Does a gluten-free diet lead to better glycemic control in children with type 1 diabetes? Results from a feasibility study and recommendations for future trials

Pancreatic Comorbidities in Pediatric Celiac Disease: Exocrine Pancreatic Insufficiency, Pancreatitis, and Diabetes Mellitus

Celiac disease (CD) is a chronic and immune-mediated disorder triggered by the ingestion of gluten in some genetically predisposed individuals. CD can be associated with extra-gastrointestinal manifestations and diseases affecting several organs. In this review, the aim is to analyze and discuss the pancreatic alterations and/or comorbidities that could arise in the context of pediatric CD. Exocrine pancreatic insufficiency (EPI) can be observed in a variable fraction (up to 30%) of children diagnosed with CD at the diagnosis; indeed, it usually resolves after the implementation of a gluten-free diet (GFD). The main pathophysiological mechanisms of EPI could be represented by the impaired pattern of gastrointestinal hormones in CD patients. Conversely, pancreatitis seems to be a very rare comorbidity in CD children, since very few cases have been described in children. Therefore, there is no evidence that pancreatitis (including autoimmune forms) represents a relevant comorbidity in pediatric CD. Type 1 diabetes mellitus (T1DM) is a well-known and frequent comorbidity in CD children. The main determinant of this epidemiological association is the common HLA-related predisposing background, even if other (non-HLA-related) genetic and environmental factors (viruses, gut microbiome, and others) are likely to be also implicated in the development of both these autoimmune diseases. T1DM children with concomitant CD may experience specific challenges in the adherence to GFD, which has no negative impact on the glycemic and, in general, metabolic control of diabetes, if it is properly implemented and followed up.

Gluten-free diets for metabolic control of type 1 diabetes mellitus in children and adolescents: a systematic review and meta-analysis

The aim of this review is to comprehensively assess the association between a gluten-free diet (GFD) and metabolic control of type 1 diabetes mellitus (T1DM) in children and adolescents with T1DM and with T1DM plus coeliac disease (CD). PubMed, Embase, Cochrane Library, and Web of Science were searched until June 19, 2023. Primary outcomes were hemoglobin A1c (HbA1c), insulin dose, insulin dose adjusted A1c (IDAA1c), blood glucose (B-glu) at 90 min during Mixed Meal Tolerance Test (MMTT), C-peptide area under the curve (AUC), and C-peptide. Seven studies involving 355 T1DM patients were included. Three studies involving 141 patients compared a GFD to a standard diet in children and adolescents withT1DM without CD. Additionally, two studies with 164 patients examined the same diet comparison in those with T1DM and concurrent CD. A comparison between T1DM with CD and T1DM alone, using a GFD, was conducted in two studies encompassing 50 patients. Patients withT1DM alone had similar HbA1c [pooled weighted mean difference (WMD) = -0.5, 95% confidence interval (CI): -1.0 to 0.1, P = 0.079] and IDAA1c (pooled WMD = -0.4, 95%CI: -0.9 to 0.1, P = 0.095) levels after a GFD and a standard diet. In children and adolescents withT1DM and CD, a GFD was associated with a significantly lower HbA1c compared with a standard diet (pooled WMD = -0.64, 95%CI: -1.22 to -0.05, P = 0.034). Insulin dose was significantly lower in T1DM combined with CD patients having a GFD vs a standard diet (pooled WMD = -0.34, 95%CI: -0.66 to -0.03, P = 0.032). Our study suggests that a GFD may offer significant benefits for children and adolescents with both T1DM and CD over a standard diet. While the evidence indicates improved glycemic control with a GFD, the quality of this evidence is low, highlighting the need for rigorous, randomized trials to confirm these preliminary findings. In the interim, enhancing dietary awareness and providing tailored nutritional guidance could be pivotal for optimizing glucose management in this patient population.

Meta-Analysis: Global Prevalence of Coeliac Disease in Type 1 Diabetes

BACKGROUND

Coeliac disease (CD) is common in patients with type 1 diabetes (T1D), but prevalence varies globally due to differing screening protocols. There have been substantial changes in screening guidelines over the past two decades.

