Characteristics and care of young people with type 2 diabetes included in the national diabetes audit datasets for England.

INTRODUCTION: We report contemporary age-related prevalence, characteristics and care of children and young people with type 2 diabetes in England. METHODS: Individuals with a recorded diagnosis of type 2 diabetes between January 2019 and March 2020 were identified from a whole population register. Age, sex, ethnicity, deprivation quintile, weight, HbA1c and receipt of the nine National Institute for Health & Care Excellence (NICE) recommended annual care processes were extracted from electronic clinical records and analysed by pre-specified age bands. RESULTS: In total, 122,780 (4.6%) of 2,642,435 individuals in England with type 2 diabetes were aged under 40 years, comprising; 650 (0.5%) under 16 years, 910 (0.7%) aged 16-18 years, 8245 (6.7%) aged 19-25 and 112,975 (92%) aged 26-39 years. Compared to people with type 2 diabetes aged above 40 years, young people were significantly more likely to be from minority ethnic groups: 51% under 16 years, 41% 16-18 years, 38% 19-25 years, 38% 26-39 years, 27% 40-59 years and 15% 60-79 years were of Black or Asian ethnicity. In addition, those aged under 40 years were more likely to be obese, women, to live in the most-deprived socioeconomic areas and less likely to receive the NICE recommended annual care processes or achieve target HbA1c . INTERPRETATION: The substantial number of people under 40 years of age with type 2 diabetes, are more likely to have characteristics associated with inequalities and are less likely to achieve HbA1c targets and receive recommended care processes. These findings highlight the need to consider novel approaches to service provision for this high-risk group.

Effectiveness of digital and remote provision of the Healthier You: NHS Diabetes Prevention Programme during the COVID-19 pandemic.

AIMS: To assess weight change in the Healthier You: NHS Diabetes Prevention Programme (NHS DPP) delivered via video conferencing (remote) sessions or delivered via specific digital interventions through apps or websites, during the COVID-19 pandemic compared to group-based face-to-face interventions, pre-pandemic. METHODS: Prospectively collected national service-level data relating to individuals with non-diabetic hyperglycaemia (HbA1c 42-47 mmol/mol (6.0%-6.4%) or fasting plasma glucose 5.5-6.9 mmol/L) referred to the NHS DPP from June 2016 to March 2022. RESULTS: Between March 2020 and March 2022, 335,961 people were referred to the programme and were offered a choice of remote or digital intervention. This was preceded by 556,793 people referred to the face-to-face programme between June 2016 and February 2022. Uptakes to intervention sessions were 47% for those offered a choice and 39% for face-to-face. Remote and digital participants were significantly younger (60 and 56 vs. 65 years) and heavier (86.1 kg and 91.0 kg vs. 84.1 kg) compared to face-to-face. Weight change was assessed for 42,407 remote, 7699 digital and 97,205 face-to-face participants with sufficient time to have finished the programme and no missing data. Mean weight losses for participants attending at least one intervention session were: 2.40 (2.36-2.44) kg, 2.59 (2.49-2.68) kg and 2.01 (1.98-2.04) kg for remote, digital and face-to-face participants respectively. Corresponding mean weight losses for those who completed the programme were: 3.24 (3.19-3.30) kg, 4.76 (4.60-4.92) kg and 3.04 (3.00-3.07) kg. There were no significant differences in weight change between interventions by ethnicity and deprivation. CONCLUSIONS: Weight losses achieved through remote and digital interventions were greater than those previously achieved through face-to-face interventions, without evidence of exacerbation of health inequalities.

The effectiveness of digital delivery versus group-based face-to-face delivery of the English National Health Service Type 2 Diabetes Prevention Programme: a non-inferiority retrospective cohort comparison study.

