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boy checking his blood glucose

There’s still more to learn about COVID-19 and diabetes

boy checking his blood glucose

Researchers have learned a lot about COVID-19 over the past year and are continuing to learn and study more about this infection caused by the SARS-CoV-2 virus. There have been many questions about whether COVID-19 affects people with diabetes differently than those without and why this might occur.

Diabetes experts, like Brynn Marks, M.D., M.S.H.P.Ed., endocrinologist at Children’s National Hospital, have been studying the relationship between COVID-19 and diabetes, especially in the pediatric population. Dr. Marks tells us more about what we know so far and further research that needs to be done when it comes to COVID-19 and diabetes.

1.      What do we know about COVID-19 and its effect on people with known diabetes?

The Centers for Disease Control and Prevention (CDC) currently lists type 2 diabetes (T2D) as a high risk condition for severe illness related to COVID-19 infection, while stating that adults with type 1 diabetes (T1D) might be at increased risk. A recent study from Vanderbilt University found that people with T1D and T2D were at approximately equal risk for complications of COVID-19 infection. As compared to adults without diabetes, adults with T1D and T2D were 3-4 times more likely to be hospitalized and to have greater illness severity. Given these comparable risks, both the American Diabetes Association and the Juvenile Diabetes Research Foundation are lobbying for adults with T1D to be given the same level or priority for COVID-19 vaccines as adults with T2D.

However, as pediatricians, we all know to be wary of extrapolating adult data to pediatrics. Children are less likely to be infected with COVID-19 and if they are, the clinical course is typically mild. To date, there have not been any studies of the impact of COVID-19 on youth with known T2D. Our clinical experience at Children’s National Hospital and reports from international multicenter studies indicate that youth with T1D are not at increased risk for hospitalization from COVID-19 infection. However, paralleling ongoing disparities in T1D care, African Americans with known T1D and COVID-19 infection were more likely to be develop diabetic ketoacidosis (DKA) than their White counterparts.

With the increased use of diabetes technologies, including continuous glucose monitors, insulin pumps and automated insulin delivery systems, diabetes care lends itself well to telemedicine. Studies from Italy during the period of lockdown showed better glycemic control among youth with T1D. Further studies are needed to better understand the implications of telehealth on diabetes care, particularly among those in rural areas with limited access to care.

Brynn Marks

Diabetes experts, like Brynn Marks, M.D., M.S.H.P.Ed., endocrinologist at Children’s National Hospital, have been studying the relationship between COVID-19 and diabetes, especially in the pediatric population.

2.      What do we know about the impact of the COVID-19 pandemic on children with newly diagnosed diabetes?

Nationwide studies from Italy and Germany over the first few months of the pandemic found no increase in the incidence of pediatric T1D during the COVID-19 pandemic as compared to the year before; in fact, the Italian study found that fewer children were diagnosed with T1D during the pandemic. However, many centers are seeing higher rates of DKA and more severe DKA at diagnosis during the pandemic, possibly due to decreased primary care visits and/or fears of contracting COVID-19 while seeking care.

To date, no studies have been published exploring the incidence of T2D in youth. A group from Children’s National, including myself, Myrto Flokas, M.D., Abby Meyers, M.D., and Elizabeth Estrada, M.D., from the Division of Endocrinology and Randi Streisand, Ph.D., C.D.C.E.S. and Maureen Monaghan, Ph.D., C.D.C.E.S., from the Department of Psychology and Behavioral Health, are gathering data to compare the incidence of T1D and T2D during the pandemic as compared to the year before.

3.      Can COVID-19 cause diabetes to develop?

This has been area of great interest, but the jury is still out. The SARS-CoV-2 virus, which causes COVID-19 infection, binds the angiotensin-converting enzyme 2 (ACE2) receptor which is located in many tissues throughout the body, including the pancreas. SARS-CoV-2 has been shown to infect pancreatic tissue leading to impaired glucose stimulated insulin secretion. Although the SARS-CoV-2 virus could plausibly cause diabetes, assessment has been complicated by many confounders that could be contributing to hyperglycemia in addition to or rather than the virus itself. Stress-induced hyperglycemia from acute illness, the use of high dose steroids to treat COVID-19 infection, and the disproportionate rates of infection among those already at high risk for T2D, as well as weight gain due to changes in day-to-day life as a result of social distancing precautions are all likely contributing factors.

woman writing data to medical form and glucometer for checking sugar level

New grant to assess screening tools for cystic fibrosis-related diabetes

woman writing data to medical form and glucometer for checking sugar level

A grant from the Cystic Fibrosis Foundation will help Children’s National researchers assess the feasibility and accuracy of two new cystic fibrosis-related diabetes screening tools.

