Diabetes and Celiac Disease

By Shelley Case, B.Sc., RD posted in Healthy Living Professionals & Educators
Updated

bagels and other carbs The co-existence of type 1 diabetes (DM) and (CD) in both children and adults has been reported in many studies around the world. The reported prevalence of CD in type 1 diabetes rangesbetween1- 9% with several Canadian studies reporting 5-8%. The odds of having both diseases were reported as high as 9.2% in people with diabetes who also had a sibling with diabetes. Clinical observations indicate that in most persons with combined disease, diabetes precedes CD or both are diagnosed at the sometime. The relationship between DM and CD is not completely understood but implicates genetic factors. It appears that a yet unidentified gene within the region of the HLA complex,probably DR3, is common in both diabetes and CD. It is interesting to note that a number of other autoimmune disorders are found not only in people with diabetes but also in those with CD as well (e.g., autoimmune thyroid disease, Addison’s disease and Sjögrens syndrome). Many people with DM and CD area symptomatic for CD or have atypical or subtle symptoms. Untreated CD may contribute to poor or erratic glycemic control. Other risk/complications of untreated CD can include:

1) poor linear growth
2) delayed puberty
3) anemia
4) dental enamel hypoplasia
5) osteopenia (low bone mineral density)
6) osteoporosis
7) thyroid disease
8) miscarriage and infertility
9) lymphoma and other cancers
10) development of other autoimmune disorders

There are several reliable serological screening tests for CD, but the gold standard for diagnosis of CD is the small intestinal biopsy. However, there continues to be great debate in the medical community regarding routine screening for CD in people with type 1 diabetes, especially since the majority of people with diabetes are asymptomatic for CD. Some clinicians feel that the dietary challenges are so great that it is too difficult to ask people with diabetes with asymptomatic CD to follow a gluten-free diet. The problems are compounded by the high cost of the gluten-free diet and the cost of diabetes supplies, as well as the limitation of carbohydrate choice and availability in the combined diet. However, many others recommend that all children with type 1 diabetes be routinely screened and those positive for CD be treated with a gluten-free diet because of the long-term risks of untreated CD. Those in favor of routine screening recommend that initial screening should begin 1-2 years after the diagnosis of type 1 diabetes. Further studies are needed to assess the appropriate interval to follow-up seropostive patients with a normal biopsy as some of these patients may subsequently develop celiac disease.

CELIAC DISEASE

Celiac Disease (CD) is a genetically based, life-long autoimmune disorder in which the absorptive surface of the small intestine is damaged by a substance called gluten. Specific protein fractions called prolamins in wheat, barley and rye set off a chain of events that lead to tissue damage. A wide range of symptoms may be present which can vary greatly in number and severity from one person to another, making diagnosis difficult. Also, some people area symptomatic in spite of gluten-sensitivity and CD can be found in overweight and non-Caucasian persons. Classic symptoms include: bloating, gas, diarrhea, vomiting, weight loss, anemia, chronic fatigue, weakness, bone pain and muscle cramps. Other symptoms can include constipation, constipation alternating with diarrhea, balance problems, migraine headaches, seizures or other neurological complaints, behavior, memory and learning challenges, growth and maturation problems, mouth ulcers, dental enamel defects, infertility and bone disease. There are specific blood screening tests including IgA endomysial and IgA issue transglutaminase antibodies. Total serum IgA levels must also be measured as there is an increased prevalence of IgA deficiency in celiac disease. Patients with IgA deficiency will have false negative screening test results. However, the only definitive test for diagnosis of CD is the small intestinal biopsy.A gluten-free diet should never be started before the blood test and biopsy are done as this can interfere with making the correct diagnosis. New research indicates that CD is one of the most under-diagnosed common disease today, affecting1in every 150-250 people in North America

GLUTEN-FREE DIETT

he treatment for CD is a strict gluten-free diet (GFD) for life. While the presence of gluten is evident in baked goods (e.g., breads, cakes,cookies) and pasta, it is often a”hidden ingredient”in many other items such as luncheon meats, frozen hamburger patties, sauces, seasonings, salad dressings, soups, bouillon cubes, soy sauce, soy beverages, baking powder, candy and occasionally in some vitamin/mineral supplements and pharmaceuticals. Gluten-containing foods to avoid include:

