anderson.outpaitent.di1.2.1.4.diseasemanagementpresentation
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TYPE 1 DIABETES AND
CELIAC DISEASE Seth Anderson
Disease Management Presentation
Alaska Native Medical Center – Diabetes Program
UAA Dietetic Intern, 2014 – 2015
PRE- TEST
1. True or False. The only treatment for Celiac Disease is following a Gluten-Free diet.
2. Diagnosis for Celiac Disease uses:
a) Genetic testing
b) Autoantibody testing
c) Biopsy
d) B & C
3. True or False. A skin biopsy could be used for diagnosis of Celiac Disease if the patient has Dermatitis herpetiformitis.
4. Patients with Type 1 Diabetes are at more risk for what conditions?
a) Celiac disease
b) Thyroid disorders
c) Pancreas disorders
d) All of the above
5. True or False. “The Rule of 7” is the common name for treating hypoglycemia.
ETIOLOGY – CELIAC DISEASE (CD)1,2
Autoimmune disease caused by the ingestion of gluten
Can develop in any point in life
Exact cause unknown
Risk Factors:
Family history – 1st degree relatives
Genetics – Human Leukocyte Antigen (HLA) DQ2 or DQ8
Caucasian ethnicity or of European ancestry
Female sex
Other names: coeliac disease, celiac sprue, gluten-sensitive enteropathy, & non-tropical sprue
PATHOPHYSIOLOGY – CELIAC DISEASE1-3
Three groups: typical, atypical, and potential CD
Sources of gluten: wheat, barely, rye, triticale
Immune-mediated response after eating gluten leads to :
Inflammation
Villous atrophy
Crypt hyperplasia
Longer-standing disease consequences
Vitamin deficiencies – vitamin A,D,E, K; iron & folic acid
Risk of developing other autoimmune diseases
Rheumatoid Arthritis, Type 1 Diabetes, Hashimoto’s Thyroiditis
SIGNS AND SYMPTOMS – CELIAC DISEASE1
“celiac disease iceberg”- based on
signs and symptoms
Common symptoms: bloating,
diarrhea, constipation, brain fog,
eczema, anemia
Uncommon symptoms: bladder
infections, GERD, low blood sugar
ETIOLOGY – TYPE 1 DIABETES (T1DM)4
Chronic autoimmune disease of the beta-cells
5.3% incidence annually in the US
Cause: unknown
Genetic factors: HLA DBQ1
Environmental Factors for onset:
Enteroviruses and other viruses
Bacteria and “leaky gut”
Inadequate vitamin D during infancy
PATHOPHYSIOLOGY – T1DM4
1. Genetic susceptibility
2. Environmental trigger
3. Autoantibody development
4. Clinical onset
5. Loss of C-peptide
SIGNS AND SYMPTOMS – T1DM5
Polyuria
Polydipsia
Polyphagia
Weakness/fatigue
Irritability
Sudden weight loss
EVIDENCE ANALYSIS LIBRARY – CELIAC DISEASE6
CD: Assessment of Food/Nutrition-Related History
The RD should assess food and nutrition-related history of individuals w/ CD
including the following:
Food and nutrient intake
Medication and herbal supplement use
Knowledge, beliefs or attitudes
Behavior
Factors affecting access to food and food and nutrition-related supplies
Grade: Strong, imperative
EVIDENCE ANALYSIS LIBRARY – CELIAC DISEASE6
CD: Assessment of other disease states
The RD should assess for the presence of other disease states, such as thyroid
conditions, other autoimmune and endocrine disorders and diabetes, when
implementing medical nutrition therapy (MNT). Identification of all nutritional
issues is optimal to integrate MNT for individuals with CD into overall disease
management.
Grade: consensus, imperative
EVIDENCE ANALYSIS LIBRARY – DIABETES MELLITUS7
DM: MNT and number/length of initial series of encounters
MNT provided by RD is recommended for individuals with type 1 and type 2 diabetes. An
initial series of three to four encounters each lasting form 45 to 90 minutes is
recommended. This series, beginning at diagnosis of diabetes or at first referral to an RD
for MNT for diabetes, should be completed within 3- 6 months. The RD should determine if
additional MNT encounters are needed after the initial series based on the nutrition
assessment of learning need and progress towards desired outcomes. Studies based on
range in the number and length report sustained positive outcomes at one year and
longer. Studies implementing a variety of nutrition interventions report a reduction in A1c
levels, and some studies also report improved lipid profiles, improved weight
management, adjustments in mediations, and reduction in the risk of onset and progression of comorbidities.
