Leah Wyckoff, a stay-at-home mom of four from West Chester, Ohio, knew there was something seriously wrong with her 8-year-old son Sam when her daughters—ages 7, 10, and 11—alerted her that his face looked scary.
He had been sick for about a day and vomiting frequently; the pediatrician had told her there was a stomach bug going around. Wyckoff thought he was probably just dehydrated. But when she went to look at him, she was shocked. He had dark circles under his eyes, and his mouth was so dry his lips kept sticking to his gums. “He looked like he had lost 10 pounds in like hours. I thought he was disappearing in front of my eyes,” she says.
A trip to the emergency room explained what was happening. Sam had severe diabetic ketoacidosis (DKA), a life-threatening condition where the body isn’t able to use sugar for energy, and starts breaking down fat at too fast a pace, causing the blood to become acidic. He had lost 15% of his body weight, and was quickly deteriorating.
“We think your son has Type 1 diabetes,” the doctors told Wyckoff and her husband. This was surprising, as he didn’t have any of the classic onset symptoms such as excessive urination or thirst, but the diagnosis was clear. Sam was admitted to the intensive care unit to be stabilized—and put in isolation.
At the hospital, he had also tested positive for covid.
The two things might be coincidental, the doctors told Wyckoff. Or they might not be. “They explained in the hospital that most likely something in his genetic makeup means he was more predisposed to developing Type 1 [diabetes] and covid was what brought the onset,” she says. “They said there are a couple of different viruses that can bring the onset and covid happens to be one of them.”
Sam Wyckoff isn’t the only child to be diagnosed with Type 1 diabetes at the same time as, or shortly after, covid. In fact, Type 1 diabetes is could be up to 77% more likely in children who have had covid, according to some preliminary studies.
Covid as a possible trigger of Type 1 diabetes
Upticks of diabetes diagnoses in coincidence with covid-19 have been registered by several studies. A study done by the University of California, San Diego, found that from March 2020 and March 2021, 57% more children were admitted into the hospital with a diagnosis of Type 1 diabetes than were expected based on data from the previous years. Data analysis from the US Centers for Disease Control and Prevention (CDC), found an increased risk—ranging from 31% to 166% higher, depending on the body of data analyzed—of Type 1 diabetes diagnosis in patients under 18, 30 days after a covid infection. In Germany, the new diagnoses of Type 1 diabetes in children and adolescents increased significantly in 2020 and 2021, and studies from Norway and Finland have arrived at similar findings.
Most of this research is done through data analysis of hospitalization numbers and diagnoses, and is far from establishing any causation link between covid and diabetes. Many things could explain the numbers, says Sharon Saydah, a senior scientist at the CDC who worked on the diabetes study. It could be that covid triggers an autoimmune response that leads to diabetes; perhaps children who were predisposed to diabetes had more severe cases of covid, and were diagnosed with diabetes only after; or parents might be more vigilant with children who had covid, and quicker to recognize the signs of diabetes.
Wyckoff’s other children were tested for the four autoantibodies associated with Type 1 diabetes. Her eldest daughter, Audrey, was positive for all of them, and while she doesn’t have full-fledged diabetes yet, she is all but sure to develop it, making theirs one of the rare families in which more than one member has Type 1 diabetes. This points to the complicated nature of autoimmune diseases, and the roles that unrelated viruses may play in triggering their onset. The Epstein-Barr virus is believed to be the possible trigger of autoimmune conditions such as lupus and multiple sclerosis, and even the flu has been associated with the onset of Type 1 diabetes.
Whatever the cause, says Saydah, the association between covid and diabetes is important enough to demand further research to understand what is happening, and why.
How does diabetes work?
Diabetes is a disease in which the body doesn’t produce the hormone insulin, or does not respond to it appropriately. This results in a failure to absorb and use carbohydrates as energy, and in elevated levels of glucose in the blood. There are two types of diabetes. Type 1 is a condition in which the pancreas doesn’t have the ability to produce sufficient insulin for the metabolization of sugars. It is rare and chronic, managed through administration of synthetic insulin. It is overwhelmingly diagnosed in childhood, and accounts for almost all of the of diabetes diagnoses in children under age 10. Type1 diabetes is an organ-specific autoimmune disease, in which autoantibodies attack pancreatic beta cells, hindering their ability to produce insulin.
