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Impact of COVID-19 on metabolic parameters in patients with type 2 diabetes mellitus

BMC Pulmonary Medicine volume 25, Article number: 58 (2025) Cite this article

Abstract

Background and aim

The Coronavirus Disease 2019 (COVID-19) pandemic has disproportionately affected individuals with Type 2 Diabetes Mellitus (T2DM), making them more susceptible to viral infections. Additionally, COVID-19 and the associated lockdown restrictions have influenced metabolic regulatory mechanisms in this population. This study aims to evaluate the impact of COVID-19 infection and lockdown measures on physiological parameters in individuals with T2DM.

Methods

This retrospective cohort study included 118 individuals with a prior diagnosis of T2DM. Medical records were reviewed for laboratory tests conducted within three months before the onset of the COVID-19 pandemic in Iran. Fifty-nine patients with confirmed COVID-19 infection during the first three months of the pandemic underwent follow-up laboratory tests six months post-diagnosis. An age- and gender-matched group of 59 noninfected individuals underwent follow-up tests six months after the pandemic’s onset. Clinical and laboratory parameters were analyzed and compared within each group.

Results

In the COVID-19 positive group, significant reductions were observed in triglycerides (TG) (P = 0.001), total cholesterol (TC) (P = 0.028), body mass index (BMI) (P = 0.034), atherogenic index of plasma (AIP) (P = 0.027), triglyceride-glucose (TyG) index (P = 0.001), and triglyceride-glucose-BMI (TyG-BMI) index (P < 0.001) during the six months following infection compared to pre-pandemic levels. Other variables remained unchanged. In the COVID-19 negative group, significant reductions were noted in TC (P = 0.001) and low-density lipoprotein cholesterol (LDL-C) (P = 0.01).

Conclusion

T2DM patients with mild to moderate COVID-19 infection exhibited improvements in TC, TG, BMI, and insulin-related indices. Lockdown restrictions were associated with decreased TC and LDL-C levels in T2DM patients without a history of COVID-19 infection.

Peer Review reports

Introduction

Type 2 Diabetes Mellitus (T2DM) is a chronic and widespread metabolic disorder, affecting approximately 10.5% of adults worldwide. The disease is primarily characterized by insulin resistance and hyperglycemia [1], which predispose individuals with T2DM to an increased susceptibility to various pathogens and infections, including common types [2]. For instance, a cohort study demonstrated that individuals with T2DM have a 30% higher risk of developing lower respiratory tract infections compared to controls after one year of follow-up [3]. Hyperglycemia compromises the glycolytic metabolism and ATP production of immune cells, thereby reducing their functional capacity to combat infections [4]. Moreover, hyperglycemia has been found to promote the replication of several pathogens, including SARS-CoV-2, by meeting their glycemic demands [5].

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is the causative agent of Coronavirus Disease 2019 (COVID-19), which was declared a global pandemic in March 2020 [6]. A bidirectional relationship between COVID-19 and Type 2 Diabetes Mellitus (T2DM) has been documented, wherein diabetes exacerbates the severity of COVID-19 infection, and the virus may aggravate dysglycemia in individuals with pre-existing diabetes [7,8,9,10].

The development of SARS-CoV-2 infection is partly attributed to the virus’s ability to delay the production of type-I interferons in host cells [11]. These interferons, produced by all nucleated cells in response to infection, serve as alarm signals that recruit immune cells to the site of infection. Additionally, elevated blood lactate levels, commonly observed in individuals with T2DM, have been shown to further impair type-I interferon production [12]. Together, these factors contribute to the heightened susceptibility of T2DM patients to COVID-19 infection.

The precise pathophysiological mechanisms underlying COVID-19-induced dysglycemia remain unclear. Studies have shown that Angiotensin I-Converting Enzyme type 2 (ACE2), which serves as a receptor for SARS-CoV-2, is abundantly expressed in pancreatic beta cells [13,14,15]. This interaction may disrupt insulin secretion during acute infection. Furthermore, the proinflammatory cytokine cascade, including TNF-α, IL-1, and IL-6, triggered by the immune response to the virus, has been implicated in increasing insulin resistance [16].

In addition to the direct effects of COVID-19, the associated lockdowns significantly impacted the lifestyle and healthcare access of individuals with T2DM. During the lockdown in Iran, routine outpatient visits and access to medical facilities were limited. However, telemedicine and online consultations became more prevalent, promoting self-management behaviors such as adequate hydration, healthy eating, regular exercise, and blood sugar monitoring [17].

While much of the existing literature has explored the immediate impacts of the pandemic, limited data are available on the long-term effects of COVID-19 infection on metabolic parameters in individuals recovering from the initial phase of the disease [18,19,20,21]. This study aims to address this gap by investigating the metabolic changes associated with COVID-19 in patients with preexisting T2DM.

