Coeliac Disease and Type 1 Diabetes

Type 1 Diabetes & Coeliac Disease

Diabetes is a condition where there is too much glucose (sugar) in the blood (hyperglycaemia). The pancreatic hormone insulin is responsible for the transport of glucose from the blood to the body’s cells where it is used as a vital source of energy. In those with diabetes, either insufficient insulin is produced by the pancreas, or the insulin produced does not work properly1.

The classic symptoms of diabetes include: a lack of energy, excessive urine production, thirst, and unexplained weight loss1

Types of Diabetes

There are two main forms of diabetes: type 1 and type 2 diabetes.

Type 1 diabetes is an autoimmune disease where the ß-cells in the pancreas responsible for producing insulin are destroyed. Type 1 diabetes usually develops before the age of 30, with 50% of individuals diagnosed before the age of 162.

Treatment of type 1 diabetes involves insulin replacement via injection or insulin pump therapy, regular carbohydrate containing meals and snacks, and frequent monitoring of blood glucose levels. Those with type 1 diabetes have an increased risk of developing coeliac disease.

In those with type 1 diabetes, the excess glucose in the blood is passed into the urine (glycosuria). This increases the amount of urine produced (polyuria). Excessive urination leads to increased thirst to replace the lost fluid. In addition, as the body is unable to access the glucose to use as energy, it turns to its fat and protein stores (muscle) as alternative energy sources. This use of fat stores as a metabolic fuel may result in “ketoacidosis”. If untreated this will lead to coma and eventual death1 .
Type 2 diabetes is more common than type 1 diabetes (although incidence of both is increasing11). It is an “insulin-resistant” form of diabetes where insulin is still produced but in an ineffective form and/or in smaller amounts. There is a genetic basis to this disease and its development is closely linked with obesity. It most commonly develops in people over the age of 55, but with rising levels of obesity in the population, it is becoming increasingly common in younger adults and even children. Diet and lifestyle changes may be sufficient to control the disease, but most patients will also require oral medication. Eventually, some people may need to have insulin injections1. There is no link between coeliac disease and type 2 diabetes, however it is possible for both of these conditions to occur in the same person but independent of each other.

How is Type 1 Diabetes related to Coeliac Disease?

If a person has one autoimmune disease, they are at an increased risk of developing another. As many as 10% of children and adolescents with type 1 diabetes also develop coeliac disease3-9. The diabetes diagnosis is usually the first to occur, with coeliac disease diagnosed on subsequent routine screening (although it is commonly suspected that coeliac disease may have been present prior to the diagnosis of diabetes in many). Coeliac disease often causes no obvious digestive symptoms in those with diabetes, despite severe inflammation in the small intestine7, 9 & 14. Undiagnosed coeliac disease has also been associated with increased frequency of (life-threatening) hypoglycaemic episodes13.

Those with type 1 diabetes need to carefully monitor their intake of food and drinks containing carbohydrate. When diagnosed with coeliac disease, gluten containing carbohydrates (wheat, rye, barley and oats) must be removed from the diet. This can impact on the control of blood glucose levels due to the inclusion of different carbohydrate containing foods. If you are diagnosed with both conditions, advice should be sought from a dietitian about your combined dietary requirements.

Diagnosing Type 1 Diabetes

To test for type 1 diabetes, your doctor will assess your blood glucose levels and test your urine for glucose and ketones. High levels of glucose and ketones (in the blood and urine) are highly suggestive of type 1 diabetes. It is important not to delay the diagnosis of type 1 diabetes, as it can be life threatening if left untreated. If you suspect you have type 1 diabetes, speak to your doctor.

Treatment of Type 1 Diabetes

Type 1 diabetes is a lifelong condition for which there is currently no cure. The management of type 1 diabetes involves insulin replacement via frequent daily injections or insulin pump therapy, regular blood glucose monitoring along with the right balance of healthy food choices and physical activity. If coeliac disease also develops, a gluten free diet is required as well. It is important to consider the amount and type of carbohydrate consumed. Management is a team affair. Regular medical consultations with your family doctor and/or specialists (usually endocrinologist and gastroenterologist or paediatrician), diabetes educator and dietitian are important for managing the conditions. The aim of treatment is good blood glucose (glycaemic) control. A number of factors can influence glucose levels e.g. insulin injections, diet, exercise and illness1. Poorly controlled coeliac disease can cause brittle blood sugar control.

Consequences of Type 1 Diabetes

If type 1 diabetes is not managed appropriately, a number of consequences can result. Preventable complications of diabetes can cause unnecessary illness and sometimes death1, 16. If blood glucose levels are consistently too high (hyperglycaemia), this increases the risk of diabetes complications including: Diabetic retinopathy (which may lead to poor vision and sometimes blindness), Diabetic nephropathy (renal disease), Diabetic neuropathy (nerve damage which may affect the feet, legs or gastrointestinal tract) and cardiovascular disease. Tight control of blood glucose levels and regular diabetes complications screening is essential to reduce the risk of these complications.

