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.

DISEASE OVERVIEW

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

MEDICAL NUTRITION THERAPY AND DISEASE

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

RESEARCH ARTICLES

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.