Cystic fibrosis-related diabetes (CFRD) is the most common non-pulmonary manifestation of cystic fibrosis (CF), affecting up to 30% of adolescents and 50% of adults living with CF, according to the Cystic Fibrosis Foundation (CFF). CFRD is often asymptomatic and so the CFF recommends that people living with CF be screened for CFRD annually starting at 10 years of age using an oral glucose tolerance test.

Although early detection and treatment of CFRD can lead to significant clinical improvements and prolong life, rates of screening are poor, likely due to the burdensome nature of oral glucose tolerance testing (OGTT). Rates of OGTT screening in patients 10-17 years of age vary widely among CF care centers, ranging 5.9% to 100% with a median of 61.3% of patients at a given center completing screening. At Children’s National, only 46.4% of pediatric CF patients without CFRD completed the OGTT in 2019.  The most commonly cited reason for failure to complete recommended OGTT screening is the additional burden that this time-consuming fasting test, requiring three blood draws, places upon patients who already contend with multiple medical interventions.

“People living with CF face tremendous medical burdens.,” says Brynn Marks, M.D., MSHPEd, pediatric endocrinologist at Children’s National Hospital. “Novel, more convenient approaches to CFRD screening that can provide both diagnostic and therapeutic information are urgently needed.”

Dr. Marks and Carol Chace, MSW, a social worker at Children’s National, have collaborated to receive a $160,000 Pilot and Feasibility Award from the CFF that will allow researchers to assess the feasibility and accuracy of two new CFRD screening tools, the Dexcom G6 Pro, a continuous glucose monitoring (CGM), and the Digostics GTT@home, a home-based OGTT kit. The Dexcom G6 Pro is the first unblinded professional CGM that enables patients to see their glucose values and trends in real-time. The GTT@home uses a built-in timer and audio-visual cues to guide users to collect capillary blood samples through finger sticks.

“While the idea of home-based testing is exciting in general, it is particularly important in the midst of the COVID-19 pandemic, as many are limiting preventative health care visits,” says Dr. Marks. “This research will hopefully inform future larger studies that could one day allow for this screening to be done at home.”

Brynn Marks

Bringing diabetes technology to patients and providers

Brynn Marks

Brynn Marks, M.D., endocrinologist at Children’s National Hospital, was diagnosed with Type 1 diabetes at the age of five years old and knows too well the struggles that may come with managing this chronic condition. After finding the right, knowledgeable provider as a teen, Dr. Marks realized that she wanted to become an endocrinologist and be that resource and support for others with Type 1.

Developments in diabetes technologies, including continuous glucose monitors (CGM) and insulin pumps, hold great promise for improving diabetes control while also improving quality of life for those living with Type 1. However, the pace of development also presents challenges for busy clinicians who must keep up with rapid developments in the field. Dr. Marks is focused on making sure patients and providers have the latest information and training on diabetes technologies with the goal that they can be more effectively used by more people in the real world.

“These diabetes technologies are very important for kids and teens with diabetes because they can help them to live life as normally as possible while affording the freedom they need to just be kids,” says Dr. Marks.

Dr. Marks’ recent research includes a study where she used an app to deliver medical education about diabetes technology. Participants received authentic, case-based scenarios focused on the technologies to help them apply knowledge of these technologies to real-world clinical scenarios involving insulin pumps and CGMs. All of the education was delivered through questions and explanations in an effort to keep the learners engaged with the curriculum. The questions were repeated over 3-4 months to improve learning and long-term knowledge retention. The study showed that knowledge and confidence about these technologies improved and ultimately led to better patient care.