AIM

To evaluate CD prevalence in patients with T1D, focusing on screening studies using antitissue transglutaminase (anti-tTG) antibody.

METHODS

We searched PubMed, Web of Science, Embase and Scopus for studies published up to 11 December 2023 using keywords related to CD and diabetes. We used random-effects models for overall prevalence and all subgroups, with heterogeneity assessed using Cochran's Q test and the I2 statistic performed in STATA 18.

RESULTS

We included 106 articles involving 65,102 T1D patients across 40 countries. The pooled CD seroprevalence and confirmed CD prevalence were 9% (95% confidence interval, CI, 8%-10%) and 6% (95% CI 5%-7%), respectively. The prevalence was higher in females and children. Denmark, Saudi Arabia and Libya exhibited the highest prevalence (11%), followed by India and Egypt (10%). Belgium, France, Germany, South Africa and the United States had the lowest prevalence (2%). High-income countries showed significantly a lower CD prevalence than middle-income countries (p = 0.03). Meta-regression based on the Human Development Index (HDI) indicated that countries with higher HDI have lower seroprevalence and confirmed CD prevalence.

CONCLUSION

Approximately 1 in 16 patients globally and 1 in 12 patients in Asia and the Middle East with T1D has CD. We suggest that all patients with T1D should be screened for CD.

Nutritional Consequences of Celiac Disease and Gluten-Free Diet

Celiac disease is an immune-mediated condition triggered by gluten ingestion in genetically predisposed individuals. The global prevalence of celiac disease is significant, affecting approximately 1.4% of women and 0.7% of men, with incidence rates of 17.4 and 7.8 per 100,000 person-years, respectively. The clinical presentation of celiac disease may range from overt diarrhea and malabsorption to more subtle features such as nutritional deficiencies and extraintestinal manifestations. It is the most common cause of global malabsorption in Western countries. A life-long gluten-free diet is the only available treatment for celiac disease. Moreover, a gluten-free diet is often adopted by individuals without celiac disease, either to address non-celiac gluten sensitivity or for other reasons. This review aims to explore the current understandings of the nutritional consequences of untreated celiac disease and the impact of the gluten-free diet itself. Physicians and dietitians specializing in celiac disease should focus on providing a well-rounded nutritional scheme to address deficiencies caused by the disease and prevent the instauration of new nutritional imbalances.

Predictors of celiac disease in patients with type 1 diabetes and positive tissue transglutaminase immunoglobulin A

OBJECTIVES

Identify clinical and serologic features that more accurately predict a diagnosis of celiac disease (CD) in children with type 1 diabetes mellitus (T1DM), particularly focusing on the degree of elevation of tissue transglutaminase immunoglobulin A (TTG IgA) and dilution of positive endomysial antibody (EMA).

METHODS

We performed a single-center retrospective review of patients with T1DM who underwent endoscopy from 2016 to 2022 for evaluation of CD. We compared demographic, anthropometric, and laboratory data as well as symptoms and endoscopy findings for subjects with and without CD.

RESULTS

Of 123 subjects who underwent esophagogastroduodenoscopy, 74 (60%) were diagnosed with CD. Univariate logistic regression analysis revealed the factors associated with CD were degree of TTG IgA elevation, EMA positivity, and degree of EMA dilution. For every 10-fold increase in TTG IgA, there was a 4.7× increased risk of CD. TTG IgA ≥10 times the upper limit of normal (ULN) provided a positive predictive value (PPV) of 85% (confidence interval [CI]: [0.76-92]) in all subjects and 91% in asymptomatic subjects (CI: [0.75-0.98]). Of 66 subjects with EMA data, 41 (62%) were positive and 32 had CD (PPV = 0.78). Of 12 asymptomatic subjects with positive EMA, eight had CD (PPV = 0.67). For subjects with EMA ≥ 1:80, all were diagnosed with CD, and all had TTG IgA ≥10 times the ULN.