·Barley           .Oats**
·Bran              ·Oat bran**
·Bulgur          ·Rye
·Couscous     ·Semolina
·Durum         ·Spelt*
·Einkorn*     ·Triticale
·Emmer*      ·Wheat
·Farro*         ·Wheat germ
·Kamut*       ·Wheat starch
·Malt, malt extract and malt flavoring
* Types of wheat
** Many recent studies have shown that oats are safe for people with CD, however, the main concern is the issue of cross contamination of oats with wheat, therefore, oats are not recommended in North America at this time
INGREDIENTS TO QUESTION
It is important to confirm the source of the components in the following ingredients as they may contain gluten:
  • Flavorings
  • Hydrolyzed plant or vegetable protein
  • Starch and modified food starch
  • Seasonings
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NUTRITIONAL MANAGEMENT OF CELIAC DISEASE AND DIABETES MELLITUS

People with CD and DM not only have to avoid gluten but also must balance what and when they eat with their insulin and activity levels. Monitoring blood glucose levels and maintaining a food diary are very important to assess the effect of various gluten-free foods on diabetes control. Frequent changes in the insulin dosage may be necessary for up to 6-12 months after the gluten-free diet is initiated. The following key nutritional strategies can help prevent wide fluctuations in blood glucose levels: 1. Carbohydrate counting is essential for people with CD/DM as many gluten-free(GF) products are higher in carbohydrate than their gluten-containing counterparts.

Wheat Bagel                                47 g.CHOT

Tapioca Rice Bagel*                   57 g. CHO

Wheat Hot Dog Bun                  22 g. CHO
Tapioca Rice Hot Dog Bun*     40 g. CHO
All Purpose Wheat Flour          95 g. CHO

(1 cup/250mL)

Rice Flour (1 cup/250mL)        127 g. CHO
Potato Flour (1 cup/250mL)    133 g. CHO
* Kinnikinnick Foods, Edmonton, AB.

2. Glycemic response to many GF carbohydrate foods tends to be higher and faster than similar gluten-containing foods, as they are often higher in starch, lower in fibre and higher in sugar, therefore it is important to:

  • incorporate a solid protein choice* at each meal and the evening snack as this allows for a mixture of food to slow digestion.
  • choose more fibre-rich* gluten-free foods such as amaranth, corn bran, flax seed meal, garbanzo flour, garfava flour (garbanzo and fava beans), quinoa, rice bran, brown rice, soy flour, legumes, nuts, seeds, fruits and vegetables.
  • choose higher protein gluten-free flours such as amaranth, bean, buckwheat, quinoa, soy and teff.
* Protein, fat and dietary fibre can slow down the rate of digestion and release of glucose from carbohydrate containing foods.
There are other nutritional concerns for people with DM and CD:
1. Early bone disease is an issue for people with CD so it is critical to ensure adequate amounts of calcium and Vitamin D.
  • Encourage regular consumption of milk and milk products such as yogurt and cheese as they are excellent sources of available calcium. Other foods contain calcium (e.g., canned salmon or sardines with bones, fortified orange juice and soy beverages) but most contain smaller amounts and/or the calcium is in a form that is poorly absorbed by the body (e.g., almonds, broccoli, spinach, sesame seeds, legumes).
  • The practice of substituting milk choices for other carbohydrate foods can be done occasionally but it is prudent to regularly consume milk choices in order to meet the dietary reference intake (DRI) for calcium and vitamin D.
  • For those people who do not consume adequate amounts of calcium from milk products and other foods, a gluten-free calcium and Vitamin D supplement is recommended.
2. Iron deficiency, with or without anemia is often seen in CD, therefore recommend to:
  • Eat more iron-rich gluten-free foods such as meat, fish, poultry, legumes, nuts, seeds, dried fruit, amaranth, flax, quinoa, rice bran and soy flour.
  • Include heme sources of iron (e.g., red meat, fish and poultry) on a regular basis as they are more readily absorbed by the body (23%) compared to non-heme sources (e.g., grains, fruits, vegetables and eggs) from which only 3-8% of the iron is absorbed.
  • Consume a vitamin C-rich food (citrus fruits, kiwi, berries, broccoli, tomatoes, green and red peppers and cabbage) with non-heme iron sources and/or an iron supplement to enhance iron absorption.

 

GLUTEN-FREE PRODUCTS
There are a wide variety of gluten-free specialty products available from companies in Canada and the USA. Examples include ready-to-eat baked products (e.g., breads, buns, bagels, muffins, cakes, cookies, pies, pizza crusts), baking mixes and specialty flours, hot and cold cereals, crackers, snack foods, entrees, pastas (corn, quinoa, rice and legumes), and other products such as bread crumbs, coating mixes, gravy mixes, sauces, communion wafers, ice cream cones and granola bars.

