Type 1 and Type 2 Diabetes and COVID-19 Related Mortality in England: A Cohort Study in People with Diabetes

Background: Although diabetes has been associated with COVID-19 mortality, its scale and relationships with modifiable risk factors including hyperglycaemia and obesity in Type 1 and Type 2 diabetes remain unclear. Methods: National diabetes and mortality data in England identified deaths in people with Type 1 and Type 2 diabetes weekly from 1st January 2017 to 1st May 2020. Cox proportional hazards analysis investigated the relationship between risk factors and COVID-19 related death in a cohort alive on 1st January 2020 and followed to 1st May 2020. Findings: Weekly deaths in Type 1 and Type 2 diabetes more than doubled from the week ending 3rd April 2020 exceeding expected variation (3SD). Among 265,090 people with Type 1 and 2,889,210 people with Type 2 diabetes there were 418 and 9377 COVID-19 related deaths respectively. The adjusted hazard ratio (HR) of HbA1c >86 mmol/mol compared to HbA1c 48-53 mmol/mol was 2·19 (95% CI 1·46-3·29) for Type 1 and 1·62 (95% CI 1·48-1·79) for Type 2 diabetes. The relationship between BMI and COVID-19 mortality was U-shaped; HRs for BMI >40 kg/m2 compared to 25-29.9 kg/m2 were 2·15 (95% 1·37-3·36) and 1·46 (95% CI 1·50-1·79) for Type 1 and Type 2 respectively. Interpretation: Deaths in people with diabetes in England have more than doubled during the COVID-19 epidemic. Hyperglycaemia and obesity in both Type 1 and Type 2 diabetes were independently associated with increased COVID-19 mortality. Risk factor control could diminish the impact of COVID-19 in diabetes. Funding: NHS England & Improvement and NHS Digital. Conflict of Interest: Jonathan Valabhji is National Clinical Director for Diabetes and Obesity at NHS England & Improvement. Partha Kar is National Specialty Advisor for Diabetes and Obesity at NHS England & Improvement. Bob Young is Clinical Lead for the National Diabetes Audit and a trustee of Diabetes UK. Kamlesh Khunti has acted as a consultant and speaker for Novartis, Novo Nordisk, Sanofi-Aventis, Lilly and Merck Sharp & Dohme. K.K. has also received grants in support of investigator and investigator-initiated trials from Novartis, Novo Nordisk, Sanofi-Aventis, Lilly, Merck Sharp & Dohme, Pfizer and Boehringer Ingelheim and has served on advisory boards for Novo Nordisk, Sanofi-Aventis, Lilly and Merck Sharp & Dohme. NH carries out Diabetes UK funded research. Emma Barron is Head of Health Intelligence (Diabetes), Public Health England. Chirag Bakhai is Primary Care advisor to the NHS Diabetes Programme. NS has consulted for Amgen, Astrazeneca, Boehringer Ingelheim, Eli Lilly, Novo Nordisk, Pfizer and Sanofi and received grant support from Boehringer Ingelheim.