Hospitalization Factors, Nutritional Recommendations, and Physiology Connecting COVID-19 and Diabetes

April 15, 2020

COVID-19 Testing, Hospital Admission, and Intensive Care Among 2,026,227 United States 2 Veterans Aged 54-75 Years

Retrospective review

Large dataset with more complete medical records from the US:

PREPRINT (has not been peer reviewed).  This study examined data on  over 2 million patients from the VA national Corporate Data Warehouse who were between the age of 54-75. Patients who were tested for COVID-19 from 2/8/2020 - 3/30/2020 were identified.  Other data collected on the patients who were tested were demographics, outpatient and inpatient encounters, diagnoses, laboratory results, vital signs, health factors (e.g., smoking and alcohol health behaviors), and pharmacy dispensing records.

A significant advantage of this study is the use of a large database where multiple health related factors could more easily be obtained (including medication prescriptions) than in other studies examining COVID-19 demographics and outcomes.

While COPD, diabetes, hypertension, kidney disease, vascular disease and exposure to ACE/ARB were associated with hospitalization and intensive care in unadjusted analyses, they were not significantly associated after adjusting for laboratory abnormalities and vital signs.

The most pronounced association was for patients with FIB-4>3.25 – adjusted OR 8.73 (95% CI 4.11-18.56) for hospitalization and 258 8.40 (95% CI 2.90-24.28) for intensive care – compared to those with FIB-4<1.45.

Black Veterans were twice as likely to be tested and 2.5 times as likely to test positive than non-black Veterans, even after adjusting for urban residence and conditioning on geographic location.  However black veterans were not more likely to require hospitalizations or ICU care.

Conclusion: Risk of hospitalization and intensive care associated with Covid-19 may be better characterized by vital signs and measures of physiologic injury than by comorbid conditions or medication history

Nutritional recommendations for COVID-19 quarantine

Commentary covering nutrition related concerns during home isolations.  Eating out of boredom, carbohydrate cravings, sleep disorders, stress eating, micronutrient sufficiency, and foods that may increase immunity reviewed.

PREPRINT (has not been peer reviewed) released last weekend

Factors associated with hospitalization and critical illness among 4,103 patients with COVID-19 disease in New York City

Retrospective review

PREPRINT (has not been peer reviewed) released last weekend

Large study from the United States examining factors leading to poor outcomes.  Data was collected from the NYU Lagone Health System (126 clinics and 4 acute care hospitals) from March 1, 2020 and ending on April 2, 2020 with follow up completed through April 7, 2020.  Participants had a confirmed positive test for COVID-19.  Primary outcomes were in patient hospitalization and critical illness.

The median age of the Covid-19 positive study population was 52 years (interquartile range, 36 to 65), and 2,072 (50.5%) were male. A total of 614 (15.0%) had diabetes, 1,100 (26.8%) obesity, and 1,235 (30.1%) cardiovascular disease. **Note 15% is consistent with the estimated rate of diabetes in NYC and obesity rates in NYC are estimated to be about 22%.  

Hospitalized patients were more likely to be male (62.6% vs 39.0%) and had substantially more comorbidities than non-hospitalized patients, particularly with regard to cardiovascular disease (44.6% vs. 16.4%), diabetes (31.8% vs 5.4%) and obesity (39.8% vs. 14.5%) 

Results overall were consistent with most of the numbers from China.  Age was the risk factor most strongly associated with hospitalization.  Early elevations in CRP and d-dimer had the strongest association with the need for mechanical ventilation and death. Obesity was the chronic condition that had the strongest association with poor outcomes.

Conclusion: Overall, we find that age and comorbidities are powerful predictors of requiring hospitalization rather than outpatient care; however, degree of oxygen impairment and markers of inflammation are strongest predictors of poor outcomes during hospitalization. Clinicians should consider routinely obtaining inflammatory markers during hospitalizations for Covid-19. 

Coronavirus infections and type 2 diabetes - shared pathways with therapeutic implications

Review Paper

This is a review paper on the physiology connecting diabetes and COVID-19 that might be responsible for the increase in poor outcomes after COVID-19 infection for people who suffer from diabetes.

Data from other Corona and influenza outbreaks and diabetes was reviewed. Consistent with early data from the current COVID-19 pandemic, diabetes and obesity have been a risk factor for poor outcomes in past viral outbreaks.

The physiology of ACE2 and DPP4 in relation to both diabetes and potentially as a factor in COVID-19 infection is reviewed in detail. There has been no association with use of DPP4 inhibitors and increased viral infections or immunity in multiple studies.   

Overall recommendations for a number of diabetes medications are that their use and or dose should only be altered in severe COVID-19 disease for reasons that would be considered with any severe acute illness (dehydration, acute renal or liver failure, etc).