Crozet Annals of Medicine: Starving in the Midst of Plenty

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Working in a pediatric ER in the winter can be a challenging ordeal. Viruses circulate widely amongst indoors-bound children, and it seems like every treatment space is packed with coughing, sneezing, feverish, snotty, puking, pooping, blotchy miserable kids accompanied by parents who often look the same. It doesn’t help that during the pandemic some office-based practitioners are advising any such patients that this could be Covid so don’t come in to the office; go to the ER for a test.

But I like working on the pediatric side of our ER. Compared to our adult patients, most kids are generally healthy and recount their symptoms in a straightforward manner. They heal quickly and completely and never fight being discharged to go home. While 25% of our adult patients require a hospital admission and 25% of those go to an ICU, the vast majority of the kids go directly home, and rather quickly. This makes for a busy turnaround of the rooms but makes the day seem to pass swiftly. 

One group of kids, though, always requires hospital admission: kids with a first-time diagnosis of diabetes. This is a life-altering diagnosis, and the kids are usually pretty sick. We work hard on these kids, tailoring a complex treatment strategy while also tending to the parents’ (and our) emotional responses to this new reality. It is always a big deal and big news when we hear that one of these kids is being referred in by an outside pediatrician for our specialty care. Thankfully, it is a relatively rare occurrence. 

So, I was surprised on a recent pediatric shift to get three of these kids transferred in. And while they definitely had new-onset diabetes, none of them was very sick, or sick at all really. All had recently had Covid and none was vaccinated. 

I asked our endocrinologist if this was a Covid side effect and she just shrugged. 

Diabetes classically is broken down into two different types. Type 1 diabetes, previously referred to as juvenile-onset diabetes, is caused by a complete lack of insulin. Insulin is made by specialized cells in the pancreas gland, just adjacent to the liver. Insulin allows all cells in the body to take in glucose, the cells’ main energy source. Most often, a preceding otherwise harmless viral infection in a susceptible child seems to trigger the body’s own immune system to kill all the insulin producing cells in the pancreas. 

When that happens glucose can’t get into cells, so the level of glucose in the blood spikes up to critical levels. The kidneys compensate by flushing out the glucose, but in the process loses a lot of water. This is one of the hallmarks of diabetes, polyuria, or peeing a lot. 

As the body loses water it triggers the thirst receptors and another hallmark of diabetes occurs, polydipsia, or drinking a lot.

Because the cells aren’t getting enough fuel, the hunger hormones are triggered and the third poly, polyphagia, or eating a lot, becomes manifest. 

Finally, despite the high blood glucose level, the cells aren’t getting enough nutrition, and so dramatic weight losses are seen. We call this “starvation in the midst of plenty.”

To a certain extent, cells can be fueled by compounds other than glucose. There are three different molecules the liver can make by dissolving normal fatty acids that cells can scrape by on. These molecules (ketones) are acids and ultimately toxic to the body. This is how the new-onset diabetics get into trouble and come into the ER so sick. They are dehydrated, malnourished and above all profoundly acidotic. If they don’t get insulin and fluids they will die. They will require insulin for the rest of their lives. Without insulin, this “diabetic ketoacidosis” will once again threaten their lives. 

That is type 1 diabetes. It is still mostly a disease of children, but for unclear reasons some adults are now getting it. 

Type 2 diabetes, sometimes called adult-onset diabetes, is characterized by insulin resistance at the cellular membrane level. The body still produces some insulin, but the receptors on the cell wall don’t recognize it, and so blood glucose levels spike because it can’t get into the cells very well. Enough gets in however to prevent the acute, life-threatening diabetic ketoacidosis. 

Type 2 diabetes is closely associated with obesity, diet and activity level. Some genetic factors contribute as well. Long-term complications can be severe such as vision loss, kidney failure, heart attacks and amputations. While this has traditionally been a disease of adults, recently more children are acquiring it as pediatric lifestyle changes engender higher body mass and sedentary pursuits such as staring at screens. 

Covid has exacerbated this trend toward pediatric obesity. In a recent study of nearly half a million children age 2-19 years old, the rate of body mass index (BMI) increase doubled during the pandemic compared to the pre-pandemic period.  

As accustomed as I am to seeing Covid patients in the ED, now mostly in the unvaccinated, I was still unaccustomed to seeing three new onset diabetics in one shift, so I looked into it. 

There are two large studies of children under than 18 years old diagnosed with diabetes after getting Covid. One study of 80,000 kids showed a whopping 166% increase in new diabetes diagnoses after contracting Covid when compared to children without Covid. When comparing Covid-19 to other respiratory virus infections in the pre-pandemic era, the risk from Covid was 116% more diabetes diagnoses. The other study was even larger with over 400,000 kids, and it showed an increase risk of diabetes of 31% after contracting Covid compared to uninfected children. Similar results have been found in adults as well. 

It is too soon to know what this all means, which is probably why the endocrinologist just shrugged off my question. Certainly, my three Covid-related diabetics did not look like most other new-onset diabetics in that they were less sick. But if I were a parent of a kid 5 years old or older, I would surely get them vaccinated and boosted. And have them wear mask in school. And social distance. I am not talking about politics, and I am not talking about freedom, and I am not talking about mandates. I am talking about diabetes. And I am talking about children. 

Ask your pediatrician. 

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