Diabetes and Celiac Disease

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

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 (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


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
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


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.


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.

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.
  • 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
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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.