Methods

Study design

This retrospective cohort study was conducted at the Yazd Diabetes Research Center in Yazd, Iran, using data retrospectively collected from the medical records of eligible patients who attended the center between February 20, 2020, the date of the first officially reported COVID-19 case in Iran, and October 21, 2020. Ethical approval for the study was obtained from the Research Ethics Council of Shahid Sadoughi University of Medical Sciences in Yazd, Iran (IR.SSU.REC.1401.097).

Participants

A total of 372 T2DM patients visited our medical center between February 20, 2020, and October 21, 2020. Of these, 118 patients met the study’s inclusion criteria and were enrolled. Participants provided informed consent to use their medical records for the study, ensuring their personal information would remain confidential.

Clinical data and laboratory measurements were extracted from the medical records of the 118 participants. The duration of diabetes ranged from 3 to 7 years, and the participants exhibited minimal diabetic complications. Before the pandemic, all participants were under the supervision of healthcare professionals at the center and were receiving insulin and/or oral antidiabetic medications. Patients aged 40 years and older were prescribed statins, specifically Atorvastatin, at doses of 20 mg or 40 mg. No new treatments were introduced during the study period, aside from adjustments to existing medication dosages based on laboratory test results.

All participants were between 30 and 60 years of age, as individuals in this range typically had regular follow-up visits and were prescribed medications. According to national guidelines, individuals with T2DM are advised to undergo clinical and laboratory assessments by a primary care physician every three to six months [22]. Participants were excluded if they had irregular follow-up visits, lacked medical records within three months before the pandemic onset, or had a history of immunodeficiency, neoplasia, co-infections, or smoking.

The “COVID-19 positive” group included 59 patients who tested positive for COVID-19 using the polymerase chain reaction (PCR) technique between February 20 and May 19, 2020. These patients were not hospitalized and recovered on an outpatient basis. Corticosteroid therapy was not administered during the infection phase, and adjustments to diabetes-related medications were made based on individual laboratory results. Patients who were not receiving statins prior to contracting COVID-19 did not initiate statin therapy during the infection. Individuals lacking medical records six months after their initial positive PCR test or those with documented reinfection during this period were excluded.

The “COVID-19 negative” group consisted of 59 individuals with no documented history of COVID-19 infection between February 20 and October 21, 2020. Patients without medical records six months after the pandemic onset in Iran were excluded. Gender and age matching was conducted to ensure homogeneity between the two groups.

Clinical variables and laboratory measures

Clinical data included age, gender, body mass index (BMI), and systolic and diastolic blood pressure. Blood samples collected after 12 h of fasting were analyzed for hemoglobin A1C (HbA1C), fasting plasma glucose (FPG), total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), blood urea nitrogen (BUN), and creatinine (Cr). The estimated glomerular filtration rate (eGFR) was calculated using the CKD-EPI formula [23]. Some of the lipid-related indices, including triglyceride glucose (TyG) index, triglyceride glucose-body mass index (TyG-BMI), and atherogenic index of plasma (AIP), were calculated using the following Eqs. [24, 25]:

TyG Index = Ln (fasting glucose (mg/dL) × triglycerides (mg/dL)/2).

TyG-BMI = BMI × TyG index.

API = \(\:log\frac{Triglycerides}{HDL}\)

Statistical analysis

Statistical analyses were conducted using SPSS version 27. Data normality was evaluated using the Shapiro–Wilk test. Variables with a normal distribution were expressed as means ± standard deviation (SD), while non-normally distributed variables were reported as medians with interquartile ranges. Within-group differences were analyzed using the paired t-test for normally distributed variables and the Wilcoxon test for non-normally distributed variables. A P-value of < 0.05 was considered statistically significant.

Results

A total of 59 T2DM patients were included in each group for analysis. Of these, 42 (71.2%) were female, and 17 (28.8%) were male. The median age of the ‘COVID-19 positive’ group was 55 years (interquartile range: 8), while the median age of the ‘COVID-19 negative’ group was 56 years (interquartile range: 8), with no significant difference between the groups (P = 0.84). None of the COVID-19 positive patients required hospitalization and were managed on an outpatient basis.

In the ‘COVID-19 positive’ group, six months post-recovery, significant reductions were observed in weight (P = 0.036), BMI (P = 0.034), atherogenic index of plasma (AIP) (P = 0.027), triglyceride-glucose (TyG) index (P = 0.001), and TyG-BMI index (P < 0.001) compared to pre-pandemic values. Levels of triglycerides (TG) (P = 0.001) and total cholesterol (TC) (P = 0.028) also decreased during this period (Table 1). No significant changes were noted in other lipid profiles, including HDL-C and LDL-C, or in systolic and diastolic blood pressure, glycemic indices, and renal function parameters.

