Sex- and age-dependent effects of celiac disease on growth and weight gain in children with type 1 diabetes: Analysis of the type 1 diabetes Exchange Clinic Registry

Nutritional Status in Children with Celiac Disease and Type 1 Diabetes Mellitus-A Narrative Review

In children with type I diabetes mellitus (T1DM) and celiac disease (CD), malabsorption could add to a deficient nutritional status, resulting in impaired growth and weight and height deficits, as well as deficiencies in vitamins and micronutrients. This narrative review aims to assess the current evidence regarding the consequences of the concomitant diagnoses of CD and T1DM on the nutritional status of children. Results regarding the influence of CD and T1DM weight, height, and BMI are controversial, especially if we consider that most of the studies have a small number of patients and that adherence to a gluten-free diet is not adequately assessed. There is a lack of studies considering specific dietary habits and ethnic and cultural differences. Children with T1DM and longer time with positive serology for CD have lower levels of ferritin, vitamin D 25OH, and folate and also lower bone mineral density.

14. Children and Adolescents: Standards of Care in Diabetes-2025

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Adherence to gluten free diet and problems faced by children with celiac disease and type 1 diabetes mellitus

Introduction

Celiac disease (CD) in children can be associated with Type 1 Diabetes Mellitus (T1DM) as both share autoimmune etiology. Mainstay of treatment in celiac disease is total avoidance of gluten in diet whereas treatment in child with both the diseases will be Insulin therapy, exercise along with gluten free diet (GFD). There is dearth of literature regarding adherence to GFD and barriers for children with both T1DM and CD.

Methods

A questionnaire-based study was done at a tertiary care institute so as to compare the self-reported gluten adherence and the problems faced by children with dual diseases (TIDM and CD) and CD alone. Thirty children of age group 5-14 years each withType 1 DM and CD (T1DMCD group) and celiac disease (CD group) were selected consecutively. A questionnairewas filled by asking questions from either children (above 8 years) or parents (below 8 years) and the results were compiled, compared and further analysed.

Results

Baseline demographic parameters were comparable in both the groups. Gluten adherence was found to be worse in T1DMCD group as compared to CD group. Greater number of problems were experienced by children with both TIDM and CD as compared to children with CD alone (P < 0.05). Financial burden more so in T1DMCD group, unawareness about disease and benefits of GFD, less availability and social isolation were found to be the most significant barriers to diet adherence.

Conclusion

As these children face dual diseases, they should be made more aware regarding benefits of GFD. Such information is valuable to primary care physicians for better management and rehabilitation of children suffering from these chronic diseases.

Role of Gluten-Free Diet on HbA1c Level in Children with Type 1 Diabetes Mellitus and Celiac Disease

Background

Due to autoimmune mechanisms, celiac disease (CD) may affect patients with type 1 diabetes mellitus (T1DM) more than the general population.

Objectives

We evaluated the effect of a gluten-free diet (GFD) on HbA1c levels in patients with both type 1 diabetes and CD.

Methods

In this cross-sectional study, biochemical and clinical information was gathered from 174 children with T1DM from January 2013 to January 2019.

Results

We assessed 174 children with T1DM (93 girls and 81 boys). Celiac disease was diagnosed in 18 out of 174 cases (10.34%). Height and weight percentiles showed significant differences between children with CD and those without CD (P = 0.015 and P = 0.026, respectively). The average HbA1c in the celiac group was 8.61 ± 2.20 (95% CI: 5.1 - 12.1) prior to GFD therapy. HbA1c was assessed six and twelve months following the initiation of the GFD and was found to be 8.32 ± 1.46 (95% CI: 6 - 9.8) and 8.37 ± 1.67 (95% CI: 6.1 - 10.2), respectively. No significant change in HbA1c was observed before and after therapy (P = 0.501).

Conclusions

Diabetic children with CD exhibit lower weight and height compared to those without CD. Gluten-free diet therapy in patients with CD did not affect HbA1c levels.

Celiac disease - a pluripathological model in pediatric practice

Being defined as an autoimmune, chronic pathology, frequently encountered in any age group, but especially in pediatrics, celiac disease (also called gluten enteropathy), is gaining more and more ground in terms of diagnosis, but also interest in research. The data from the literature of the last decades attest the chameleonic way of its presentation, there may be both classic onset symptoms and atypical symptoms. Given the impact played by celiac disease, especially in the optimal growth and development of children, the current narrative review aims to highlight the atypical presentation methods, intended to guide the clinician towards the inclusion of the pathology in the differential diagnosis scheme. To these we add the summary presentation of the general data and therapeutic lines regarding the underlying condition and the existing comorbidities. In order to place the related information up to date, we performed a literature review of the recent articles published in international databases. We bring forward the current theories and approaches regarding both classic celiac disease and its atypical manifestations. Among these we note mainly constitutional, skin or mucous, bone, neuro-psychic, renal, reproductive injuries, but also disorders of biological constants and association with multiple autoimmunities. Knowing and correlating them with celiac disease is the key to optimal management of patients, thus reducing the subsequent burden of the disease.

