Screening and Treatment Outcomes in Adults and Children With Type 1 Diabetes and Asymptomatic Celiac Disease: The CD-DIET Study

Abstract

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 Experience of a Gluten-free Diet in Children with Type 1 Diabetes and Celiac Disease

“…High rates of asymptomatic CD in patients with T1D have also been reported in the CD-DIET study by Mahmud et al which found that these patients with T1DCD can feel overwhelmed in managing the substantial lifestyle implications of both diseases despite facilitated access to no-cost care ( 6 ). Modified clinical approaches may well be needed to support families of asymptomatic children with CD, compared to children with symptomatic CD ( 19 ).…”

“…Upon starting a GFD, several positive outcomes have been described in children with T1DCD including improvements in gastrointestinal symptoms, reduced number of hypoglycemic events and restoration of weight and growth ( 4 , 5 ). A recent study reports no differences in hemoglobin A1c over the first year of starting a GFD but provides evidence that a transition to a GFD is safe for children with T1D, with no differences in hypoglycemic time or adverse events ( 6 ). While health benefits from a GFD in children with T1DCD have been described, parents of these children have also reported significant challenges in managing both T1D and CD simultaneously including financial concerns and impact on mental/emotional health ( 7 ).…”

Early vs late histological confirmation of coeliac disease in children with new-onset type 1 diabetes

“…However, whether or not a GFD reduces the risk of complications in those with type 1 diabetes and coeliac disease remains to be investigated. It is important to note that studies investigating whether or not individuals with asymptomatic type 1 diabetes benefit from a GFD report inconsistent results, and the long-term benefits of a GFD in asymptomatic children identified by routine screening have not been proven [ 7 – 10 ]. Therefore, screening for coeliac disease in asymptomatic children with coexisting type 1 diabetes, which may already be a burden, is still controversial [ 30 ].…”

Celiac Disease as a Cause of Anemia and Brittle Diabetes in Type 1 Diabetes Mellitus

“…Brittle diabetes or unstable diabetes control should be thoroughly investigated for co-existing medical conditions. 7 Even though routine serologic screening test for CD in adult patients with T1DM yield no clinical benefits, 8 the possible co-existence of CD in T1DM patients must be kept in mind in unexplained hypoglycemia or other non-specific symptoms such as anemia, fatigue, paresthesia, infertility, amenorrhea, male impotence, and osteopenic bone disease. T1DM patients with undiagnosed CD have poor glycemic control and higher chance of diabetic complications.…”