Black Patients With T1D and COVID-19 Face Added Risk of Diabetic Ketoacidosis

A modern African businessman is sitting at the desk at the home office and taking blood from his finger due to diabetes. The daily life of a man of African-American ethnicity person with a chronic illness who is using glucose tester.
Diabetic ketoacidosis has been found to be more prevalent among Black patients with type 1 diabetes and COVID-19, shows a new study. The condition typically disproportionately affects Black and Hispanic patients.

Black patients with type 1 diabetes mellitus (T1D) and COVID-19 are 4 times more likely to develop diabetic ketoacidosis than white counterparts with T1D and COVID-19, shows a study published in The Journal of Clinical Endocrinology & Metabolism.

Diabetic ketoacidosis is a condition that can occur in patients with type 1 diabetes and can manifest with a viral infection like COVID-19. The condition can to lead to sepsis and septic shock which are serious complications associated with a COVID-19 diagnosis.2

This study is unique, in part, because although type 2 diabetes has been associated with poorer prognoses in Black and Hispanic patients with COVID-19, few studies have examined whether similar disparities affect patients with type 1 diabetes.

Led by Irl B. Hirsch, MD, chair of Diabetes Treatment and Teaching at the University of Washington, researchers found a significant association among Black patients in this study. And in Hispanic patients, the odds of developing diabetic ketoacidosis was two times greater than that of White patients, but this finding was not found to be statistically significant (adjusted OR [95% CI]: 1.9 [0.7-5.7]).

“Our findings underscore the high risk that racial and ethnic minorities face from COVID-19 and T1D, signaling to clinicians that further interventions are needed to prevent and provide a tailored approach to mitigate poor outcomes,” wrote authors who were led by Irl B. Hirsch, MD, chair of Diabetes Treatment and Teaching at the University of Washington.


In this retrospective, multicenter, cross-sectional study—which was first published online December 19—sociodemographic and clinical data of 180 patients with COVID-19 and T1D treated across 52 endocrinology centers within the T1D Exchange network between April 2020 and August 2020, were examined. The study’s primary outcome was the presence of diabetic ketoacidosis (ie, blood glucose >200 mg/dL).

In this study group, 44% of patients were White (of non-Hispanic origin) (51% men; >19 years, 66%); 30% were Black (non-Hispanic) (49% men; >19 years, 53%); and, 26% were Hispanic (20% men; >19 years, 40%).

Researchers found that median glycated hemoglobin A1c (HbA1c) levels were greater among Black patients (11.7%) and Hispanic patients (9.7%) compared with White patients (8.3%; P <.001 and P =.001, respectively). The use of an insulin pump was less prevalent among Black (7%) and Hispanic patients (22%) than among White patients (54%), and hospitalizations for COVID-19 were more frequent for Black and Hispanic patients (76%, 59%, respectively, compared to and 29% of White patients.

The prevalence of diabetic ketoacidosis—which required hospitalization in all cases—was greater in Black patients as compared to White patients (55% vs 13%, respectively; P <.001). A greater percentage of Black (13%) and Hispanic (12%) patients as compared to White (1%) patients were newly diagnosed with T1D (P =.001).

In an analysis adjusted for potential confounders (eg, age, sex, and type of insurance), Blacks were found to be approximately 4 times more likely to have diabetic ketoacidosis compared with NH White patients (adjusted odds ratio, 3.7; 95% CI, 1.4-10.6).

Study limitations include its cross-sectional nature, the lack of data on additional social determinants of health, and the possible inclusion in this cohort of patients with T2D.

Black (non-Hispanic) and Hispanic people have been found to be disproportionately infected with, hospitalized for, and die from COVID-19 compared to White patients. While Black patients make up 13% of the US population, approximately 34% of COVID-19 deaths in the US represent Black patients. In fact, both Black and Hispanic patients are 3 times more likely to contract COVID-19 and 2 times more likely to die from the disease compared to White patients.

Disparities in care among this group of patients has long been well documented. In this study, while 50% of White patients had public insurance, 87% of Hispanic patients and 78% of Black patients had public insurance.

“This study is the first systematic examination of racial-ethnic disparities for people with T1D and COVID-19 infection, using a diverse cohort, with equal representation from both non-Hispanic Black and Hispanic groups. Our findings demonstrate that non-Hispanic Black patients with COVID-19 and T1D have an additional risk of diabetic ketoacidosis (DKA) beyond the risk already conferred from having longstanding diabetes or being of minority status,” the authors wrote. “There is a critical need to understand how COVID-19 modifies T1D-specific risks.”


  1. Ebekozien O, Agarwal S, Noor N, Albanese-O’Neill A, Wong J, et al. Inequities in diabetic ketoacidosis among patients with type 1 diabetes and covid-19: data from 52 us clinical centers. The Journal of Clinical Endocrinology & Metabolism. Published online December 19, 2020. doi: 10.1210/clinem/dgaa920
  2. “Frequently Asked Questions: COVID-19 and Diabetes,” American Diabetes Association. Accessed Feb. 11, 2021.