14. Children and Adolescents: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Metabolic control, adherence to the gluten-free diet and quality of life among patients with type 1 diabetes and celiac disease

AIMS

In this cross-sectional study, we aimed to evaluate metabolic control, adherence to a gluten-free diet (GFD), and quality of life (QoL) in individuals with type 1 diabetes (T1D) and celiac disease (CD).

METHODS

We targeted individuals with T1D and CD at a major tertiary hospital in Saudi Arabia. We gathered retrospective data from medical records and prospectively assessed glycemic control using HbA1c and ambulatory glucose metrics, adherence to a GFD using the Celiac Dietary Adherence Test (CDAT), and QoL using the Celiac Disease Quality of Life survey (CD-QoL).

RESULTS

Forty-eight out of 1095 patients screened (4.38%) were included. Mean age and HbA1c were 21.3 (± 6.6) and 8.3% (± 0.8%). The average time in range% and above range% were 38.5 (range 24-68) and 29.6 (± 7.4). The median hypoglycemic events/month was 8, with a median duration of 80 min. The median overall CDAT and CD-QoL scores were 20.5 and 54. No significant correlations were observed between glucose management indicator (GMI), % in target, and CDAT/CD-QoL scores (all p > 0.05).

CONCLUSIONS

No significant effect of GFD on QoL or glycemic control was observed. Further prospective studies are warranted to establish solid evidence of the impact of GFD on individuals with T1D and CD.

14. Children and Adolescents: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The impact of gluten-free diet on growth, metabolic control and quality of life in youth with type 1 diabetes and celiac disease: A systematic review

AIMS

To evaluate the impact of gluten free diet (GFD) on growth, metabolic control and quality of life in children and adolescents with type 1 diabetes (T1D) and celiac disease (CD).

METHODS

A systematic search was performed including studies published in the last 15 years. PICOS framework was used in the selection process and evidence was assessed using the GRADE system.

RESULTS

Overall, studies comparing youth with T1D + CD on GFD to those with T1D only, showed no significant differences in growth parameters, HbA1c, number of episodes of hypoglycemia, total daily insulin doses. Studies assessing the effect of GFD introduction showed stable BMI and HbA1c. Only two studies assessed QoL of life, which was not different between T1D + CD vs T1D only youth, as well as pre- and post-CD diagnosis and introduction of GFD.

CONCLUSION

This systematic review, including only studies of moderate-high evidence quality level and reporting data on objectively assessed adherence to GFD, highlights that adherence to GFD in youth with T1D + CD leads to regular growth, stable BMI, without any negative effect on HbA1c and insulin requirements. Although assessed in few studies, lipid profile and QoL improved with the introduction of GFD.

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

OBJECTIVE

This study examined overall self-reported adherence to gluten-free diet (GFD) in children with type 1 diabetes and celiac disease (T1DCD) compared to children with celiac disease (CD). Secondary objectives included gaining insight into self-reported symptoms, barriers to adherence, and experience of a GFD between groups.

METHODS

Children <18 years old who had been seen at BC Children's Hospital for T1DCD or CD were invited to participate in a web-based questionnaire and medical record review.

RESULTS

A total of 26 children with T1DCD and 46 children with CD participated in the study. The groups' demographics and symptoms of CD were similar; however, a greater proportion of those with T1DCD were asymptomatic at diagnosis (T1DCD 27%; CD 7%; P = 0.016). Overall adherence to a GFD was high in both groups (T1DCD 92%; CD 100%; P = 0.38) but those with T1DCD reported a significantly less positive effect on their health (P = 0.006) and a significantly greater negative effect on activities from a GFD (P = 0.03). Children with T1DCD reported more significant barriers to eating gluten-free at home and at restaurants, specifically with social pressure, cost and taste compared to those with CD only.

CONCLUSION

Children with T1DCD face specific barriers in adherence that are more impactful compared with children living with CD. These children are more often asymptomatic at diagnosis, and they go on to experience different impacts of a GFD spanning across home and social settings. Given the complexity of having a dual diagnosis, CD care should be tailored specifically to children living with T1DCD.

Growth and development in type 1 diabetes

PURPOSE OF REVIEW

The purpose of this review is to summarize the current literature on the subject of linear growth in children and adolescents with or at risk for type 1 diabetes mellitus (T1DM).

RECENT FINDINGS

Poor glycemic control in T1DM is associated with growth hormone resistance, and improving glycemic control can improve linear growth. Newer reports suggest that the increasingly popular very low carbohydrate diets, may reduce linear growth velocity.