BACKGROUND: Face-to-face group-based diabetes prevention programmes have been shown to be effective in many settings. Digital delivery may suit some patients, but research comparing the effectiveness of digital with face-to-face delivery is scarce. The aim was to assess if digital delivery of the English National Health Service Diabetes Prevention Programme (NHS DPP) is non-inferior to group-based face-to-face delivery in terms of weight change, and evaluate factors associated with differential change. METHODS: The study included those recruited to the NHS DPP in 2017-2018. Individual-level data from a face-to-face cohort was compared to two cohorts on a digital pilot who (i) were offered no choice of delivery mode, or (ii) chose digital over face-to-face. Changes in weight at 6 and 12 months were analysed using mixed effects linear regression, having matched participants from the digital pilot to similar participants from face-to-face. RESULTS: Weight change on the digital pilot was non-inferior to face-to-face at both time points: it was similar in the comparison of those with no choice (difference in weight change: -0.284 kg [95% CI: -0.712, 0.144] at 6 months) and greater in digital when participants were offered a choice (-1.165 kg [95% CI: -1.841, -0.489]). Interactions between delivery mode and sex, ethnicity, age and deprivation were observed. CONCLUSIONS: Digital delivery of the NHS DPP achieved weight loss at least as good as face-to-face. Patients who were offered a choice and opted for digital experienced better weight loss, compared to patients offered face-to-face only.

Developing services to support the delivery of care to people with early-onset type 2 diabetes.

Early-onset type 2 diabetes occurring in childhood or early adulthood carries a significant excess burden of microvascular diabetes complications, cardiovascular disease and premature death, compared to later onset type 2 diabetes along with adverse pregnancy outcomes in women of child-bearing age. National audit data in England reveal that 122,780 individuals under the age of 40 years are currently living with type 2 diabetes, with an over-representation of people from minority ethnicities and those in the most socioeconomically deprived quintiles. A diagnosis of type 2 diabetes earlier in life poses some unique challenges to healthcare providers that are not routinely encountered when type 2 diabetes presents later. These include; (1) the need to ensure correct diabetes classification in an age group that carries a higher probability of other types of diabetes, (2) overcoming difficulties in engaging with individuals who are of working age or in full-time education, (3) appreciating and addressing the lower attainment of diabetes treatment targets and (4) proactively supporting women of child-bearing age to optimise their future pregnancy outcomes through better preparation for pregnancy, including achieving optimum glycaemic control at the time of conception. Meanwhile, approaches to prevent type 2 diabetes in younger age groups are challenged by difficulties in identifying those at highest risk, by poorer attendance at lifestyle interventions to prevent or delay the onset of type 2 diabetes and by attenuation of associated weight loss in those that do attend. In this article, we discuss the importance of recognising and addressing the distinct challenges in delivering healthcare to those with early-onset type 2 diabetes, the greater challenges in preventing type 2 diabetes at younger ages, and key components of strategies that might address these challenges to drive improvements in pregnancy outcomes, microvascular and cardiovascular outcomes.

Prediabetes, participation in the English National Health Service Diabetes Prevention Programme, and associations with COVID-19-related mortality: A whole population study.

AIMS: To assess the effects of non-diabetic hyperglycaemia (NDH, also known as pre-diabetes), including the impact of the NHS Diabetes Prevention Programme (NHS DPP), on COVID-19-related mortality during the pandemic. METHODS: This study included all 61,438,225 individuals registered with General Practices in England and alive on 1st March 2020. We assessed COVID-19-related mortality in the 2,290,280(3.7 %) individuals with diagnosed NDH between March 2020 and February 2022 compared to those without diagnosed NDH or diabetes using Cox regression to adjust for demographic factors and cardiovascular comorbidities. Individuals with diagnosed NDH were further sub-categorised based on their contact with the NHS DPP (N = 376,590). Analyses were stratified by age (years) (<50, 50-69 and ≥ 70). RESULTS: There were 158,070 COVID-19 deaths; 17,280(11 %) for people with diagnosed NDH. The adjusted hazard ratio (HR) was 0.95(0.93-0.96),p < 0.001 for those with diagnosed NDH compared to those without diagnosed diabetes or NDH. By age (years), HRs were, 2.53(2.23-2.88),p < 0.001 for < 50, 1.29(1.24-1.35),p < 0.001 for 50-69 and 0.87(0.85-0.89),p < 0.001 for ≥ 70. NHS DPP attendance was associated with lower COVID-19 mortality with a dose-response relationship with engagement. CONCLUSIONS: Younger people with diagnosed NDH were at higher relative risk of COVID-19 mortality. Attendance at the NHS DPP was associated with significantly lower COVID-19-related mortality.

Early outcomes of referrals to the English National Health Service Digital Weight Management Programme.

