Nationwide cohort of 5,084,889 US adults with 599,744 COVID-19 positive cases matched 1:1 to controls.

SARS-CoV-2 infection independently associated with increased 5-year risk of prediabetes (HR 1.23; 95% CI 1.21–1.25) and type 2 diabetes (HR 1.40; 95% CI 1.37–1.43).

Risk peaked in the first month post-infection (both outcomes: HR 1.87) and remained elevated through year 5 (prediabetes: HR 1.23; type 2 diabetes: HR 1.48).

Associations consistent across sex, obesity, and hypertension subgroups with clinically meaningful absolute risk differences.

Rigorous propensity matching controlled for demographics, comorbidities, and metabolic parameters; residual confounding and exposure misclassification possible.

Clinical Relevance

SARS-CoV-2 infection history represents a clinically actionable risk marker for dysglycemia that should be integrated into diabetes screening algorithms. For adults without known diabetes, endocrinologists and primary care providers should consider targeted glycemic testing at 1–3 months post-recovery, with repeat assessment at 6–12 months and continued periodic surveillance in high-risk groups (males, obesity, hypertension, additional cardiometabolic risk factors). The sustained 5-year risk elevation—comparable to traditional risk factors—combined with accelerated prediabetes-to-diabetes progression (HR 1.13; 95% CI 1.08–1.18) and more hyperglycemia-predominant disease phenotype among COVID-19 patients warrants intensified lifestyle counseling and consideration of metformin prophylaxis per ADA guidelines. While causality cannot be established from observational data, the consistency across sensitivity analyses, biological plausibility, and magnitude of effect support incorporating COVID-19 history into individualized metabolic risk assessment and surveillance strategies.

To assess the long-term association between SARS-CoV-2 infection and the incidence of prediabetes and type 2 diabetes over a five-year period.

We conducted a nationwide, population-based cohort study including adults who had a positive COVID-19 test (599,744) and adults with a negative COVID-19 test (4,485,145) between January 1, 2020, and December 31, 2020. Participants did not have a history of prior SARS-CoV-2 infection, diagnosis of prediabetes or type 2 diabetes, and were followed for 5 years. Propensity score matching was used to control confounding, and time-to-event analyses were performed using Kaplan–Meier analysis and Cox proportional hazards models.

Among 5,084,889 individuals followed for a median of 2.6 years, those with confirmed SARS-CoV-2 infection exhibited a significantly increased risk of developing prediabetes (HR 1.23; 95% CI, 1.21–1.25) and type 2 diabetes (HR 1.40; 95% CI, 1.37–1.43) compared to uninfected individuals. The risk was most pronounced within the first month following infection (prediabetes: HR 1.87; 95% CI, 1.75–1.98; type 2 diabetes: HR 1.87; 95% CI, 1.79–1.96) and, although attenuated, remained significantly elevated over the subsequent five years (prediabetes: HR 1.23; 95% CI, 1.20–1.27; type 2 diabetes: HR 1.48; 95% CI, 1.43–1.53).

SARS-CoV-2 infection is associated with a significantly increased risk of developing prediabetes and type 2 diabetes, with the highest incidence observed during the acute post-infection phase and persistent elevation in risk extending up to five years.