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Type 1 Diabetes and Celiac Disease: Overview and Medical Nutrition Therapy

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Type 1 Diabetes and Celiac Disease: Overview and Medical Nutrition Therapy Nutrition FYI Type 1 Diabetes and Celiac Disease: Overview and Medical Nutrition Therapy Sarah Jane Schwarzenberg, MD, and Carol Brunzell, RD, CDE In patients with celiac disease (gluten- problems recognized only retrospec- glycemia, but only several months sensitive enteropathy, or GSE), inges- tively as resulting from celiac disease; after initiation. tion of the gliadin fraction of wheat it is common for “asymptomatic” It seems likely that a malabsorp- gluten and similar molecules (pro- patients to report improved health or tive disease could create opportunity lamins) from barley, rye, and possibly sense of well-being when following a for hypoglycemia in diabetes, partic- oats causes damage to the intestinal gluten-free diet. Up to one-third of ularly in patients under tight control. epithelium. The injury results from an patients may have unexplained failure Serological testing for GSE in abnormal T-cell response against to thrive, abdominal pain, or short patients with type 1 diabetes, with gliadin. Thus, GSE is a disease in stature.3,6 early diagnosis of GSE, may reduce which host susceptibility must be More controversial is the question this risk by allowing patients to be combined with a specific environmen- of whether GSE affects blood glucose diagnosed in a pre-symptomatic tal trigger to affect injury.1 control. A study by Acerini et al.7 in a state. It also seems prudent to closely Typically, patients with GSE have type 1 diabetic population found no monitor insulin needs and blood glu- chronic diarrhea and failure to thrive. difference between the celiac and non- cose control during the early phase of However, some patients present with celiac subpopulation in terms of instituting a gluten-free diet. short stature, flatulence, or recurrent hemoglobin A1c or total insulin needs. abdominal pain. Dermatitis herpeti- Some celiac patients had morning Testing People With Diabetes for GSE formis, a pruritic papular rash, is hypoglycemia after starting a gluten- Serological testing is an important directly related to GSE.2 Other atypi- free diet, but no statistically signifi- screening tool for patients with atypi- cal presentations are increasingly rec- cant change in insulin needs was cal or silent celiac disease or family ognized, among them iron-deficiency found. Another study8 of adults with members of patients with GSE. While anemia, osteopenia/osteoporosis, type 1 diabetes and GSE found no dif- the evolving nature of serological test- short stature, dental enamel hypopla- ference in metabolic control of dia- ing for GSE makes any recommenda- sia, arthritis and arthralgia, chronic betes with treatment of GSE. tion difficult, most investigators hepatitis/hypertransaminasemia, and It has been observed that patients would advocate a profile consisting of neurological problems. GSE has also with GSE have hypoglycemic episodes three antibody assays: 1) anti-gliadin been found in asymptomatic individu- and reduced insulin needs before diag- IgG, 2) anti-gliadin IgA, and 3) either als who nonetheless have evidence of nosis, presumably because of malab- an anti-endomysial or an anti-tissue intestinal mucosal injury on biopsy.1 sorption.9 In a detailed study of transglutaminase assay. Serum IgA growth parameters, blood glucose must be quantitated in all patients Celiac Disease and Type 1 Diabetes control, and dietary intake in a group because the most specific antibodies An association of diabetes with GSE of children and adolescents with GSE are IgA, and GSE is more common in has been observed since the late and type 1 diabetes, Westman et al.10 patients with IgA deficiency.12–14 1960s. In recent years, it has become found no differences between GSE Patients with positive serological clear that the incidence of GSE in and non-GSE patients. This popula- tests and those who have symptoms patients with type 1 diabetes is sub- tion was screened annually for GSE compatible with GSE and negative stantial. A prevalence rate of 4–6% and so were diagnosed at an asympto- serology should be referred to a gas- in type 1 diabetes has been report- matic point of the illness. In a case- troenterologist for further diagnostic ed.3–5 Some of the variation in preva- controlled study of the incidence of studies. In the past, the diagnosis of lence can be attributed to the differ- hypoglycemia in patients with GSE required three small-bowel biop- ent diagnostic criteria used in the untreated GSE, Mohn et al.11 found sies generally performed endoscopi- studies. that there were significantly more cally. The first, done while the patient The majority of patients with GSE episodes of hypoglycemia in the GSE was symptomatic, would show are asymptomatic4 or are not aware of patients than in controls. Institution mucosal injury. A second biopsy symptoms. Some patients present with of a gluten-free diet reduced hypo- would be performed after a minimum 197 Diabetes Spectrum Volume 15, Number 3, 2002 Nutrition FYI of 1 year on a gluten-free diet. If the lymphoma diagnoses in