Black Patients at Higher Risk When Type 1 Diabetes and COVID Combine
The coronavirus pandemic has highlighted health care disparities in the United States, but a new study puts that issue into sharper focus, finding that Black and Hispanic people with type 1 diabetes who get COVID-19 are much more likely to have serious complications or die.
The study found that Black people with type 1 diabetes and COVID-19 were nearly four times more likely to be hospitalized for diabetic ketoacidosis, a very serious condition that can be fatal even without complications from the novel coronavirus.
"I think, most people won't be surprised that there are inequities, but I feel most people get surprised at the magnitude of the inequities. Almost four times, that's really significant once you think of all the population in general. The depths of inequities … is something that calls for more attention," said study author Dr. Osagie Ebekozien, vice president for quality improvement and population health at the T1D Exchange in Boston.
Diabetic ketoacidosis (DKA) happens when a person's body produces high levels of blood acids. In addition to finding much higher numbers of DKA in Black and Hispanic patients, the researchers also found that these patients had worse glycemic control and were less likely to use diabetes technology, such as continuous glucose monitors and insulin pumps, than white patients.
In the study, published Jan. 7 in the Journal of Clinical Endocrinology & Metabolism, the researchers analyzed data from 180 people with type 1 diabetes and COVID-19, from 52 clinical sites in the United States between April and August 2020.
Ebekozien called the study the first major examination of racial/ethnic inequities for people with type 1 diabetes and COVID-19. He urged targeted interventions, including culturally appropriate diabetic ketoacidosis awareness campaigns and increased continuous glucose monitoring coverage for minority patients.
The problem is systemic, said study co-author Dr. Shivani Agarwal, an assistant professor in the department of medicine at Albert Einstein College of Medicine in New York City.
Among other issues, there's a history of mistrust between minority populations and the health care system. It's possible that patients may not have received proper care earlier because they didn't feel they could trust their physicians, she said.
A hospital stay can impact many other parts of a person's life, Agarwal added. They've left behind responsibilities and, if they survive, they may lose their jobs. They're left with medical bills.
"Having one DKA episode can be quite intrusive into all kinds of parts of life that you wouldn't necessarily think about. It's not just the medical implications," Agarwal noted.
Type 1 diabetes is less common than type 2 diabetes, representing about 5% to 10% of people who have diabetes, according to the U.S. Centers for Disease Control and Prevention. It happens when the pancreas doesn't make or makes too little insulin, a hormone that helps blood sugar enter cells, according to the CDC.
Continuous glucose monitoring (CGM) allows for real-time monitoring by the patient of their own blood sugar, so they can catch issues before the problem is so big they have to go to the hospital, Agarwal said. It has the potential to stave off DKA altogether, she explained.
"CGM helps the patient connect with their health care provider in real time," Agarwal said.
That minority patients are less likely to have this technology is a multipronged issue, Agarwal said. In some states, the issue is insurance coverage, but her research has shown that providers also aren't offering the technologies to patients. Racism or implicit bias is what's happening, Agarwal said.
Ebekozien said he has also been considering distribution of the COVID-19 vaccines and equity, as they become available to the public.
"I think we have opportunities to ensure that we are very intentional in equitable distribution of the vaccines," Ebekozien said.
At a fundamental level, systemic issues have led to poorer outcomes for people of color, said Dr. Robert Gabbay, chief scientific and medical officer for the American Diabetes Association (ADA).
"Everybody with diabetes should have access to healthy foods. That is not the case and that disproportionately affects people of color. Everybody with diabetes should have access to the technology that helps them best manage their diabetes," Gabbay said. "Everyone should have access to the medications to treat their disease."
About 40% of people dying from COVID-19 in the United States have diabetes, Gabbay added.
The ADA is addressing some of these issues with advocacy and education, including through its Health Equity Now initiative.
"You can see how all of these things layered on top of each other are part of this," Gabbay said. "And then, you throw out the impact of COVID, where the racial disparities in outcomes are really incredible, five times as likely to be hospitalized, mortality significantly higher. So, we really feel that it's the confluence of these multiple factors."
The U.S. Centers for Disease Control and Prevention has more on the impact of certain health conditions, including diabetes, and COVID-19.
SOURCES: Osagie Ebekozien, MD, MPH, assistant professor, population health, University of Mississippi Medical Center, Jackson, and vice president, quality improvement and population health, T1D Exchange, Boston; Shivani Agarwal, MD, MPH, assistant professor, department of medicine, Albert Einstein College of Medicine, New York City; Robert Gabbay, MD, PhD, chief scientific and medical officer, American Diabetes Association; The Journal of Clinical Endocrinology & Metabolism, Jan. 7, 2021