Worsening glycemic control in youth with type 2 diabetes during COVID-19.

Introduction: The COVID-19 pandemic has disproportionately affected minority and lower socioeconomic populations, who also have higher rates of type 2 diabetes (T2D). The impact of virtual school, decreased activity level, and worsening food insecurity on pediatric T2D is unknown. The goal of this study was to evaluate weight trends and glycemic control in youth with existing T2D during the COVID-19 pandemic. Methods: A retrospective study of youth <21 years of age diagnosed with T2D prior to March 11, 2020 was conducted at an academic pediatric diabetes center to compare glycemic control, weight, and BMI in the year prior to the COVID-19 pandemic (March 2019-2020) to during COVID-19 (March 2020-2021). Paired t-tests and linear mixed effects models were used to analyze changes during this period. Results: A total of 63 youth with T2D were included (median age 15.0 (IQR 14-16) years, 59% female, 74.6% black, 14.3% Hispanic, 77.8% with Medicaid insurance). Median duration of diabetes was 0.8 (IQR 0.2-2.0) years. There was no difference in weight or BMI from the pre-COVID-19 period compared to during COVID-19 (Weight: 101.5 v 102.9 kg, p=0.18; BMI: 36.0 v 36.1 kg/m2, p=0.72). Hemoglobin A1c significantly increased during COVID-19 (7.6% vs 8.6%, p=0.0002). Conclusion: While hemoglobin A1c increased significantly in youth with T2D during the COVID-19 pandemic, there was no significant change in weight or BMI possibly due to glucosuria associated with hyperglycemia. Youth with T2D are at high risk for diabetes complications, and the worsening glycemic control in this population highlights the need to prioritize close follow-up and disease management to prevent further metabolic decompensation.

The Coronavirus Disease 2019 Pandemic is Associated with a Substantial Rise in Frequency and Severity of Presentation of Youth-Onset Type 2 Diabetes.

OBJECTIVES: To evaluate the frequency and severity of new cases of youth-onset type 2 diabetes in the US during the first year of the pandemic compared with the mean of the previous 2 years. STUDY DESIGN: Multicenter (n = 24 centers), hospital-based, retrospective chart review. Youth aged ≤21 years with newly diagnosed type 2 diabetes between March 2018 and February 2021, body mass index ≥85th percentile, and negative pancreatic autoantibodies were included. Demographic and clinical data, including case numbers and frequency of metabolic decompensation, were compared between groups. RESULTS: A total of 3113 youth (mean [SD] 14.4 [2.4] years, 50.5% female, 40.4% Hispanic, 32.7% Black, 14.5% non-Hispanic White) were assessed. New cases of type 2 diabetes increased by 77.2% in the year during the pandemic (n = 1463) compared with the mean of the previous 2 years, 2019 (n = 886) and 2018 (n = 765). The likelihood of presenting with metabolic decompensation and severe diabetic ketoacidosis also increased significantly during the pandemic. CONCLUSIONS: The burden of newly diagnosed youth-onset type 2 diabetes increased significantly during the coronavirus disease 2019 pandemic, resulting in enormous strain on pediatric diabetes health care providers, patients, and families. Whether the increase was caused by coronavirus disease 2019 infection, or just associated with environmental changes and stressors during the pandemic is unclear. Further studies are needed to determine whether this rise is limited to the US and whether it will persist over time.

Pediatric obesity and the impact of COVID-19

Epidemiology Adiposity is measured using body mass index (BMI) or weight (kg)/height (m2). Because of growth and development during childhood, BMI percentiles for age and sex as defined by the Centers for Disease Control and Prevention are used to estimate adiposity, with overweight defined as 85th to less than 95th percentile , obesity 95th percentile or greater, and extreme obesity, 120% of the 95th percentile or at least 35 kg/m2.4-6 Overweight and obesity disproportionately affect racial and ethnic minority groups, particularly Hispanic and non-Hispanic Black youth, and obesity prevalence is also associated with poverty.7 The latest data from the National Health and Nutrition Examination Survey show that from 1999-2000 to 2017-2018, obesity prevalence increased from 15.8% to 19.3% in children aged 6 to 11 years. In addition to family history, the "thrifty gene hypothesis," proposed by David Barker, states that undernutrition in utero causes adaptive metabolic changes in the fetus, such as insulin resistance, that do not match the postnatal extrauterine environment, which has excess calories with decreased physical activity.13,14 This concept of fetal origins of adult disease has been implicated in the association of intrauterine growth restriction and small for gestational age, with increased later cardiometabolic risk.15 Epigenetics has also been implicated, with DNA methylation changes and posttranslational histone modifications causing heritable genetic changes, potentially programming later diseases.16 Early hypernutrition can also be a risk factor, with rapid weight gain in the first 4 to 6 months of life associated with obesity later in childhood.17 In rare cases, genetic syndromes, such as Prader-Willi, Alstrom, and Bardet-Biedl syndromes, and monogenic mutations, such as MC4R, LEP, and POMC mutations, can cause severe obesity, usually characterized by obesity onset before age 5 years. Endocrinologic causes such as hypothyroidism and Cushing Disease are also less common, and generally involve attenuated height or height velocity in addition to excess weight, in growing youth.18 Numerous environmental factors contribute to excess weight gain during childhood: dietary factors, such as consuming more sugar-sweetened beverages, eating larger portions, skipping meals, decreasing intake of fruits and vegetables (which can be related to food insecurity), and consuming more fast food. Mental health concerns, such as depression and anxiety, are also significant potential comorbidities of obesity.27 Pediatrie providers should specifically ask about symptoms of depression-hopelessness, trouble sleeping, lack of interest or motivation, and changes in appetite, as well as anxiety, spurred by loneliness, isolation, and uncertainty.28 This is especially important given the COVID-19 pandemic's exacerbation of many social stressors affecting families, such as food insecurity, poverty, and racial disparities.29 The already strained pediatric mental health infrastructure has been further challenged by the pandemic, making mental health screening by primary care providers all the more important.28 Treatment The mainstay of treatment for pediatric obesity involves behavior modification through increased physical activity, improved nutrition, and decreased sedentary activity.