FUDiabetes

First data on T1D and COVID-19

Seems like death rates are 3X that of non-diabetics. Some mitigation by HbA1C, but not a ton:

For younger people, death rates still seem low of course, but not as low as they would be if you don’t have T1D :frowning: Was really hoping by some magic that T1s were somehow special and exempt from the general trends of diabetics faring poorly

Obviously this data is not perfect.

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Am I reading this incorrectly?

A similar overall pattern of association was seen in people with Type 1 diabetes, but the raised risk was only statistically significant in those with an HbA1c ≥86 mmol/mol (HR 2·1995% CI 1·46-3·29) when compared to those with a HbA1c of 48-53 mmol/mol.

I am taking that as not being incredibly scary. An A1C of 86 mmol/mol is about 10.

Am I missing something?

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I don’t have time to read the whole paper, but all I could find in the paper was that the death rate of T1Ds with COVID exceeds 3 standard deviations from the normal death rate of T1Ds.

My understanding is that they calculated the risks within the cohort of T1Ds, so we still don’t know anything about the risks compared to the general population.

I am confused… this part seems like it’s saying three times as many deaths compared to nondiabetics:

“People with Type 1 diabetes have 3·5 (95% CI 3·15-3·89) times the odds,
and people with Type 2 diabetes 2·0 (9% CI 1·97-2·09) times the odds, of dying in hospital with COVID-19,
compared to the population without known diabetes, independent of age, sex, socioeconomic status and
ethnicity.”

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I guess I overlooked that. That doesn’t seem to come from their own data though, since they report that in the introduction. It must come from one of the sources cited in the sentence before or after.

I think you have to read the whole paragraph:

The degree of hyperglycaemia was strongly associated with risk of death related to COVID-19 after adjusting for other risk factors. For people with Type 2 diabetes, those with an HbA1c of 59-74 mmol/mol had a hazard ratio of 1·23 (95% CI 1·15 – 1·32) compared with people with an HbA1c of 48-53mmol/mol. In people with Type 2 diabetes and an HbA1c of ≥86mmol/mol the HR was 1·62 (95% CI 1·48-1·79). A similar overall pattern of association was seenin people with Type 1 diabetes, but the raised risk was only statisticallysignificant in those with an HbA1c ≥ 86 mmol/mol (HR 2·19 95% CI 1·46-3·29) when compared to those with a HbA1c of 48-53 mmol/mol. The hazard ratio in people with Type 2 diabetes and a low HbA1c ( <48mmol/mol) was 1·11 (95% CI 1·04 – 1·18) and a similar, but non-statistically significant risk was seen in the equivalent glycaemic control group in people with Type 1 diabetes (HR 1·22 95% CI 0·78 – 1·91).

So they’re comparing in this section the relative risk of dying among diabetics…so what they’re saying here is that on average, having a lower A1C was protective for T1Ds but that this effect only reached statistical significance when you compared people in the lowest A1C group with those in the highest A1C group, which means in essence that A1C is not as clearly protective in this group as it is in the T2s. That could be because A1C is less of a definitive factor for T1s, or it could be because fewer people died overall, so this group is sort of underpowered to see a difference.

But correct me if I am reading it wrong…

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I don’t read it the same way as you. I think they couldn’t determine a hazard ratio for the low A1c T1 group.

Also, what is confusing to me is that the question I would like to see answered is what is the relative risk of dying with T1 and a low A1c vs a age and sex matched control group without diabetes, which they don’t seem to have done, even though they have a nice large sample size to perform this analysis on.

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you think they couldn’t determine a hazard ratio because there were not enough people in that group to make the statistical analysis robust?

Obviously I would love to see that second question answered. Maybe they have to pay for certain subsets of data or something, and decided to just get data on T1s, without comparing it the overall UK population. But yes, this analysis leaves a lot to be desired. it’s also just written in a really confusing way I think.

I agree with you, this would be one of those talks to sit through at a conference and really enjoy the questions, because I think there are many that would get asked. It is confusing.