Hypoglycaemia occurs when blood glucose levels fall below 4mmol/l1. This can be the result of a missed or delayed meal, not consuming enough carbohydrate at the last meal, being more physically active than usual, too much insulin or alcohol (especially if consumed on an empty stomach)1. The signs of hypoglycaemia include sweating, shakiness, nausea, increased heart rate and irritability. If glucose levels continue to fall, brain function can be impaired, causing confusion, disorientation, slurred speech and increasingly disturbed and often aggressive behaviour. Eventually the person may become unconscious. Treatment for a “hypo” in the early stages involves ingesting approximately 15g of rapidly absorbed carbohydrate. If unconsciousness occurs, the person is extremely drowsy, unable to take direction and/or having a seizure, do not give anything by mouth. Place them in the recovery position and call an ambulance, stating “diabetic emergency”. If available, give a glucagon injection. Glucagon is the hormone responsible for releasing stored glucose from the liver1. Additional slower acting carbohydrate should be ingested following initial recovery. In the event of hypoglycaemia, treating quickly with enough carbohydrate is the priority. If a person has both coeliac disease and diabetes, they should not hesitate to eat or drink a food or beverage that contains gluten should they experience a hypoglycaemic episode when no gluten free carbohydrate alternative is available. The danger associated with hypoglycaemia outweighs the immediate risk associated with gluten ingestion.

References

1. Thomas B, Manual of Dietetic Practice. Blackwell Publishing Company, 2001

2. Australasian Paediatric Endocrine Group for Department of Health and Ageing. Clinical practice guidelines: Type 1 diabetes in children and adolescents. NHMRC, 2005.

3. Atkay AN, Lee PC, Kumar V, Oarton E, Wyatt DT, Werlin SL: The prevalence and clinical characteristics of coeliac disease in juvenile diabetes in Wisconsin. Journal of Paediatric Gastroenterology & Nutrition 33:462-465, 2001.

4. Calero P, Ribes-Koninckx C, Albiach V, Carles C, Ferrer J: IgA antigliadin antibodies as a screening method for nonevert coeliac disease in children with insulin-dependent diabetes mellitus. Journal of Paediatric Gastroenterology & Nutrition 23:29-33, 1996.

5. Carlsson AK, Axelsson IE, Borulf SK, Bredberg AC, Lindberg BA, Sjoberg KG, Ivarsson SA. Prevalence of IgA-antiendomysium and IgA-antigliadin autoantibodies at diagnosis of insulin-dependent diabetes mellitus in Swedish children and adolescents. Pediatrics 103:1248-1252, 1999

6. Crone J, Rami B, Huber WD, Granditsch G, Schober E: Prevalence of Coeliac Disease and Follow-up of EMA in Children and Adolescents with Type 1 Diabetes Mellitus. Journal of Pediatric Gastroenterology & Nutrition 37:67-71, 2003

7. De Vitis I, Ghirlanda G, Gasbarrini G: Prevalence of coeliac disease in type 1 diabetes: a multicentre study. Acta Paediatrica Supplement. 412:56-57, 1996

8. Hansen D, Bennedbaek FN, Hansen LK, Hoier-Madsen M, Hegedu LS, Jacobsen BB, Husby S: High prevalence of coeliac disease in Danish children with type 1 diabetes mellitus. Acta Paediatrica 90:1238-1243, 2001

9. Not T, Tommasini A, Tonini G, Buratti E, Pocecco M, Tortul C, Valussi M, Crichiutti G, Berti I, Trevisiol C, Azzoni E, Neri E, Torre G, Martelossi S, Soban M, Lenhardt A, Cattin L, Ventura A: Undiagnosed coeliac disease and risk of autoimmune disorders in subjects with Type 1 diabetes mellitus. Diabetologia 44:151-155, 2001

10. Cerutti F, Bruno G, Chiarelli F, Lorini R, Meschi F, Sacchetti C. 10. Cerutti F, Bruno G, Chiarelli F, Lorini R, Meschi F, Sacchetti C. Younger age at onset and sex predict celiac disease in children and adolescents with type 1 diabetes: an Italian multicenter study. Diabetes Care 27:1294-1298, 2004

11. Amos AF, McCarty DJ, Zimmet P. The rising global burden of diabetes and its complications: estimates and projections to the year 2010. Diabetic Medicine 14 (Suppl 5):S1-S85, 1997

12. Pozzilli P and Di Mario U. Autoimmune Diabetes Not Requiring Insulin at Diagnosis (Latent Autoimmune Diabetes of the Adult). Diabetes Care 24:8; 1460-1467, 2001

13. Mohn A, Cerruto M, Lafusco D, Prisco F, Tumini S, Stoppoloni O, Chiarelli F. Coeliac disease in children and adolescents with type 1 diabetes: importance of hypoglycemia. Journal of Paediatric Gastroenterology & Nutrition 32:34-40, 2001

14. Saukkonen T, Vaisanen S, Akerblom HK, Savilahti E. Childhood Diabetes in Finland Study Group: Coeliac disease in children and adolescents with type 1 diabetes: a study of growth, glycaemic control, and experience of families. Acta Paediatrica 91:297-302, 2002

15. World Health Organisation. Definition, Diagnosis and Classification of Diabetes Mellitus and its Complications. Geneva: WHO, 2000

16. Laing SP, Swerdlow AJ, Slater SD. The British Diabetic Association Cohort Study, II: Cause-specific mortality in patients with insulin-treated diabetes mellitus. Diabetic Medicine 16:466-471, 1999