In the ‘COVID-19 negative’ group, only TC (P = 0.001) and LDL-C (P = 0.01) levels showed significant reductions during the first six months of the lockdown (Table 2). Other clinical and laboratory variables remained largely unchanged.

Table 1 Clinical and laboratory data of patients in the ‘COVID-19 positive’ group
Full size table
Table 2 Clinical and laboratory data of patients in ‘COVID-19 negative’ group
Full size table

Discussion

We conducted a retrospective cohort study to examine the effects of COVID-19 infection and pandemic-related restrictions on metabolic parameters in individuals with T2DM. The study included 118 participants divided into two groups: ‘COVID-19 positive’ and ‘COVID-19 negative.’ The groups were matched for age and gender to ensure comparability.

Our findings revealed a significant reduction in TC and TG levels over six months following infection in the ‘COVID-19 positive’ group. A Mendelian randomization study suggested that dyslipidemia observed during the acute phase of COVID-19 is likely driven by an exacerbation of pre-existing dyslipidemia rather than a direct viral effect [26]. This could explain the potential improvement in acute-phase dyslipidemia among T2DM patients as COVID-19-related inflammation subsides. Additionally, a study investigating diabetic patients during the post-COVID-19 period found no evidence of chronic inflammation six months after recovery [27]. The resolution of inflammation following the acute phase of the disease may enable a return to normal lipid profiles. Our findings of improved TC and TG levels, along with the stability of HDL-C levels, align with these observations and suggest a similar recovery pattern in T2DM patients post-COVID-19 infection.

We observed a reduction in weight and BMI among non-hospitalized patients with mild to moderate COVID-19. This decrease may be attributed to a prolonged period of diminished appetite following COVID-19, which can persist for up to 180 days after recovery [28]. Psychological stress related to the fear of reinfection and insufficient knowledge about the virus and its treatments may also contribute to reduced body weight [29].

Post-COVID-19 symptoms, such as loss of appetite and taste disorders, were frequently reported and left patients susceptible to malnutrition, characterized by poor dietary quality and inadequate protein intake [30]. Malnutrition has been found to be more common among non-hospitalized patients compared to hospitalized individuals, often resulting in significant weight loss [31]. The combination of increased energy demands for tissue repair and reduced fat and protein intake likely contributed to both weight loss and the observed reductions in TC and TG levels.

Lipid-related indices, including AIP, TyG, and TyG-BMI, showed decreased levels in our study. These indices are positively correlated with insulin resistance and visceral obesity in individuals with diabetes [32, 33].

A reduction in TG levels significantly lowers these indices, even in the absence of concurrent improvements in insulin resistance. This phenomenon is particularly observed in malnourished individuals with insufficient protein and mineral intake [34]. In our study, post-COVID-19 appetite loss and associated weight loss likely contributed to the observed decrease in TG levels. However, this reduction did not translate into improved insulin sensitivity, as evidenced by the lack of enhancements in glycemic control and HDL-C levels. Our findings align with previous research indicating that insulin resistance can persist for up to six months following COVID-19 infection [27].

No significant increase in HbA1C levels was observed in the ‘COVID-19 positive’ group. The transient dysfunction of pancreatic beta cells induced by COVID-19, which leads to hyperglycemia during the acute phase of infection, did not progress into a chronic condition. Insulin production appeared to return to pre-infection levels [27]. The changes in HbA1C observed during the recovery period may reflect a balance between restored insulin secretion and increased insulin resistance following the infection.

The ‘COVID-19 negative’ group had a notable reduction in TC and LDL-C levels over the first six months of the lockdown period. This finding aligns with previous studies [19, 26, 35, 36], although some other research has shown inconsistencies [20, 35, 37]. However, there were no statistically significant changes in TG and HDL-C levels during the same period [38]. The first public health emergency declaration prompted many diabetic patients to adopt healthier dietary habits [18,19,20]. Dietary recommendations encouraging reduced intake of saturated fats and increased consumption of soluble fibers likely influenced lipid profiles by decreasing serum TC and LDL-C levels, while having little to no effect on TG and HDL-C levels [39, 40]. It is important to note that there was a lack of data on adjustment in statin dosages during the study period for individuals with T2DM who had been prescribed these medications based on their physician’s recommendations before the pandemic. This limitation makes it difficult to thoroughly assess the combined effects of dietary changes and possible medication adjustments on lipid profiles.