GLUTEN-FREE RESOURCES
1. Canadian Celiac Association
5170 Dixie Road, Suite 204, Mississauga, ON
L4W 1E3 1-800-363-7296
website: www.celiac.ca email: celiac@look.ca
Many pamphlets, books, cookbooks, videos and other resources, including diabetes and celiac disease publications are available for patients and health care professionals. There are also local celiac chapters across Canada that provide support for people with celiac disease.
2. Gluten-Free Diet: A Comprehensive Resource Guide by Shelley Case, B.Sc., RD Available from specialty food stores, celiac associations and Case Nutrition Consulting at 1940 Angley Court, Regina, SK. S4V 2V2 website: www.glutenfreediet.ca email: info@glutenfreediet.ca This 176 page book contains a wealth of practical information on all aspects of the gluten-free diet for patients and health care professionals who counsel them.
Includes:
  • Over 1600 gluten-free specialty foods listed by company and product name
  • Directory of more than 130 Canadian, American and international companies
  • Gluten-free diet by food groups
  • Nutrition information
  • Labeling regulations
  • Shopping guidelines
  • Creative ideas for meals and snacks
  • Recipes and baking tips
  • Resources- cookbooks, books, magazines, newsletters, web sites and more
REFERENCES DIABETES 
1.  The prevalence and clinical characteristics of celiac disease in juvenile diabetes in Wisconsin.
      J Pediatr Gastroenterol Nutr 2001 Oct; 33 (4):462-465.   Aktay, A.N., et al.
2.  High prevalence of celiac disease in patients with type 1 diabetes detected by antibodies to endomysium
      and tissue transglutaminase.
      Can J Gastroenterol 2001 May;15 (5):297-301. Gillet, P.M., et al
3.   Celiac disease and type 1 diabetes mellitus- the case for screening.
      Diabet Med 2001 Mar;18 (3):169-77.  Holmes, G.K.
4.   Undiagnosed celiac disease and risk of autoimmune disorders in subjects with type 1 diabetes mellitus.
      Diabetologia 2001 Feb.; 44 (2):151-5.   Not, T., et al.
5.   Comparative analysis of organ-specific autoantibodies and celiac disease: associated antibodies in type 1
      diabetic patients, their first-degree relatives and healthy control subjects.
      Diabetes Care 2001 Jan.; 24(1): 27-32.   Jaeger, C., et al.
6.   Celiac disease in children and adolescents with type 1 diabetes: importance of hypoglycemia
      J Pediatr Gastroenterol Nutr 2001 Jan.; 32 (1) 37-40.  Mohn, A., et al.
7.   Development of celiac disease-associated antibodies in offspring of parents with type 1 diabetes.
      Diabetolgia 2000 Aug.; 43 (8):1005-11.  Hummel, M., et al.
8.   Gluten-dependent, diabetes-related and thyroid-related autoantibodies in patients with celiac disease.
      J Pediatr 2000 Aug; 137 (2):263-5. Ventura, A., et al.
9.   Risk for silent celiac disease is higher in diabetic children with a diabetic sibling than in sporadic cases.
      Diabetes Care 2000 July; 23 (7): 1027-8. Cerutti, F., et al.
10. Autoantibodies to tissue transglutaminase are sensitive serological parameters for detecting silent
      celiac disease in patients with type 1 diabetes mellitus.
      Diabet Med 2000 June; 17 (6):441-4.  Kordonouri, O., et al.
11. Screening by anti-endomysial antibody for celiac disease in diabetic children and adolescents in Austria.
      J Pediatr Gastroenterol Nutr 2000 Apr.; 30 (4):391-6.  Schrober, E., et al.
12. Effect of gluten-free diet on the metabolic control of type 1 diabetes in patients with diabetes and celiac disease (letter).  
      Diabetes Care 2000 May; 23 (5): 712-13. Iafusco, D., et al
13. Transglutaminase antibodies in children with a genetic risk for celiac disease.
      J Pediatr 2000  Sept.; 137 (3):356-60.  Hoffenberg, E.J., et al.
14. No effect of gluten-free diet on the metabolic control of type 1 diabetes in patients with diabetes and celiac disease (letter).
      Diabetes Care 1999 Oct.; 22 (10):1747-8.  Kaukinen, K., et al.
15. Type 1 diabetes mellitus, celiac disease and lymphoma: a report of four cases.
