to try to teach adolescents and young adults how to transition to adulthood, like for example,to learn how to navigate through the health insurance. You know, it can be complicated. And also discuss other issues that are pertinent to late adolescence or young adulthood.

Host Amber Smith: Well, Dr. Izquierdo, I really appreciate you making time for this interview.

Roberto Izquierdo, MD: Oh, thank you very much and have a good day.

Host Amber Smith: My guest has been Dr. Roberto Izquierdo. He's a professor of medicine and of pediatrics, and he's the chief of pediatric endocrine and diabetes at Upstate. "The Informed Patient" is a podcast covering health, science and medicine brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

Find our archive of previous episodes at upstate.edu/informed. This is your host, Amber Smith, thanking you for listening.