children To aid patients in maintaining the those results were normal, the patient in this region; the risk may rise in diet, they should be tested regularly then would be challenged carefully adults, particularly if the diet is not for ingestion of gluten (at least yearly with gluten, and a third biopsy, maintained. This constitutes the most and perhaps more often for those who which would again show abnormali- compelling reason to advocate strict have difficulty following the diet). ties, would be performed either when adherence to the diet. Antigliadin antibodies rise within the patient was symptomatic or after Many GSE patients, despite their weeks of gluten ingestion in patients 1 year on gluten.15 The evolution of resistance to the diet, find they feel with GSE and constitute a useful serological testing has allowed modi- better and have more energy when marker of dietary management. fication of this protocol, although their diets are gluten-free. Frequently, Patients may inadvertently ingest individual patients may still require both children and adults have more gluten because of its abundant use in multiple biopsies to distinguish GSE energy, feel less irritable and cranky, many prepared foods. Contamination from diseases that produce a similar display better skin color, and report of gluten-free foods in a family toaster histopathological injury.16 better overall health following treat- full of wheat crumbs, for example, There are limitations to serological ment of GSE. Some people with dia- may be discovered by interviewing the testing. First, a positive serological betes and GSE report that blood glu- family after a positive antigliadin anti- test is not diagnostic of GSE. Small- cose control is easier to maintain body test. bowel biopsy is required to confirm when they follow the gluten-free diet. Most studies suggest that osteope- the diagnosis. Second, patients under While these are not universal benefits, nia and vitamin and mineral deficien- the age of 2 years may have false-neg- they should be noted in discussions cies associated with GSE resolve on ative results on serology. When celiac with patients. the gluten-free diet. Thus, in patients disease is strongly suspected in Finally, patients with untreated adhering to the diet, little long-term patients within this age-group, they celiac disease are at risk of multiple screening for these deficiencies is war- should have a small-bowel biopsy deficiencies of micronutrients and vit- ranted. despite negative antibody testing. If amins because of the malabsorption It should be noted that immediately they are asymptomatic, they should of these nutrients by the injured small after diagnosis, some supplements and be re-tested at an older age. Third, it intestine. Among the reported prob- dietary modifications may be neces- is clear that a single serological test lems are iron and vitamin B12 defi- sary that will be unnecessary after the with negative results does not pre- ciency. At diagnosis, many celiac intestinal mucosa is healed. Patients clude the later development of celiac patients have osteopenia, which are frequently lactose-intolerant at disease. Although clear recommenda- resolves on a gluten-free diet. Clearly, diagnosis because of injury to the di- tions are not available, many centers the risk of malnutrition is another saccharidases in the small intestine. test yearly for the first 3 years of important reason to advocate a strict Patients should be screened at diagno- diagnosed diabetes, every 3–5 years gluten-free diet. sis for iron, zinc, B12, folate, calcium, thereafter, and whenever symptoms Celiac disease is a lifelong condi- magnesium, and fat-soluble vitamin develop. tion; thus, the diet is a permanent deficiencies and treated if abnormali- change for these patients. Many ties are found. Most specific supple- Treatment of GSE patients become exquisitely sensitive ments can be stopped 6–12 months Current U.S. and Canadian recommen- to the ingestion of even small amounts into therapy. dations for the treatment of GSE of gluten after a gluten-free period. Because gluten-free foods may be include a strict gluten-free diet to be Violent vomiting, severe diarrhea, lower in B vitamins, folate, iron, and maintained for life. For many patients abdominal cramping, and even shock fiber, careful planning is necessary to with diabetes, this may seem unreason- may occur in these patients. ensure adequate intake of these nutri- able given the changes they have no In some patients, ingestion of small ents.19,20 A daily multivitamin may be doubt already made to their diet after amounts of gluten will not produce recommended for patients with GSE. their diabetes diagnosis. However, the overt symptoms. Some patients expe- stringency of this recommendation is rience a reduction in response to The Diet based on sound reasoning. gluten during their teens—the so- Ideally, a gluten-free diet would elimi- First, strict elimination of gluten called “honeymoon period.” nate any prolamin or similar protein has been shown to lower the risk of Unfortunately, despite the lack of per- capable of stimulating an adverse T- small-bowel lymphoma associated ceived symptoms, biopsies of the cell response.
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