Despite the advent of sensitive and specific serologic testing, routine screening for celiac disease (CD) in diabetic populations may not be universal practice, and many clinicians struggle to find the optimal approach to managing CD in pediatric Type 1 diabetes (T1D) patients. While some clinicians advocate screening for CD in all patients with T1D, others are unsure whether this is warranted. The diagnosis of patients who present with symptomatic CD, including malabsorption and obvious pathology upon biopsy, remains straightforward, with improvements noted on a gluten-free diet. Many patients identified by screening, however, tend to be asymptomatic. Evidence is inconclusive as to whether the benefits of screening and potentially treating asymptomatic individuals outweigh the harms of managing a population already burdened with a serious illness. This review focuses on current knowledge of CD in children and youth with T1D, highlighting important elements of the disease's pathophysiology, epidemiology, clinical presentation, and diagnostic challenges.

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Background and Objective Celiac disease (CD), the most common genetically‐based food intolerance, affects 3% to 16% of children with type 1 diabetes (T1D). Treatment involves lifelong adherence to a gluten‐free diet (GFD). Individualized dietary education is resource‐intensive. We, therefore, sought to develop and test the usability of an e‐learning module aimed at educating patients and caregivers regarding implementation of the GFD in children with concurrent CD and T1D. Methods An interactive e‐learning module was developed based on extensive review of CD, T1D, and educational literature. A mixed‐methods usability testing approach was used to refine and evaluate the module, using qualitative semi‐structured interviews, observations, and satisfaction and knowledge questionnaires in two iterative cycles. The module was refined based on themes identified from each usability cycle. Results Eighteen patients (8 in cycle 1, 10 in cycle 2) and 15 caregivers (7 in cycle 1, 8 in cycle 2) participated. Patient participants had CD and T1D for a mean (SD) of 6.1 ± 5.1 and 8.3 ± 5.5 years, respectively. Their mean age was 13.5 ± 4.5 years. Thematic analysis of usability interviews showed the module to be appealing and resulted in minor module revisions after each cycle to improve usability. Mean satisfaction scores post‐module completion were high (4.67 ± 0.54), indicating participants were “very satisfied” with the education. Knowledge test scores increased significantly from pre‐ to post‐module completion (P = 0.001). Conclusion A multifaceted user‐centered usability approach demonstrated that an innovative, interactive e‐learning module is effective in knowledge retention and can provide comprehensive and accessible information in the implementation of the GFD teaching in children with CD and T1D.

The additional diagnosis of CD has minimal impact on quality of life in children with T1D; however, parents of CD + T1D children did express greater concern about their child's social functioning.

IntroductionCoeliac disease (CD) is an autoimmune condition characterised by gluten-induced intestinal inflammation, and observed at a 5–10 fold greater prevalence in type 1 diabetes. While universal screening for CD in patients with diabetes is frequently advocated, objective data is limited as to benefits on diabetes control, bone health or quality of life related to the adoption of a gluten-free diet (GFD) in the large proportion of patients with diabetes with asymptomatic CD. The Celiac Disease and Diabetes-Dietary Intervention and Evaluation Trial (CD-DIET) study is a multicenter, randomised controlled trial to evaluate the efficacy and safety of a GFD in patients with type 1 diabetes with asymptomatic CD.Methods and analysisChildren and adults (8–45 years) with type 1 diabetes will be screened for asymptomatic CD. Eligible patients with biopsy-proven CD will be randomly assigned in a 1:1 ratio to treatment with a GFD for 1 year, or continue with a gluten-containing diet. The primary outcome will evaluate the impact of the GFD on change in glycated haemoglobin. Secondary outcomes will evaluate changes in bone mineral density, blood glucose variability and health-related quality of life between GFD-treated and the regular diet group over a 1-year period. The study was initiated in 2012 and has subsequently expanded to multiple paediatric and adult centres in Ontario, Canada.Ethics and disseminationThe findings from this study will provide high-quality evidence as to the impact of GFD treatment on glycaemic control and complications in asymptomatic children and adults with CD and type 1 diabetes.Trial registration numberNCT01566110.