Grade: Strong, imperative
NUTRITION CARE MANUAL – CELIAC DISEASE 8
Strict adherence to a Gluten-Free Diet (GFD)
Increased risk of vitamin and mineral deficiencies
Nutrition Counseling Goals:
Education gluten-free diet
Reading food labels – hidden sources of gluten
Planning gluten-free meals at home
Food Safety – cross-contamination
Non-food items containing gluten – medications & supplements
Grains to Avoid Grains to Include Foods potentially containing wheat,
barely, rye
• Wheat
• Barley
• Rye
• Cross-bread varieties (triticale)
• Rice
• Corn
• Amaranth
• Quinoa
• Teff
• Millet
• Sorghum
• Montina
• Arrowroot
• Buckwheat
• Flax
• Potato
• Soy
• Legumes
• Seeds & nuts
• Oats (if uncontaminated)
• Bouillon cubes
• Brown rice syrup
• Candy
• Cold cuts, hot dogs, salami,
sausage
• Communion wafers
• French fries
• Gravy
• Imitation fish
• Licorice
• Matzo
• Rice mixes
• Sauces
• Seasoned snack
• Seitain
• Self-basting turkey
• Soups
• Soy sauce
• Vegetables in sauce
CELIAC DISEASE FOUNDATION9
Dermatitis Herpetiformis (DH):
Itchy bumps or blisters appear on the body
Affects 15%-25% people with CD
Skin biopsy and blood tests
Diagnostic Tests:
Genetic tests – HLA DQ2 or DQ8
Antibody – IgA tissue transglutamase (tTGA- IgA)
Endoscopic Biopsy – gold standard
Skin biopsy – only if DH is present
MARSH STAGES
Stage 1: epithelial cells
are being infiltrated by
lymphocytes
Stage 2: increased
lymphocytes and
crypts are starting to
enlarge
Stage 3 : like stage 2 but
with villi starting to flatten
Stage 4: villi are
completely flattened
and crypts are shrunken
NUTRITION CARE MANUAL – DIABETES10
MNT Goals:
1. Promote & support healthy eating habits
2. Address individual nutrient needs with pt
3. Maintain pleasure of eating
4. Provide practical tools for day-to-day eating
planning
5. For youth: meet proper energy needs for
growth & development
Other topics to discuss:
Physical activity, alcohol use, acute illness,
treating hypoglycemia
AMERICAN DIABETES ASSOCIATION10
Insulin basics
Standard insulin regimen for T1DM
Insulin delivery
Team approach for care
Hyper-/Hypoglycemia & physical activity
SEARCH ENGINES AND TERMS
Search Engines:
PubMed
Google Scholar
Search Terms:
Celiac Disease
Type 1 Diabetes
Diagnosis
Gluten-free
Complications
Diet
Emphasis on nutrition care for
patients with T1DM and CD
CELIAC DISEASE TESTING12 – 15
Al-Sinani S, et al. 2013
Frohlich-Reiterer EE, et al. 2011
Simpson SM, et al. 2013
Leonard MM, et al. 2015 Multiple methods used for screening and diagnosis
Screening ranges varied
Upon diagnosis of T1DM or GI symptoms of CD
Checked annually or biannually if tested negative
Most outpatient facilities did not screen for CD in patients with T1DM14
Diagnosis criteria for classical and subclinical CD:
1. Presence of symptoms associated with CD
2. Positive serological biomarkers associated with CD
3. Presence of HLA-DQ2 or DQ8 alleles during genetic testing
4. Small intestinal biopsy showing March III category
5. Symptom improvement on GFD
GLUTEN-FREE DIET16 – 18
Taler I, et al. 2011
Abid N, et al. 2011
Lionetti E, et al. 2014.
Encouraged starting GFD for patients with T1DM and
symptomatic CD
Asymptomatic patients no solid answer for GFD
Short-term benefits of GFD
GI symptom relief & improved growth
Delayed introduction of gluten-containing foods during
infancy
For infants with high-risk for CD
Increased risk for poor growth and development
RISK FOR OTHER COMPLICATIONS19 – 21
Gopee E, et al. 2013
Mollazadegan K, 2013
Simek DG, 2013
Mainly observing consequences of GFD
Benefits for renoprotection – no changes in albumin
to creatinine ratio (ACR)
Glycemic control – decreased episodes of
hypoglycemia and diabetic ketoacidosis (DKA)
Increased risk for diabetic retinopathy (DRP) – years
after diagnosis of CD; 10 -15 years after CD diagnosis
increased risk of DRP
SUMMARY
Screen patients with T1DM for CD as soon as possible
Know what diagnosis criteria our medical facility uses
Using GFD for symptomatic CD patients
GFD could improve glycemic control for patients with T1DM and CD
Delaying introduction of gluten-containing foods in the first months of the
second half of the first year of life
Monitor diabetes complications with the patient and care team
throughout the patient’s life.
POST- TEST
1. True or False. The only treatment for Celiac Disease is following a Gluten-Free diet.
2. Diagnosis for Celiac Disease uses:
a) Genetic testing
b) Autoantibody testing
c) Biopsy
d) All of the above
3. True or False. A skin biopsy could be used for diagnosis of Celiac Disease if the patient has Dermatitis herpetiformitis.