Type 2 diabetes happens when the body does not respond properly to insulin. It is a metabolic condition typically linked to lifestyle and diet, and it is usually diagnosed during or after adolescence. It’s very common—an estimated 10% of Americans have Type 2 diabetes, and one-in-three have pre-diabetes. The onset of Type 2 diabetes is usually slower than in Type 1, and insulin isn’t always needed as some cases can be managed with diet and lifestyle changes. In the vast majority of cases, Type 1 diabetes is diagnosed by age 10, while adult-onset diabetes is almost exclusively Type 2. In adolescence, diagnosing whether diabetes is Type 1 or 2 can be more challenging.
Studies have shown an increase in Type 2 diabetes in connection with covid, too. A study by the Colorado Children’s Hospital found a dramatic increase in youth-onset (under 21), Type 2 diabetes in 2020, about double the number they would ordinarily see. A broader review of data from 24 facilities confirmed it: there was a 77% increase in cases of Type 2 diabetes among youth (8- to 21-years-old) during the first year of pandemic.
Diabetes could be a long covid outcome
While increases in Type 2 diabetes diagnoses might be driven by lifestyle factors—the result of a more sedentary lifestyle during lockdowns, or a poorer diet—the increase in Type 1 diabetes suggests covid might be triggering an autoimmune response. “It could be due to the effects of the [covid] infection directly on organ systems involved in diabetes risk. It might be that covid is leading to diabetes through, say, direct attack on pancreatic cells,” says Saydah.
“Type 1 diabetes is thought to be an autoimmune disease and prior infections could trigger it, so we were not necessarily shocked that it would be increased following covid,” says, a professor of medicine at Case Western Reserve University and co-author of an electronic health data study that found an increase in the disease of nearly 80% among children under 10 who had covid. “However, it was increased even above other respiratory infections—so clearly, covid had had some kind of an association.”
The link between covid and Type 1 diabetes might be found in the autoimmune response. (In the absence of data on the type of diabetes, Davis’s research team picked the child’s age as an imperfect, but functional proxy for the type of diabetes, as most diagnoses before 10 years old are of Type 1.) “There are a lot of reports of increased autoimmune antibodies in patients who have covid, and since Type1 diabetes is thought to be an autoimmune disease, we thought that this might well provide a risk factor,” says Davis.
In a way, diabetes might fall into the still growing list of long-term consequences of covid. Autoimmune antibodies have been found in long covid patients, for instance, although the attack on pancreatic beta cells (and consequent diabetes) is particularly concerning because they don’t regenerate themselves like many other body cells.
What can parents do?
“This could be a big issue and it could be a driving health problem as the pandemic wears on,” says Davis, adding that there are many new aspects of the long tail of covid we are still struggling to understand.
In this case, follow-up studies are needed to tease out whether there is, in fact, a causal link between covid and Type 1 diabetes, and how it works—though it might take time before those questions are answered. “Those are very difficult studies and require a long-term commitment both on the part of the investigating physicians and on the part of the family,” says Davis. Another challenge, says Saydah, is finding a good control group, because Type 1 diabetes is a rare condition, and it’s difficult to predict what children will develop it, and then compare their situation with that of children who have had covid.
While scientists continue to investigate the link, parents and caregivers can take action, starting with vaccinating children to protect them from the most severe consequences of covid including, potentially, diabetes. “It is better to prevent the disease and everything that comes afterwards [...] Vaccination does very well at that,” says Davis.”I can tell you that my grandchildren are all vaccinated.” Sam Wyckoff was in between his two doses of vaccine when he got covid, and it’s likely he wouldn’t have been infected had he completed the course. Yet so far, the uptake of covid vaccination in children has been abysmal: Just above 30% of children between ages 5 and 11 are vaccinated, and less than 10% of children under 5 have received at least one dose of vaccine.
Further, parents should monitor their children, and be especially vigilant in the weeks and months after they have had covid, even if vaccinated. Increased thirst and frequent urination, weight loss, and extreme fatigue can be signs of diabetes, and an early diagnosis helps avoid the risk of DKA, which can be deadly. “Parents of children who had covid should be aware of the different signs and symptoms of diabetes, so they can make sure that they get the care that they need,” says Saydah.