SUMMARY

Linear growth during childhood is a complex process regulated influenced by genetic, hormonal, nutritional and environmental factors. Linear growth may be impaired in children with T1DM, correlating with poor metabolic control; an extreme example is Mauriac syndrome. This decrement in linear growth appears to be driven in part by a reduction in growth hormone responsiveness, leading to low insulin-like growth factor-1 (IGF-1) levels. Improving glycemic control can lead to improved IGF-1 levels and linear growth. Other factors associated with poor linear growth in T1DM include celiac disease and dietary alterations, with early reports suggesting that very low carbohydrate diets, if not carefully managed, may increase risk of attenuated linear growth. This review examines the latest data regarding the associations between T1DM and linear growth in children.

14. Children and Adolescents: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Celiac disease in children with type 1 diabetes varies around the world: An international, cross-sectional study of 57 375 patients from the SWEET registry

BACKGROUND

Children with type 1 diabetes (T1D) are at much higher risk of developing celiac disease (CD) than the general population. The aim of the study was to assess the prevalence and differences in clinical presentation of CD in T1D in different regions of the world.

METHODS

This study is based on the Better control in Pediatric and Adolescent diabeteS: Working to crEate cEnTers of Reference (SWEET) database. There were 57 375 patients included in the study, aged ≤18 years from 54 SWEET centers. Only centers with screening for celiac disease were included. Regression models adjusted for age, diabetes duration, and gender and a fixed effect in the models for region was used. Diabetes duration, age at diabetes onset, and sex were presented as unadjusted results.

RESULTS

CD was present in 2652 subjects (4.5%), with different prevalence among regions: from 1.9% in Asia/Middle East to 6.9% in Australia/New Zealand. CD was observed more often among females. Comparing children with and without CD, characteristics for those with CD were younger age at diabetes onset (6.3 [3.3; 9.8] vs 8.1 [4.6; 11.3], P < 0.001) and had longer diabetes duration (6.4 [3.6; 9.8] vs 4.8 [2.1; 8.2], P < 0.001). Further, they had lower glycosylated hemoglobin (HbA1c) in Europe and North America/Canada; lower body mass index (BMI)-SD score (BMI-SDS) in southern Europe, North America, and Canada; In most regions daily insulin dose was lower, height-SDS was lower, and the percentage of insulin pump users was higher in children with T1D and CD.

CONCLUSIONS

The prevalence and the anthropometric and metabolic consequences of CD in children with T1D differ around the world.

13. Children and Adolescents: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Type 1 Diabetes Mellitus and Celiac Disease: Distinct Autoimmune Disorders That Share Common Pathogenic Mechanisms

BACKGROUND

The relatively common co-occurrence of type 1 diabetes (T1D) and celiac disease (CD) suggests these disorders share common pathogenic etiologies.

SUMMARY

T1D and CD are strongly linked to closely related high-risk human lymphocyte antigens (HLA-DR-DQ). High-risk HLA molecules bind specific fragments of gluten or the islet self-antigen(s) and present these antigens to antigen-responsive T cells. In an appropriate proinflammatory environment, the autoimmune response results in destruction of the intestinal enterocyte and/or the pancreatic beta cell. Environmental factors have been implicated in the etiology of T1D and CD because (1) identical twins are only partially concordant for these disorders and (2) incidence rates of T1D and CD have been steadily rising for decades. Prospective studies in infants genetically predisposed to T1D and CD showed that antibody positivity to both disorders begins in the first 1-3 years of life. Viral infections and early exposure to gluten or cow's milk in the infant diet have been implicated in disease pathogenesis. However, delaying introduction of gluten in the infant diet until 12 months of age had no impact on the development of islet or celiac autoimmunity. Weaning nursing infants to hydrolyzed infant formula had no impact on the development of T1D. Viral infections have been suspected of playing a role in T1D pathogenesis for decades. A large international prospective study (TEDDY) has shown increased risk of T1D autoimmunity particularly when >5 respiratory infections or febrile infections have occurred in the 9 months preceding the appearance of islet antibodies. Provocative data in animal models of T1D suggest the microbiome may play an important role in the pathogenesis of T1D. Breastfeeding, diet, infections, antibiotics, and method of birth alter the composition of the microbiome. Human data indicate subtle differences in the microbiome of children with T1D autoimmunity, while intestinal dysbiosis has been clearly demonstrated in CD. Alterations of the integrity of the intestinal mucosa plays an important role in the pathogenesis of CD, and the NOD mouse model suggests an important role of a leaky intestinal epithelium in T1D as well. Key Message: Immunogenetics and the environment are closely interrelated in the pathogenesis of T1D and CD. Large well-designed prospective studies in at-risk populations informed by scientifically rigorous studies in animal models are likely to have the greatest impact on our understanding of the complex pathogenesis of these detrimental autoimmune disorders.

13. Children and Adolescents: Standards of Medical Care in Diabetes-2020

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

13. Children and Adolescents: Standards of Medical Care in Diabetes-2019

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.