4. Patients with Type 1 Diabetes are at more risk for what conditions?
a) Celiac disease
b) Thyroid disorders
c) Pancreas dis orders
d) All of the above
5. True or False. True or False. “The Rule of 7” is the common name for treating hypoglycemia.
POST- TEST
1. True or False. The only treatment for Celiac Disease is following a Gluten-Free diet.
2. Diagnosis for Celiac Disease uses:
a) Genetic testing
b) Autoantibody testing
c) Biopsy
d) All of the above
3. True or False. A skin biopsy could be used for diagnosis of Celiac Disease if the patient has Dermatitis herpetiformitis.
4. Patients with Type 1 Diabetes are at more risk for what conditions?
a) Celiac disease
b) Thyroid disorders
c) Pancreas disorders
d) All of the above
5. True or False. “The Rule of 7” is the common name for treating hypoglycemia.
REFERENCES
1. Barker JM, Liu E. Celiac Disease: Pathophysiology, clinical manifestations and associated autoimmune conditions. Adv Pediatr. 2009. 55: 349 – 365.
2. PubMed Health. Celiac disease – sprue. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001280/. Published February 21 2014. Access verified January 2015.
3. Escott-Stump S. Celiac disease. In: Escott-Stump S, Nutrition and Diagnosis-Related Care. 7th ed. Baltimore, MD: Walters Kluwer, Lippincott Wiliams & Wilkins; 2012: 414 – 418.
4. Van Bell TL, Coppieters KT, Von Herrath MG. Type 1 diabetes: Etiology, immunology, and therapeutic strategies. Physiological Rev. 2011. 91(1): 79 – 118.
5. Escott-Stump S. Type 1 diabetes mellitus. In: Escott-Stump S, Nutrition and Diagnosis-Related Care. 7th ed. Baltimore, MD: Walters Kluwer, Lippincott Wiliams & Wilkins; 2012: 528 – 526.
6. Evidence Analysis Library. Celiac disease. http://www.andeal.org/topic.cfm?menu=5279. Access verified January 16 2015.
7. Evidence Analysis Library. Diabetes Type 1 and 2. http://www.andeal.org/topic.cfm?menu=5305&cat=3254. Access verified January 16 2015.
8. Celiac disease. Nutrition Care Manual website. http://www.nutritioncaremanual.org.proxy.consortiumlibrary.org/topic.cfm?ncm_category_id=1&ncm_toc_id=22684&ncm_heading=Nutrition%20Care&ncm_content_id=79695#Overview. Accessed January 17 2015.
9. Celiac Disease Foundation. Celiac disease. http://celiac.org/celiac-disease/. Published 2015. Access verified January 18 2015.
10. Type 1 diabetes. Nutrition Care Manual website. http://www.nutritioncaremanual.org.proxy.consortiumlibrary.org/topic.cfm?ncm_category_id=1&lv1=5517&lv2=18399&ncm_toc_id=18399&ncm_heading=Nutrition%20Care. Accessed January 17 2015.
11. American Diabetes Association. Type 1 diabetes. http://www.diabetes.org/diabetes-basics/type-1/?loc=db-slabnav. Published 2015. Access verified January 18 2015.
REFERENCES 12. Al-Sinani S, et al. Prevalence of celiac disease in omani children with type 1 diabetes mellitus: A cross-
sectional study. Oman Med J. 2013. 28(4): 260 – 263.
13. Frohlich-Reiterer EE, Kaspers S, Hofer S, Schober E, Kordonouri O. Anthropometry, metabolic control, and follow-up in children and adolscents with type 1 diabetes mellitus and biopsy-proven celiac disease. J Pediactrics. 2011. 158(4): 589 – 593.e2
14. Simpson SM, et al. Celiac disease in patients with type 1 diabetes. Diabetes Educator. 2013. 39(4): 532 – 540.
15. Leonard MM, Cureton PA, Fasano A. Managing coeliac disease in patients with diabetes. Diabetes Obese Metabol. 2015. 17: 3 – 8.
16. Taler I, Philip M, Lebenthal Y, de Vries L, Shamir R, Shalitin S. Growth and metabolic control in patients with type 1 diabetes and celiac disease: A longitudinal observational case-control study. Pedriatr Diabetes. 2012. 13: 597 – 606.
17. Abid N, McGlone O, Cardwell C, McCallion W, Carson D. Clinical and metabolic effects of gluten free diet in children with type 1 diabetes and coeliac disease. Ped Diab. 2011. 12:322 – 325.
18. Lionetti E, et al. Introduction of gluten, HLA status, and the risk of celiac disease in children. N Engl J Med. 2014. 371: 1295 – 303.
19. Gopee E, van den Oever ELM, Cameron F, Thomas MC. Coeliac disease, gluten-free diet and the development and progression of albuminuria in children with type 1 diabetes. Pediatric diab. 2013. 14: 455 –458.
20. Mollazadegan K, et al. A population-based study of the risk of diabetic retinopathy in patients with type 1 diabetes and celiac disease. Diabetes Care. 2013. 36: 316 – 321.
21. Simek DG, et al. Diabetes care, glycemic control, complications, and concomitant autoimmune disease in children with type 1 diabetes in Turkey: A multicenter study. J Clin res Pediatr Endocrinol. 2013. 5(1): 20 – 26.
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