OBJECTIVE: The study objective was to assess participant weight change for the English National Health Service (NHS) Digital Weight Management Programme, the first such digital intervention to achieve population coverage. METHODS: A service evaluation was used to assess intervention effectiveness for adults with obesity and a diagnosis of hypertension and/or diabetes, between April 2021 and March 2022, using prospectively collected, national service-level data in England. RESULTS: Of the 63,937 referrals made from general practices, within the time period, 31,861 (50%) chose to take up the 12-week Programme. There were 31,718 participants who had time to finish the Programme; of those, 14,268 completed the Programme (defined as attending ≥60%), a 45% completion rate. The mean weight change for those who had time to finish the Programme was -2.2 kg (95% CI: -2.25 to -2.16), for those who completed it was -3.9 kg (95% CI: -3.99 to -3.84), and for those who had time to finish the Programme but did not complete it was -0.74 kg (95% CI: -0.79 to -0.70). CONCLUSIONS: The NHS Digital Weight Management Programme is effective at achieving clinically meaningful weight loss. The outcomes compare favorably to web-based weight management interventions tested in randomized trials and those delivered as face-to-face interventions, and results suggest that the approach may, with increased participation, bring population-level benefits.

Indirect effects of the COVID-19 pandemic on diagnosing, monitoring, and prescribing in people with diabetes and strategies for diabetes service recovery internationally.

The COVID-19 pandemic has caused major disruptions in clinical services for people with chronic long-term conditions. In this narrative review, we assess the indirect impacts of the COVID-19 pandemic on diabetes services globally and the resulting adverse effects on rates of diagnosing, monitoring, and prescribing in people with type 2 diabetes. We summarise potential practical approaches that could address these issues and improve clinical services and outcomes for people living with diabetes during the recovery phase of the pandemic.

Comparison of weight change between face-to-face and digital delivery of the English National Health service diabetes prevention programme: An exploratory non-inferiority study with imputation of plausible weight outcomes.

Worldwide evidence suggests face-to-face diabetes prevention programmes are effective in preventing and delaying the onset of type 2 diabetes by encouraging behaviour change towards weight loss, healthy eating, and increased exercise. There is an absence of evidence on whether digital delivery is as effective as face-to-face. During 2017-18 patients in England were offered the National Health Service Diabetes Prevention Programme as group-based face-to-face delivery, digital delivery ('digital-only') or a choice between digital and face-to-face ('digital-choice'). The contemporaneous delivery allowed for a robust non-inferiority study, comparing face-to-face with digital only and digital choice cohorts. Changes in weight at 6 months were missing for around half of participants. Here we take a novel approach, estimating the average effect in all 65,741 individuals who enrolled in the programme, by making a range of plausible assumptions about weight change in individuals who did not provide outcome data. The benefit of this approach is that it includes everyone who enrolled in the programme, not restricted to those who completed. We analysed the data using multiple linear regression models. Under all scenarios explored, enrolment in the digital diabetes prevention programme was associated with clinically significant reductions in weight which were at least equivalent to weight loss in the face-to-face programme. Digital services can be just as effective as face-to-face in delivering a population-based approach to the prevention of type 2 diabetes. Imputation of plausible outcomes is a feasible methodological approach, suitable for analysis of routine data in settings where outcomes are missing for non-attenders.

Comparative Incidence of Diabetes Following Hospital Admission for COVID-19 and Pneumonia: A Cohort Study.

OBJECTIVE: The incidence of diabetes may be elevated following coronavirus disease 2019 (COVID-19), but it is unclear whether this is specific to severe acute respiratory syndrome coronavirus 2 infection, associated with shared risk factors for severe COVID-19 and diabetes, and/or a generic risk following illness. RESEARCH DESIGN AND METHODS: People admitted to the hospital for COVID-19 and/or pneumonia between 1 April 2020 and 31 August 2020 in England were linked with the National Diabetes Audit to identify incident diabetes after discharge up to 31 March 2021. Comparator cohorts admitted with pneumonia over the same dates in 2017, 2018, and 2019 were followed until 31 March 2018, 31 March 2019, and 31 March 2020, respectively. Poisson regression models were used to calculate adjusted diabetes incidence rates. RESULTS: Using the cohort of people discharged from the hospital following a diagnosis of COVID-19 without pneumonia in 2020 as the standard population (incidence rate 16.4 [95% CI 12.8-20.7] per 1,000 person-years), adjusting for age, sex, ethnicity, and deprivation, gave incidence rates of 19.0 (95% CI 13.8-25.6) and 16.6 (95% CI 13.3-20.4) per 1,000 person-years for those admitted for COVID-19 with pneumonia and pneumonia without COVID-19, respectively, in 2020. These rates are not significantly different from those found after hospital admission for pneumonia in 2019, 2018, and 2017, at 13.7 (95% CI 10.8-17.3), 13.8 (95% CI 10.9-17.4), and 14.2 (95% CI 10.9-18.3) per 1,000 person-years, respectively. CONCLUSIONS: Our data do not support a clear impact of COVID-19 on the incidence of diabetes compared with risks in several comparator groups, including contemporaneously assessed risks in people hospitalized with pneumonia.