CONCLUSIONS

Among patients with T1DM, symptoms, adjunct labs, and anthropometrics do not help predict CD, but the degree of elevation of TTG IgA and dilution of a positive EMA result do.

Dietary Components in the Pathogenesis and Prevention of Type 1 Diabetes in Children

BACKGROUND

Type 1 diabetes (T1D) is a disease closely linked to nutrition and modifications in various dietary components have been part of the effort to prevent or slow the progression of the disease even before the discovery of insulin.

SUMMARY

The scientific focus in the prevention or progression modification of T1D is mostly centered on four dietary compounds and their modifications - gluten and its omission, vitamin D supplementation, omega-3 fatty acids supplementation, and decreasing of the amount of ingested carbohydrates. The aim of this narrative review was to provide an overview of nutritional interventions studied in children either as preventive methods or as modifiers in the early stages of T1D from autoantibody positive individuals to persons with newly diagnosed T1D.

KEY MESSAGES

Our review shows that dietary modifications in various dietary components might be useful but none of them seems to provide universal effects in T1D prevention or progression modification. More research is therefore needed with focus on promising modes of action of individual dietary components.

Systemic consequences of coeliac disease in children with type 1 diabetes - is it worth following a gluten-free diet?

INTRODUCTION

Coeliac disease (CD) often coexists with type 1 diabetes mellitus (T1D). Children with double diagnosis are frequently asymptomatic, which raises the question of whether to introduce a strict gluten-free diet (GFD) or not.

AIM OF THE STUDY

To summarise data on systemic consequences of coeliac disease in children with type 1 diabetes mellitus.

MATERIAL AND METHODS

The PubMed database was searched for papers to identify meta-analyses, reviews and clinical trials focusing on children.

RESULTS

Coeliac disease, like type 1 diabetes may adversely influence glycaemic control, growth, weight gain, lipid profile and bone health as well as increase the risk of vascular complications. A strict gluten-free diet, at least partly, prevents the development of systemic complications of both disorders.

CONCLUSIONS

Dietary restrictions do not have a negative impact on the quality of life of young diabetic patients hence a gluten-free diet with its multifaceted beneficial effects should be recommended to all children with diabetes and coeliac disease.

Gluten-Free Diet in Co-Existent Celiac Disease and Type 1 Diabetes Mellitus: Is It Detrimental or Beneficial to Glycemic Control, Vascular Complications, and Quality of Life?

Celiac disease (CeD) is associated with type 1 diabetes mellitus (T1DM), and both have the same genetic background. Most patients with T1DM who develop CeD are either asymptomatic or have mild CeD-related gastrointestinal symptoms. Therefore, children affected by T1DM should undergo screening for asymptomatic CeD. The aim of this review is to highlight the influence of a gluten-free diet (GFD) on glycemic control, growth rate, microvascular complications, and quality of life in patients with T1DM and CeD. PubMed, Google Scholar, Web of Science, and Cochrane Central databases were searched. Reports reviewed were those published from 1969 to 2022 that focused on the interplay of T1DM and CeD and examined the effect of diet on glycemic control, growth rate, and quality of life. The most challenging aspect for a child with T1DM and CeD is that most GFD foods have a high glycemic index, while low glycemic index foods are recommended for T1DM. Interestingly, dietary therapy for CeD could improve the elevated HbA1c levels. Avoiding gluten added to a diabetic dietary regimen in T1DM patients might impose practical limitations and lead to important restrictions in the lifestyle of a young patient. Consequently, non-adherence to GFD in patients with T1DM and CeD is common. GFD in patients with T1DM and CeD seems to lower the incidence of micro- and macrovascular complications, but this requires further investigation. It seems that adherence to GFD in young patients with T1DM and CeD leads to regular growth and a stable body mass index without any negative effect on HbA1c or insulin requirements. Furthermore, the lipid profile and quality of life seem to have improved with the introduction of GFD.