To describe celiac disease (CD) screening rates and glycemic outcomes of a gluten-free diet (GFD) in patients with type 1 diabetes who are asymptomatic for CD. RESEARCH DESIGN AND METHODSAsymptomatic patients (8-45 years) were screened for CD. Biopsy-confirmed CD participants were randomized to GFD or gluten-containing diet (GCD) to assess changes in HbA 1c and continuous glucose monitoring over 12 months. RESULTSAdults had higher CD-seropositivity rates than children (6.8% [95% CI 4.9-8.2%, N 5 1,298] vs. 4.7% [95% CI 3.4-5.9%, N 5 1,089], P 5 0.035) with lower rates of prior CD screening (6.9% vs. 44.2%, P < 0.0001). Fifty-one participants were randomized to a GFD (N 5 27) or GCD (N 5 24). No HbA 1c differences were seen between the groups (10.14%, 1.5 mmol/mol; 95% CI 20.79 to 1.08; P 5 0.76), although greater postprandial glucose increases (4-h 11.5 mmol/L; 95% CI 0.4-2.7; P 5 0.014) emerged with a GFD. CONCLUSIONSCD is frequently observed in asymptomatic patients with type 1 diabetes, and clinical vigilance is warranted with initiation of a GFD.Celiac disease (CD) is an immune reaction-mediated condition triggered by gluten, a protein found in wheat, barley, and rye. CD risk is increased in patients with type 1 diabetes and is characterized by a broad spectrum of presentations, including gastrointestinal symptoms, growth alterations, and anemia, but many patients are asymptomatic (1-4).Serologic screening for CD has high sensitivity and specificity, but few reports have evaluated CD rates and the impact of treatment with a gluten-free diet (GFD) in asymptomatic CD (aCD) patients with type 1 diabetes. The Celiac Disease and Diabetes-Dietary Intervention and Evaluation Trial (CD-DIET) prospectively screened a large cohort of patients aged 8-45 years with subsequent engagement in a randomized, dietary treatment trial to evaluate changes in HbA 1c and glycemic variability.

The gluten free (GF) diet is the only treatment for celiac disease (CD). While the GF diet can be nutritious, increased reliance on processed and packaged GF foods can result in higher fat/sugar and lower micronutrient intake in children with CD. Currently, there are no evidence-based nutrition guidelines that address the GF diet. The objective of this cross-sectional study was to describe the methodological considerations in forming a GF food guide for Canadian children and youth (4-18 years) with CD. Food guide development occurred in three phases: 1) evaluation of nutrient intake and dietary patterns of children on the GF diet, 2) pre-guide stakeholder consultations with 151 health care professionals and 383 community end users, and 3) development of 1260 GF diet simulations that addressed cultural preferences and food traditions, diet patterns and diet quality. Stakeholder feedback identified nutrient intake and food literacy as important topics for guide content. Except for vitamin D, the diet simulations met 100% macro- and micronutrient requirements for age-sex. The pediatric GF plate model recommends intake of >50% fruits and vegetables, <25% grains and 25% protein foods with a stronger emphasis on plant-based sources. Vitamin D fortified fluid milk/unsweetened plant-based alternatives and other rich sources are important to optimize vitamin D intake. The GF food guide can help children consume a nutritiously adequate GF diet and inform policy makers regarding the need for nutrition guidelines in pediatric CD.

Objective: To compare the accuracy of the Osborne calculation for estimating gluten content in food in relation a laboratory (ELISA) based method. Methods: We evaluated 25 commonly consumed gluten-containing food products for ELISA testing of gluten to determine analyzed gluten content. This was compared with calculated gluten content (using the Osborne method) which was determined as 80% of the plant protein content of each food item using nutrition information. Correlation coefficient (r), along with a 95% confidence interval (CI) and Bland Altman plots were used to estimate the level of agreement between calculated and analyzed gluten. Results: A reasonable overall correlation coefficient of r = 0.46 a 95% CI (0.08-0.73, R 2 = 0.22) was seen. We observed that variability in the Osborne (calculated) and analyzed gluten increased as the average gluten content increased and the average difference was not constant over the range of gluten measurements. In addition, the calculated gluten measure tended to be higher than analyzed and thus overestimated gluten content (net overestimation was 3.3 g (95% CI-4.0 to 10). Stronger correlations were observed in foods with a gluten content that was lower than the total protein content (N=18, r=0.70, 95% CI=0.35 to 0.88, R 2 = 0.49). Conclusions: These findings indicate that the Osborne (calculated) to analyzed gluten shows a reasonable correlation in foods with lower gluten content (less than 5 g gluten), and that the Osborne method is a practical way to estimate gluten content.