Association between the month of starting a weight management program and weight change in people at high risk of type 2 diabetes: A prospective cohort study.

OBJECTIVE: Weight loss is one of the most common New Year's resolutions, but it is unclear whether attempting to lose weight in January is more successful than attempting it at other times of the year. METHODS: In this prospective cohort study from the English National Health Service (NHS) Diabetes Prevention Program, adults with nondiabetic hyperglycemia were enrolled in a structured behavioral weight management program. Repeated measures models assessed the mean difference between baseline and follow-up weight adjusting for monthly variation in weight among those with ≥1 weight measurement. RESULTS: Among 85,514 participants with a mean baseline BMI of 30.3 kg/m2 (range: 13.4 to 84.2), mean weight change at the end of the program after an average 7.9 (SD: 4.5) sessions over 6.4 (SD: 5.6) months was -2.00 kg (95% CI: -2.02 to -1.97 kg) or -2.33% (95% CI: -2.35% to -2.32%). Compared with participants starting in January, participants starting in other months lost less weight, ranging between 0.28 kg (95% CI: 0.10 to 0.45 kg) less weight in those starting in March and 0.71 kg (95% CI: 0.55 to 0.87 kg) less weight in those starting in November. April and May were the only exceptions, in which the estimates followed the same direction but were not statistically significant. Higher session attendance mediated the effects, with participants starting in January attending, on average, 0.2 to 0.7 more sessions than those starting in other months. CONCLUSIONS: People starting a weight management program in January lost 12% to 30% more weight than people starting it at other times of the year.

Prevalence of multiple long-term conditions (multimorbidity) in England: a whole population study of over 60 million people.

OBJECTIVES: To determine the prevalence of multiple long-term conditions (MLTC) at whole English population level, stratifying by age, sex, socioeconomic status and ethnicity. DESIGN: A whole population study. SETTING: Individuals registered with a general practice in England and alive on 31 March 2020. PARTICIPANTS: 60,004,883 individuals. MAIN OUTCOME MEASURES: MLTC prevalence, defined as two or more of 35 conditions derived from a number of national patient-level datasets. Multivariable logistic regression was used to assess the independent associations of age, sex, ethnicity and deprivation decile with odds of MLTC. RESULTS: The overall prevalence of MLTC was 14.8% (8,878,231), varying from 0.9% (125,159) in those aged 0-19 years to 68.2% (1,905,979) in those aged 80 years and over. In multivariable regression analyses, compared with the 50-59 reference group, the odds ratio was 0.04 (95% confidence interval (CI): 0.04-0.04; p < 0.001) for those aged 0-19 years and 10.21 (10.18-10.24; p < 0.001) for those aged 80 years and over. Odds were higher for men compared with women, 1.02 (1.02-1.02; p < 0.001), for the most deprived decile compared with the least deprived, 2.26 (2.25-2.27; p < 0.001), and for Asian ethnicity compared with those of white ethnicity, 1.05 (1.04-1.05; p < 0.001). Odds were lower for black, mixed and other ethnicities (0.94 (0.94-0.95) p < 0.001, 0.87 (0.87-0.88) p < 0.001 and 0.57 (0.56-0.57) p < 0.001, respectively). MLTC for persons aged 0-19 years were dominated by asthma, autism and epilepsy, for persons aged 20-49 years by depression and asthma, for persons aged 50-59 years by hypertension and depression and for those aged 60 years and older, by cardiometabolic factors and osteoarthritis. There were large numbers of combinations of conditions in each age group ranging from 5936 in those aged 0-19 years to 205,534 in those aged 80 years and over. CONCLUSIONS: While this study provides useful insight into the burden across the English population to assist health service delivery planning, the heterogeneity of MLTC presents challenges for delivery optimisation.