In the hopeful part of my brain, I am hoping that the risk of having a low A1c T1 is no more risky than being a non-diabetic, but the rational part of brain thinks this probably isn’t true.

Yeah, sadly my guess is that it’s at least a 1.5X increased risk. I’m acting like Samson has elevated risk compared to an average 6-year-old. So most likely he’d be fine if he contracted COVID-19, but I’m not taking chances…

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My son turned 17 this year, so we don’t get much input into his decision making at this point. He is quite independent and really smart. Fortunately for us, he has decided to take this seriously and has limited his circle to 3 close friends that are socially awkward, so his circle is small.

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Or that our confused autoimmune systems think the virus is a beta cell. :smiley:

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I suspect the average T1 out there probably has an A1C of 10+

Thus I take all this kind of data with a grain of salt. When they find a large cohort of people sub 6 to study I’ll pay attention. Comparing mortality diabetics with an A1C of 10+ is like comparing the mortality of stage 4 cancer patients to the general public

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That was true prior to BG testing and CGM, and DCCT results. I would guess 8-9 for T1s, possibly higher for T2s, both lower for folks active in diabetes forums !!

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Well I don’t really have any legitimate knowledge other than the ADA goal is < 8.0 and every doctor I’ve ever met or heard from has indicated that their patients and the diabetic population as a whole are nowhere near goal.

Had an opthomologist (who had two t1 children) tel me he’s impressed when he sees diabetics with a1c under 10

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Yeah, I don’t think the average adult with T1 has an A1c of 10% anymore. Even during the DCCT study of the '80s and '90s, the “conventional” group that didn’t do close monitoring or insulin adjustment based on carbohydrates or blood sugar trends and only took two injections a day had an A1c of 9% on average. Certainly some do have an A1c of 10% or more, but I definitely don’t think that’s average. I’d guess closer to 8%, myself.

The ADA goal has been <7.0% since at least the DCCT results came out in the mid-1990s, as far as I know. And it’s true that most people aren’t meeting that goal.

  • 6.4 A reasonable A1C goal for many nonpregnant adults is <7% (53 mmol/mol). A

Given that ophthalmologists often see patients referred for complications, I don’t think I would use one to judge what is average. It’s a bit sad to me that an ophthalmologist raising kids with T1 would be “impressed” with an A1c of under 10%! My ophthalmologist told me to “work on getting that A1c down” when mine spiked to 8.5% due to burnout several years ago.

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I wish there were more answers around almost everything having to do with this pandemic. I’m treating myself as high risk for sure. In fact, I have an appointment with my GP to talk about getting medical documentation to request accommodations for work, because the school system is starting to slowly re-open here (starting in June). It’s all very stressful trying to find the balance between being too overly paranoid and being too over confident. So far, I have not left my apartment building in weeks, and I feel like I need to find some strategies to function in the new reality. But I definitely do not feel safe just going back to normal activities, even with physical distancing and extra cleaning procedures in place and such.

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For some reason my phone isn’t letting me quote… but re average A1Cs—- of course this is all strictly anecdotal… but of the adults I’ve met with T1— the only ones with A1Cs below 8 I’ve personally met were 2 medical professionals with advanced degrees… including one who was a CDE. One of whom later drifted well above 8 while the other brought theirs into the 6’s after getting on a smart-pump.

Among other groups most have been 10+. Remarkably most of them have whipped themselves into better control over the last couple years.

Among parents with T1 children A1Cs have been mostly in the 6s

Not to imply that I know enough people for a representative scientific sample… but I’ve certainly formed my own impressions based on experience

No, that’s way higher than actual average A1c. No need to guess, there is lots of good data available, such as in this recent paper: State of Type 1 Diabetes Management and Outcomes from the T1D Exchange in 2016–2018. Here is how average A1c varies with age, well below 10%
figure2
Not 10, but not that great either. Disappointingly, the averages have not improved much from 2010-2012 to 2016-1018.

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