      Diabet Med 1999  Jul.; 16 (7):614-7.  O’Connor, T.M., et al.
16. Children with celiac disease and insulin-dependent diabetes mellitus: growth, diabetes control and dietary intake.
      J Pediatr Endocrinol Metab 1999 May-June; 12 (3):433-42.  Westman, E., et al.
17. Prevalence of IgA antiendomysium and IgA antigliadin autoantibodies at diagnosis of insulin dependent diabetes mellitus
      in Swedish children and adolescents.
      Pediatrics 1999 Jun.; 103(6 PT 1):1248-52.  Carlsson, A.K., et al.
18. Use of immunoglobulin A- antiemdomysial antibody to screen for celiac disease in North American children with
      type 1 diabetes.
      Diabetes Care 1998 Nov.; 21 (11):1985-9.  Fraser-Reynolds, K.A., Butzner, J.D., Stephure, D.K.
19. Celiac disease in children and adolescents with IDDM: clinical characteristics and response to gluten-free diet.
      Diabete Med 1998; 15:38-44.  Acerni, C.L., et al.
20. Hypoglycemia and reduction of the insulin requirement as a sign of celiac disease in children with IDDM.
      Diabetes Care 1998 Aug.; 21(8):1379-81.  Iafusco, D., Rea, F., Prisco, F.
21. Diabetes instability and celiac disease.
      Diabetes Care 1998; 21:2192-3   Andreeli, F., et al.
22. Insulin dependent diabetes mellitus and celiac disease.
      Lancet 1997; 349:1096-7.  Cronin, C.C., Shanahan, F.
23. High prevalence of celiac disease among patients with insulin-dependent (type 1) diabetes mellitus.
      Am J Gastroenterol 1997; 92:2210-12.  Cronin, C.C., et al.
24. Celiac disease in an adult population with insulin-dependent diabetes mellitus: use of endomysial antibody testing.
      Am J Gastroenterol 1997;  92:1280-4.  Talal, A.H., et al.
25. The use of IgA-antiendomysial antibody for screening for celiac disease in insulin-dependent diabetes mellitus.     
      Diabetes Nutr Metab 1996; 9:267-8-72.  Nosari, I, et al.
26. Celiac Disease: frequent occurrence after clinical onset of insulin-dependent diabetes mellitus.
      Diabet Med 1996; 13:464-70.  Saukkonen, T., et al.
27. Gluten-sensitive enteropathy in patients with insulin-dependent diabetes mellitus.
      Ann Intern Med  1996;  124(6):564-7.  Rensch, M., et al.
28. Celiac disease and insulin-dependent diabetes mellitus: a causal association.  
      Acta Paediatr 1995; 84:1432-3  Pocecco, M., Ventura, A.
29. Incidence of celiac disease identified by the presence of antiendomysial antibodies in children with chronic diarrhea,
      short stature or insulin-dependent diabetes mellitus.
      J Pediatr 1993; 123:262-4.  Rossi, T.M., Albini, C.H., Kumar, V.
30. Documented celiac disease in a child with insulin-dependent diabetes mellitus.
      Eur J Pediatr  1991; 150:832-4.  Catassi, C., et al.
31. Screening of diabetic children for celiac disease with antigliadin antibodies and HLA typing.
      Arch Dis Child 1991 ; 66:491-4.  Barera, G., et al.
32. High frequency of celiac disease in adult patients with type-1 diabetes.
      Scand J Gastroenterol 1989; 24:81-4.   Collins, P., et al.
REFERENCES CELIAC DISEASE
1. Celiac Disease: Going Against the Grain.
    Nutrition in Clinical Practice 2001 Dec; 18:335-44.   Pietzak, M., et al.
2. Current approaches to diagnosis and treatment of celiac disease: an evolving spectrum.
    Gastroenterology 2001 Feb; 120 (3): 636-651.  Fasano, A. and Cattasi, C.
3. Characteristics of adult celiac disease in the USA: results of a national survey.
    Am J Gastroenterology 2001; 96 (1): 126-31.  Green, PH., et al.
About the Author

Shelley Case is a Consulting Dietitian from Regina who specializes in food allergies, celiac disease and diabetes. A member of the Canadian Celiac Association Professional Advisory Board, she has co-authored the celiac section in the Manual of Clinical ietetics (American Dietetic Association/Dietitians of Canada), as well as other publications. Ms Case was formerly a diabetes educator at the Metabolic & Diabetes Education Centre in Regina for 12 years.