Associations between reductions in routine care delivery and non-COVID-19-related mortality in people with diabetes in England during the COVID-19 pandemic: a population-based parallel cohort study.

BACKGROUND: The Office for Health Improvement and Disparities, part of the UK Government Department of Health and Social Care, highlighted an emerging signal of increased non-COVID-19-related deaths in England between July and October, 2021, with a potentially disproportionate higher increase in people with diabetes. We aimed to substantiate and quantify this apparent excess mortality, and to investigate the association between diabetes routine care delivery and non-COVID-19-related-mortality in people with diabetes before and after the onset of the pandemic. METHODS: In this population-based parallel cohort study, we used the National Diabetes Audit (NDA) to identify people with diabetes in England. The primary outcome was non-COVID-19-related deaths between July 3, 2021, and Oct 15, 2021, in participants in the 2021 COVID-19 cohort (registered in the NDA in the periods Jan 1, 2019, to March 31, 2020, and Jan 1, 2020, to March 31, 2021) compared with deaths between June 29, 2019, and Oct 11, 2019 (the equivalent 15-week period in 2019) in the 2019 pre-COVID-19 comparator cohort (people registered in the NDA in the periods Jan 1, 2017, to March 31, 2018, and Jan 1, 2018 to March 31, 2019). In each cohort, multivariable logistic regression examined whether completion of eight diabetes care processes in each of the two years before the index mortality year was associated with non-COVID-19-related death, adjusting for diabetes type, age, sex, ethnicity, and socioeconomic deprivation. FINDINGS: There were 3 218 570 people in the 2021 cohort and 2 973 645 people in the 2019 comparator cohort. In the 2021 cohort, there were 30 118 non-COVID-19-related deaths in people with diabetes, compared with 27 132 in the comparator cohort, representing an 11% increase (95% CI 9-13). The unadjusted incidence rate ratio (IRR) for mortality in the 2021 cohort compared to the 2019 cohort was 1·026 (1·009-1·043; p=0·003), which was unchanged after adjustment for age, sex, ethnicity, socioeconomic deprivation, and diabetes type (IRR 1·023 (1·006-1·040); p=0·007). In the 2021 cohort, 853 660 (26·5%) people received all eight care processes in 2020-21 compared with 1 547 240 (48·1%) people in 2019-20; a 44·8% (95% CI 44·7-45·0) relative reduction. In the pre-COVID-19 comparator cohort, 1 370 315 (46·1%) people with diabetes received all eight care processes in 2018-19 compared with 1 437 740 (48·3%) in 2017-18; a 4·7% (95% CI 4·5-4·9) relative decrease. Non-COVID-19-related mortality in the 2021 cohort was highest in people who did not receive all eight care processes in either of the two previous years (OR 2·67 [95% CI 2·56-2·77]; p<0·001) compared with those who received all eight care processes in both previous years. Mortality was also significantly higher in those who received all eight care processes in 2019-20 but not in 2020-21 (OR 1·66 [95% CI 1·59-1·73]; p<0·001) or not in 2019-20 but in 2020-21 (OR 1·27 [1·20-1·35]; p<0·001). This pattern of association was similar in the 2019 pre-COVID-19 cohort. INTERPRETATION: Our results show an increased risk of mortality in those who did not receive all eight care processes in one or both of the previous two years. Our results provide evidence that the increased rate of non-COVID-19-related mortality in people with diabetes in England observed between July 3, and Oct 15 of 2021 is associated with a reduction in completion of routine diabetes care processes following the pandemic onset in 2020. FUNDING: None.

Uptake and impact of the English National Health Service digital diabetes prevention programme: observational study.

