A new study recently released by the National Health Service in the United Kingdom showed that people with type 1 diabetes are significantly more likely to die in the hospital setting from COVID-19 than people living with type 2 diabetes.
The study, which followed 61,414,470 individuals (263,830 with type 1 diabetes and 2,864,670 with type 2 diabetes) from March 1st to May 11th, 2020 revealed that people with type 1 diabetes are 3.5X more likely to die from COVID-19, and people with type 2 diabetes are twice as likely to die from COVID-19 as people who don’t have either condition.
The study recorded 23,804 deaths during the course of the research period (7,466 type 2 deaths and 365 type 1 deaths). The study also adjusted for age, sex, socioeconomic status, ethnicity, and place of residence.
According to this study, almost one-third of all deaths from COVID-19 among people in the hospital setting in England during the current pandemic have been associated with diabetes. However, it is significant to note that age is still a protective factor, with the average age of death in the study being 78 and 72 for type 2 and type 1, respectively. There are still few deaths for people with diabetes under 40, and no recorded deaths [in the study] under 20 years old.
Jon Cohen, emeritus professor of infectious disease at Brighton and Sussex Medical School, said, “Bacterial infections are more common and more severe in [people with] diabetes. This has generally not been thought to be such a problem with viral infections, such as Coronavirus (COVD-19), but any severe infection can cause problems with insulin control, so this too will likely contribute to the increased mortality rate in type 1 patients.”
He continued, “so (type 1) diabetic patients are probably not at greater risk of catching Coronavirus, but do have a greater risk of becoming seriously ill if they do catch it.”
But why the increased risk of dying in patients with T1D, a disease of autoimmunity and not associated with lifestyle factors as Type 2 is? A misunderstanding of proper T1D management by healthcare workers may be to blame.
A lack of hospital experience in diabetes care plays a role
People with type 1 diabetes have long complained of poor hospital care. In the case of type 1 diabetes, this is particularly dangerous, as a complete lack of pancreatic function necessitates tight glucose control to prevent hypoglycemia or DKA, both of which can rapidly lead to death. Technology allows patients to manage this for themselves at home, but that changes when entering a healthcare setting. Hospital staff are often unfamiliar with the newest insulin pumps or continuous glucose monitors (CGMs), and standard operating procedures often require that insulin dosing occurs after a meal is eaten, to prevent a hypoglycemic incident should a patient not finish their food (and any ensuing lawsuits).
However, this is in opposition to the latest standard of care which recommends dosing rapid-acting insulin at least 15-20 minutes before a meal to prevent postprandial glucose excursions. Many patients don’t know their hospital rights and will oftentimes relinquish control of their insulin pumps and/or CGMs, and rely solely on an insulin drip and the manual finger-testing that nurses perform every few hours.
This data can be spotty and doesn’t give a clear picture of management during a hospital stay. It also doesn’t allow for micro-adjustments and course-corrections, which people on intensive insulin therapy regimens are used to completing to maintain tight control. People with type 2 diabetes who are on oral medications like Metformin or manage their condition without medication often have a wider margin of error and may not be as susceptible to these weaknesses in the hospital setting.
Dealing with coronavirus and diabetes in the hospital
In the case of COVID-19, a new challenge emerges. Patients requiring hospitalization are often incoherent or sedated and do not have family members around to advocate for their care or help educate staff on their loved one’s specific needs. This reality worsens when infection control protocols limit non-essential room entrance and monitoring.
Ginger Vieira, a mother of two who lives with type 1 diabetes, recalls her hospital experience during the birth of her first child, “They withheld insulin from me, and I had to take secret injections in the bathroom to keep my blood sugar at an even 90 mg/dL for the sake of my soon to be born child.”
John Tagliareni, Iowa, agreed, “About five years ago I had an overnight stay at the hospital for surgery, and the nurse told me that I had to remove my pump for the stay. I explained I would feel more comfortable with my own settings and control. She finally relented, but made me fill out a sheet every time I bolused or checked my blood sugar, and I was yelled at several times when I forgot to fill out the form… I was happy when her shift ended.”
Typically, hospitals will allow one to sign a waiver to manage one’s own diabetes. But that’s challenging for the very sick, disoriented patient. Sporadic diabetes care, especially in the hospital setting, sets patients up for higher rates of hyperglycemia, nosocomial (associated with hospital location) infections, and now, complications from COVID-19 that can quickly turn fatal.
Nicolai Hel adds his experience, “Oh, the stories! Best one is when the emergency room nurse gave me an IV with saline + dextrose for dehydration and argued with me until I mentioned my T1D!”
Hospitals must find better ways to treat people with diabetes
While in the hospital, IV drips for hydration and nutrition are the standard of care. But hospitals don’t tell patients that those IV lines often contain dextrose (a potent form of sugar). Dextrose should only be given intravenously if a patient has low blood glucose. If a patient’s potassium levels are too high, or if a patient is NPO and has nutritional needs and can also metabolize glucose/dextrose effectively (re: they do not have diabetes).
People with diabetes should ask their doctor for a saline drip without dextrose, or they will be more likely to face extreme hyperglycemia and an increased risk of infection.
While the study did not detail why people with type 1 diabetes were so much more likely to die than people with type 2 (and why both were more likely to die than the general population), they did speculate on an association.
“The risk of developing pneumonia was reported to be 2.98 higher for Type 1 diabetes and 1.58 for Type 2 diabetes compared to the general population.” Since a major cause of death from COVID-19 is complications from pneumonia, this is significant.
It is also well-documented that people with type 1 diabetes suffer from infections more often than those with type 2: incidence ratios for infection-related hospital admissions were 3.71 for type 1, compared to 1.88 for type 2. An estimated 6% of infection-related hospital admissions and 12% of infection-related deaths have been tied to diabetes. This is something that providers should constantly be aware of when treating type 1 patients who present with COVID-19.
These findings have important implications for people with diabetes and hospitals. Most tellingly, the study should inform hospital administrators, staff, and policymakers who can improve the level of care people with type 1 diabetes receive in the hospital setting.
There are many ways to improve that care:
- Ensuring adequate sleep for patients (reduce fluorescent lighting and frequency of alarms overnight)
- Addressing patients’ mental health concerns
- Letting patients manage their own diabetes (let patients keep their insulin pumps and CGMs on and make basal/bolus adjustments as needed)
- Allowing people to dose for a meal before they eat
- Ensuring patients don’t receive dextrose IV drips
- Respecting one’s needs for a low(er) carbohydrate diet
There are many ways in which hospitals can pay better attention to the needs of their patients, especially those with type 1 diabetes who are in high-risk groups for infections, COVID-19 complications, and, as this study has shown, death.
But further exploration is needed to understand the role of the healthcare provider in an acute setting and to ensure people with type 1 diabetics are treated thoughtfully, uniquely, and most importantly: safely. Their lives depend on it.
(The authors of the study wish to reassure people who are at low absolute risk (<40 years old, low hba1cs, no comorbidities), despite having diabetes)