Dr. Marks presented two posters at a recent International Society for Pediatric and Adolescent Diabetes (ISPAD) meeting related to her efforts to make these technologies more accessible:

Experiential Learning in T1D Technology Education: Knowledge of Parents and Clinicians: Dr. Marks enrolled different groups of learners in the diabetes technology curriculum mentioned above, including parents of children with Type 1 diabetes, attending physicians, pediatric endocrine fellows and certified diabetes educators. Results showed minimal difference among those groups in terms of knowledge about the pumps and CGMs. Interestingly, clinicians who had the opportunity to wear the technologies for educational purposes had greater knowledge than clinicians who did not have the same opportunity. Based on these results, Dr. Marks advocated that opportunities to wear pumps and CGMs should be a routine part of education for clinicians working with these technologies.

A Qualitative Analysis of Clinicians’ Experiences Wearing CGM: Dr. Marks explored the reactions of clinicians without diabetes who were given the opportunity to wear continuous glucose monitors for 1 week. Participants reported that the opportunity to wear these technologies improved their knowledge and gave them greater empathy for patients using CGM.

Dr. Marks’ work to date has identified strategies to improve knowledge about insulin pumps and CGM. Moving forward, she will continue to study the best ways to educate parents and clinicians about these diabetes technologies in hopes of improving the day to day lives of the children they care for.

regional pediatric endocrinology meeting

Regional pediatric endocrinologists gather at Children’s National

regional pediatric endocrinology meeting

On Nov. 10, 2019, more than 30 pediatric endocrine physicians and nurse practitioners from Washington, D.C., Maryland and Northern Virginia gathered at Children’s National Hospital to discuss the latest in pediatric endocrinology research.

Organized by Paul Kaplowitz, M.D., Professor Emeritus of Pediatrics, this was the third regional pediatric endocrinology meeting since 2012 and the second held at the hospital. “The meetings are a great opportunity for providers to meet regional colleagues who they may communicate with about patients but rarely see face to face,” explains Dr. Kaplowitz.

The providers spent half a day at Children’s National viewing presentations and connecting with their colleagues. Among the presentations was a talk by new Children’s National faculty member Brynn Marks, M.D., MSHPEd, titled, “Medical Education in Diabetes Technologies.”

The presentation highlighted Dr. Marks’ research on how to best teach providers to make optimal use of the information provided by continuous blood glucose monitoring, as well as how to adjust insulin pump settings based on frequent blood glucose testing.

Another notable presentation was by Richard Kahn, Ph.D., recently retired former chief scientific and medical officer at the American Diabetes Association. Dr. Kahn’s talk was titled “Prediabetes: Is it a meaningful diagnosis?”

“This was an excellent talk whose message was that making a diagnosis of ‘prediabetes’ may not be nearly as helpful as we thought, since most patients tests either revert to normal or remain borderline, and there is no treatment or lifestyle change which greatly reduces progression to type 2 diabetes,” says Dr. Kaplowitz.

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Children’s National regional pediatric endocrinology meeting presentations

Welcome from Paul Kaplowitz, M.D., and Children’s National Endocrinology Division Chief Andrew Dauber, M.D.

“Prediabetes: Is it a meaningful diagnosis?”
Richard Kahn, Ph.D., University of North Carolina at Chapel Hill

“Overlapping genetic architecture of Type 2 diabetes and Cystic fibrosis-related diabetes”
Scott Blackman, M.D., Ph.D., Johns Hopkins Medicine

“Pediatric Pituitary Tumors: What we have learned from the NIH cohort”
Christina Tatsi, M.D., Ph.D., National Institutes of Health

“Medical Education in Diabetes Technologies”
Brynn Marks, M.D., MSHPEd, Children’s National Hospital

“A phenotypic female infant with bilateral palpable gonads”
Cortney Bleach, M.D., Walter Reed National Military Medical Center

“Estimating plasma glucose with the FreeStyle Libre Pro CGM in youth: An accuracy analysis”
Miranda Broadney, M.D., MPH, University of Maryland School of Medicine

“Recruiting for research project on “Arginine-Stimulated Copeptin in the diagnosis of central diabetes insipidus”
Chelsi Flippo, M.D., Fellow, National Institutes of Health