INTRODUCTION: 'Healthier You', the National Health Service (NHS) diabetes prevention programme (DPP) offers adults in England at high risk of type 2 diabetes (T2DM) an evidence-based behavioral intervention to prevent or delay T2DM onset. This study assesses the impact of a pilot digital stream of the DPP (DDPP) on glycated hemoglobin (HbA1c) and weight. RESEARCH DESIGN AND METHODS: A service evaluation employing prospectively collected data in a prospective cohort design in nine NHS local pilot areas across England. Participants were adults with non-diabetic hyperglycemia (NDH) (HbA1c 42-47 mmol/mol or fasting plasma glucose 5.5-6.9 mmol/L) in the 12 months prior to referral. The DDPP comprised five digital health interventions (DHI). Joint primary outcomes were changes in HbA1c and weight between baseline and 12 months. HbA1c and weight readings were recorded at referral (baseline) by general practices, and then at 12-month postregistration. Demographic data and service variables were collected from the DHI providers. RESULTS: 3623 participants with NDH registered for the DDPP and of these, 2734 (75%) were eligible for inclusion in the analyses. Final (12-month) follow-up data for HbA1c were available for 1799 (50%) and for weight 1817 (50%) of registered participants. Mean change at 12 months was -3.1 (-3.4 to -2.8) kg, p<0.001 for weight and -1.6 (-1.8 to -1.4) mmol/mol, p<0.001 for HbA1c. Access to peer support and a website and telephone service was associated with significantly greater reductions in HbA1c and weight. CONCLUSIONS: Participation in the DDPP was associated with clinically significant reductions in weight and HbA1c. Digital diabetes prevention can be an effective and wide-reaching component of a population-based approach to addressing type 2 diabetes prevention.

Temporal trends in emergency admissions for diabetic ketoacidosis in people with diabetes in England before and during the COVID-19 pandemic: a population-based study.

BACKGROUND: Diabetic ketoacidosis (DKA) has been reported to be increasing in frequency during the COVID-19 pandemic. We aimed to examine the rates of DKA hospital admissions and the patient demographics associated with DKA during the pandemic compared with in prepandemic years. METHODS: Using a comprehensive, multiethnic, national dataset, the Secondary Uses Service repository, we extracted all emergency hospital admissions in England coded with DKA from March 1 to June 30, 2020 (first wave of the pandemic), July 1 to Oct 31, 2020 (post-first wave), and Nov 1, 2020, to Feb 28, 2021 (second wave), and compared these with DKA admissions in the equivalent periods in 2017-20. We also examined baseline characteristics, mortality, and trends in patients who were admitted with DKA. FINDINGS: There were 8553 admissions coded with DKA during the first wave, 8729 during the post-first wave, and 10 235 during the second wave. Compared with preceding years, DKA admissions were 6% (95% CI 4-9; p<0·0001) higher in the first wave of the pandemic (from n=8048), 6% (3-8; p<0·0001) higher in the post-first wave (from n=8260), and 7% (4-9; p<0·0001) higher in the second wave (from n=9610). In the first wave, DKA admissions reduced by 19% (95% CI 16-21) in those with pre-existing type 1 diabetes (from n=4965 to n=4041), increased by 41% (35-47) in those with pre-existing type 2 diabetes (from n=2010 to n=2831), and increased by 57% (48-66) in those with newly diagnosed diabetes (from n=1072 to n=1681). Compared with prepandemic, type 2 diabetes DKA admissions were similarly common in older individuals and men but were higher in those of non-White ethnicities during the first wave. The increase in newly diagnosed DKA admissions occurred across all age groups and these were significantly increased in men and people of non-White ethnicities. In the post-first wave, DKA admissions did not return to the baseline level of previous years; DKA admissions were 14% (11-17) lower in patients with type 1 diabetes (from n=5208 prepandemic to n=4491), 30% (24-36) higher in patients with type 2 diabetes (from n=2011 to n=2613), and 56% (47-66) higher in patients with newly diagnosed diabetes (from n=1041 to n=1625). During the second wave, DKA admissions were 25% (22-27) lower in patients with type 1 diabetes (from n=5769 prepandemic to n=4337), 50% (44-56) higher in patients with type 2 diabetes (from n=2608 to n=3912), and 61% (52-70) higher in patients with newly diagnosed diabetes (from n=1234 to n=1986). INTERPRETATION: Our results provide evidence for differences in the numbers and characteristics of people presenting with DKA during the COVID-19 pandemic compared with in the preceding 3 years. Greater awareness of risk factors for DKA in type 2 diabetes and vigilance for newly diagnosed diabetes presenting with DKA during the COVID-19 pandemic might help mitigate the increased impact of DKA. FUNDING: None.

Prescription of glucose-lowering therapies and risk of COVID-19 mortality in people with type 2 diabetes: a nationwide observational study in England.