No significant changes in weight or BMI were observed in the noninfected population during the COVID-19 pandemic. The impact of the pandemic on BMI remains inconclusive, with some studies reporting an increase in BMI among uninfected individuals [20, 37, 41], while others have shown inconsistent findings [35, 42, 43]. The absence of notable weight changes may result from a complex interplay of factors, including alterations in dietary habits, physical activity levels, and emotional stress. Pandemic-related restrictions, such as stay-at-home orders and the closure of gyms and recreational facilities, led to an overall decrease in physical activity [44]. In individuals with T2DM, physical inactivity reportedly increased by an average of 21.9 min per day compared to pre-pandemic levels [45]. On the other hand, positive dietary changes were also observed in this population, including increased water consumption and higher intake of fruits, vegetables, and home-cooked meals [46, 47].

Our findings showed that there were no significant changes in other clinical and laboratory measurements, such as FPG, HbA1C, Urea, Cr, eGFR, and blood pressure, in the ‘COVID-19 negative’ group. Prior studies on these parameters have yielded conflicting results [48,49,50,51,52,53,54]. Differences in the duration of patient follow-up and pre-lockdown glycemic control may explain the variation in the studies’ findings.

To the best of our knowledge, this is the first study that simultaneously investigated the impact of the pandemic restrictions and mild COVID-19 infection on metabolic indices in individuals with T2DM who received the same level of healthcare.

The limitations of this study include the absence of data on changes in the dosages of lipid- and glucose-controlling medications in both participant groups. Furthermore, information regarding patients’ physical activity levels and dietary patterns during the initial months of the pandemic was unavailable. Additionally, certain clinical and laboratory variables, such as waist and hip circumferences, serum insulin levels, urine analysis, and albuminuria, were not included due to incomplete documentation in the medical records of some participants.

Conclusion

Our study highlights the impact of COVID-19 and associated lockdown measures on the metabolic parameters of individuals with T2DM. We found that individuals with well-managed T2DM who experienced mild to moderate COVID-19 demonstrated a decrease in specific metabolic parameters, which may reflect the sustained effects of the acute phase of the infection. Notably, our findings suggest that pandemic-related restrictions did not exacerbate diabetes control in uninfected individuals, implying that well-managed diabetes may not present a significant challenge in the context of mild to moderate COVID-19 infection.

However, the study’s limitations should be carefully considered. The retrospective, single-center design, the absence of detailed data on medication adjustments, and the lack of information on lifestyle factors during the study period may limit the robustness and generalizability of our findings. These constraints highlight the need for prospective studies to validate and expand upon our observations. Future research should focus on diverse populations and include comprehensive data on medication use, lifestyle factors, and additional clinical variables, such as markers of insulin resistance. By addressing the gaps identified in this analysis, prospective studies can provide deeper insights into the metabolic effects of COVID-19 in individuals with T2DM and the broader implications for diabetes management during public health crises.

Data availability

The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request.

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Acknowledgements

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Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. Yazd Cardiovascular Research Center, Non-Communicable Diseases Research Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran

    Motahare Shabestari

  2. Shahid Sadoughi University of Medical Sciences, Yazd, Iran

    Forouzan Salari

  3. Diabetic Research Center, Shahid Sadoughi University of Medical Sciences, Shahid Sadoughi Blvd, Yazd, 8917693571, Iran

    Reyhaneh Azizi, Akram Ghadiri-Anari & Nasim Namiranian

Authors
  1. Motahare Shabestari
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  2. Forouzan Salari
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  3. Reyhaneh Azizi
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  4. Akram Ghadiri-Anari
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  5. Nasim Namiranian
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Contributions

M.S: Methodology, Software, Formal analysis, Data Curation, Writing - Original Draft. F.S: Methodology, Writing - Original Draft R.A: Writing - Review & Editing, Investigation. A.G: Conceptualization, Validation, Investigation, Supervision, Project administrationN. N: Conceptualization, Validation, Investigation, Supervision.

Corresponding author

Correspondence to Akram Ghadiri-Anari.

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Ethics approval and consent to participate

The study was approved by the Research Ethics Committee of Shahid Sadoughi University of Medical Sciences, Yazd, Iran (IR.SSU.REC.1401.097). Written informed consent to participate was obtained from all enrolled subjects. The study was performed in accordance with the principles of the Helsinki Declaration.

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The authors declare no competing interests.

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Shabestari, M., Salari, F., Azizi, R. et al. Impact of COVID-19 on metabolic parameters in patients with type 2 diabetes mellitus. BMC Pulm Med 25, 58 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12890-025-03529-9

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12890-025-03529-9

Keywords

BMC Pulmonary Medicine

ISSN: 1471-2466

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