BACKGROUND: In patients with type 2 diabetes, hyperglycaemia is an independent risk factor for COVID-19-related mortality. Associations between pre-infection prescription for glucose-lowering drugs and COVID-19-related mortality in people with type 2 diabetes have been postulated but only investigated in small studies and limited to a few agents. We investigated whether there are associations between prescription of different classes of glucose-lowering drugs and risk of COVID-19-related mortality in people with type 2 diabetes. METHODS: This was a nationwide observational cohort study done with data from the National Diabetes Audit for people with type 2 diabetes and registered with a general practice in England since 2003. Cox regression was used to estimate the hazard ratio (HR) of COVID-19-related mortality in people prescribed each class of glucose-lowering drug, with covariate adjustment with a propensity score to address confounding by demographic, socioeconomic, and clinical factors. FINDINGS: Among the 2 851 465 people with type 2 diabetes included in our analyses, 13 479 (0·5%) COVID-19-related deaths occurred during the study period (Feb 16 to Aug 31, 2020), corresponding to a rate of 8·9 per 1000 person-years (95% CI 8·7-9·0). The adjusted HR associated with recorded versus no recorded prescription was 0·77 (95% CI 0·73-0·81) for metformin and 1·42 (1·35-1·49) for insulin. Adjusted HRs for prescription of other individual classes of glucose-lowering treatment were as follows: 0·75 (0·48-1·17) for meglitinides, 0·82 (0·74-0·91) for SGLT2 inhibitors, 0·94 (0·82-1·07) for thiazolidinediones, 0·94 (0·89-0·99) for sulfonylureas, 0·94 (0·83-1·07) for GLP-1 receptor agonists, 1·07 (1·01-1·13) for DPP-4 inhibitors, and 1·26 (0·76-2·09) for α-glucosidase inhibitors. INTERPRETATION: Our results provide evidence of associations between prescription of some glucose-lowering drugs and COVID-19-related mortality, although the differences in risk are small and these findings are likely to be due to confounding by indication, in view of the use of different drug classes at different stages of type 2 diabetes disease progression. In the context of the COVID-19 pandemic, there is no clear indication to change prescribing of glucose-lowering drugs in people with type 2 diabetes. FUNDING: None.

Risk factors for COVID-19-related mortality in people with type 1 and type 2 diabetes in England: a population-based cohort study.

BACKGROUND: Diabetes has been associated with increased COVID-19-related mortality, but the association between modifiable risk factors, including hyperglycaemia and obesity, and COVID-19-related mortality among people with diabetes is unclear. We assessed associations between risk factors and COVID-19-related mortality in people with type 1 and type 2 diabetes. METHODS: We did a population-based cohort study of people with diagnosed diabetes who were registered with a general practice in England. National population data on people with type 1 and type 2 diabetes collated by the National Diabetes Audit were linked to mortality records collated by the Office for National Statistics from Jan 2, 2017, to May 11, 2020. We identified the weekly number of deaths in people with type 1 and type 2 diabetes during the first 19 weeks of 2020 and calculated the percentage change from the mean number of deaths for the corresponding weeks in 2017, 2018, and 2019. The associations between risk factors (including sex, age, ethnicity, socioeconomic deprivation, HbA1c, renal impairment [from estimated glomerular filtration rate (eGFR)], BMI, tobacco smoking status, and cardiovascular comorbidities) and COVID-19-related mortality (defined as International Classification of Diseases, version 10, code U07.1 or U07.2 as a primary or secondary cause of death) between Feb 16 and May 11, 2020, were investigated by use of Cox proportional hazards models. FINDINGS: Weekly death registrations in the first 19 weeks of 2020 exceeded the corresponding 3-year weekly averages for 2017-19 by 672 (50·9%) in people with type 1 diabetes and 16 071 (64·3%) in people with type 2 diabetes. Between Feb 16 and May 11, 2020, among 264 390 people with type 1 diabetes and 2 874 020 people with type 2 diabetes, 1604 people with type 1 diabetes and 36 291 people with type 2 diabetes died from all causes. Of these total deaths, 464 in people with type 1 diabetes and 10 525 in people with type 2 diabetes were defined as COVID-19 related, of which 289 (62·3%) and 5833 (55·4%), respectively, occurred in people with a history of cardiovascular disease or with renal impairment (eGFR <60 mL/min per 1·73 m2). Male sex, older age, renal impairment, non-white ethnicity, socioeconomic deprivation, and previous stroke and heart failure were associated with increased COVID-19-related mortality in both type 1 and type 2 diabetes. Compared with people with an HbA1c of 48-53 mmol/mol (6·5-7·0%), people with an HbA1c of 86 mmol/mol (10·0%) or higher had increased COVID-19-related mortality (hazard ratio [HR] 2·23 [95% CI 1·50-3·30, p<0·0001] in type 1 diabetes and 1·61 [1·47-1·77, p<0·0001] in type 2 diabetes). In addition, in people with type 2 diabetes, COVID-19-related mortality was significantly higher in those with an HbA1c of 59 mmol/mol (7·6%) or higher than in those with an HbA1c of 48-53 mmol/mol (HR 1·22 [95% CI 1·15-1·30, p<0·0001] for 59-74 mmol/mol [7·6-8·9%] and 1·36 [1·24-1·50, p<0·0001] for 75-85 mmol/mol [9·0-9·9%]). The association between BMI and COVID-19-related mortality was U-shaped: in type 1 diabetes, compared with a BMI of 25·0-29·9 kg/m2, a BMI of less than 20·0 kg/m2 had an HR of 2·45 (95% CI 1·60-3·75, p<0·0001) and a BMI of 40·0 kg/m2 or higher had an HR of 2·33 (1·53-3·56, p<0·0001); the corresponding HRs for type 2 diabetes were 2·33 (2·11-2·56, p<0·0001) and 1·60 (1·47-1·75, p<0·0001). INTERPRETATION: Deaths in people with type 1 and type 2 diabetes rose sharply during the initial COVID-19 pandemic in England. Increased COVID-19-related mortality was associated not only with cardiovascular and renal complications of diabetes but, independently, also with glycaemic control and BMI. FUNDING: None.

Associations of type 1 and type 2 diabetes with COVID-19-related mortality in England: a whole-population study.

BACKGROUND: Although diabetes has been associated with COVID-19-related mortality, the absolute and relative risks for type 1 and type 2 diabetes are unknown. We assessed the independent effects of diabetes status, by type, on in-hospital death in England in patients with COVID-19 during the period from March 1 to May 11, 2020. METHODS: We did a whole-population study assessing risks of in-hospital death with COVID-19 between March 1 and May 11, 2020. We included all individuals registered with a general practice in England who were alive on Feb 16, 2020. We used multivariable logistic regression to examine the effect of diabetes status, by type, on in-hospital death with COVID-19, adjusting for demographic factors and cardiovascular comorbidities. Because of the absence of data on total numbers of people infected with COVID-19 during the observation period, we calculated mortality rates for the population as a whole, rather than the population who were infected. FINDINGS: Of the 61 414 470 individuals who were alive and registered with a general practice on Feb 16, 2020, 263 830 (0·4%) had a recorded diagnosis of type 1 diabetes, 2 864 670 (4·7%) had a diagnosis of type 2 diabetes, 41 750 (0·1%) had other types of diabetes, and 58 244 220 (94·8%) had no diabetes. 23 698 in-hospital COVID-19-related deaths occurred during the study period. A third occurred in people with diabetes: 7434 (31·4%) in people with type 2 diabetes, 364 (1·5%) in those with type 1 diabetes, and 69 (0·3%) in people with other types of diabetes. Unadjusted mortality rates per 100 000 people over the 72-day period were 27 (95% CI 27-28) for those without diabetes, 138 (124-153) for those with type 1 diabetes, and 260 (254-265) for those with type 2 diabetes. Adjusted for age, sex, deprivation, ethnicity, and geographical region, compared with people without diabetes, the odds ratios (ORs) for in-hospital COVID-19-related death were 3·51 (95% CI 3·16-3·90) in people with type 1 diabetes and 2·03 (1·97-2·09) in people with type 2 diabetes. These effects were attenuated to ORs of 2·86 (2·58-3·18) for type 1 diabetes and 1·80 (1·75-1·86) for type 2 diabetes when also adjusted for previous hospital admissions with coronary heart disease, cerebrovascular disease, or heart failure. INTERPRETATION: The results of this nationwide analysis in England show that type 1 and type 2 diabetes were both independently associated with a significant increased odds of in-hospital death with COVID-19. FUNDING: None.