ISPAD Clinical Practice Consensus Guidelines 2014. Other complications and diabetes-associated conditions in children and adolescents

Interpreting positive celiac serology in children with new-onset type 1 diabetes

OBJECTIVES

The association of celiac disease (CD) in type 1 diabetes mellitus (T1DM) is well-established, yet variation exists in screening practices. This study measures the accuracy of early screening with tissue transglutaminase immunoglobulin A (TTG-IgA) and endomysial antibody (EMA) in newly diagnosed T1DM.

METHODS

This is a retrospective study of children with T1DM between 2013 and 2019 with early CD screening and follow-up. Data elements included anthropometrics, serologies, blood pH, bicarbonate, and Hemoglobin A1c. Celiac serologies were analyzed using chi-square and receiver operating characteristic curves to calculate optimal levels for predicting CD.

RESULTS

A total of 1,292 children met inclusion criteria with 142 having positive celiac serologies; 47 (33.1 %) of whom were subsequently diagnosed with CD - an incidence of 3.6 %. All subjects with positive EMA and TTG-IgA ≥8 times upper limit of normal were diagnosed with CD. Gastrointestinal symptoms, BMI, and thyroid disease were not statistically significant variables in this cohort, although there was a trend toward CD in lower BMI patients and higher TTG IgA in those with markedly elevated HgbA1c.

CONCLUSIONS

Early celiac screening in T1DM is reliable and promotes timely CD diagnosis and treatment. Although transient positive celiac serologies were noted, the degree of TTG-IgA elevation and EMA positivity are strong predictors of coexisting CD. Larger prospective studies using these assays will further define the risk stratification algorithm that is needed for our T1DM community.

Parietal Cell Antibodies in Type 1 Diabetes Mellitus and Its Implications for Iron Deficiency: A Tertiary Centre Experience from North India

Introduction

Parietal cell antibody (PCA)-mediated auto-immune gastritis is known to increase the risk of iron-deficiency and pernicious anaemia in adults with type 1 diabetes mellitus. However, in children and young adults with type 1 diabetes, these data are scarce. We aimed to study the prevalence of parietal cell antibodies (PCAs) and its clinical associations in people with type 1 diabetes with onset below 30 years.

Methods

In a cross-sectional study, 224 children and young adults with type 1 diabetes and 171 healthy controls were enrolled. We measured haemoglobin, serum ferritin, vitamin B12, PCA, thyroid peroxidase, and anti-tissue transglutaminase antibodies in all patients. Mann-Whitney U test for continuous data and Chi square test for categorical data were used. Linear regression analysis was performed with haemoglobin as a dependent variable.

Results

The prevalence of PCA was significantly higher in patients than in controls (22% vs 10.2%; P = 0.002). Patients with PCA had a higher frequency of anaemia (60% vs 30%, P < 0.001), lower haemoglobin [7.3 (1.6) vs 7.8 (1.1) mmol/L; P = 0.002], and lower serum ferritin [46.9 (70.8) pmol/L vs 66.0 (105.3) pmol/L; P = 0.04], as compared to those without PCA. On multivariate analysis, haemoglobin was associated with PCA (β = -0.174, P = 0.005) and serum ferritin (β =0.247, P < 0.001).

Conclusion

Presence of PCA was an independent risk factor for iron deficiency and anaemia in children and young adults with type 1 diabetes.

Glycemic control and study of lipid and bone metabolism in type 1 diabetic children

Introduction. Type 1 diabetes mellitus is considered one of the most common chronic diseases of childhood. It is a high-risk factor for developing early cardiovascular disease and it also affects bone health. Objective. To describe demographic characteristics and biochemical parameters of a population of children with type 1 diabetes, evaluated in the pediatric diabetes unit of a tertiary Spanish hospital. Materials and methods. In this retrospective study, we determined metabolic, lipid, and bone parameters in 124 children with type 1 diabetes who were monitored in the pediatric diabetes unit of the Hospital Universitario Miguel Servet in Zaragoza (Spain) from May 2020 to July 2021. Results. Children with type 1 diabetes have worse metabolic control of the disease at puberty, but their lipid control is considered acceptable. We found an inverse correlation between bone formation markers and disease duration, as well as with metabolic control. Conclusion. Bone formation markers are inversely correlated with the percentage of glycated hemoglobin and diabetes evolution time. Patients’ lipid and bone profiles are more favorable when metabolic control of the disease is achieved.

Celiac Disease and Autoimmune Diseases in a Pediatric Population in Morocco: A Cross-Sectional Study

INTRODUCTION

Celiac disease (CD) is defined as an autoimmune disease (AD) caused by gluten ingestion in genetically sensitive individuals. Several publications have demonstrated the increased risk of AD in patients with CD, both adults and children, which requires systematic research. Our study aimed to determine the prevalence of AD in 60 patients diagnosed with CD and to highlight risk factors that may contribute to the emergence of AD.

MATERIALS AND METHODS

We collected medical data from all CD patients under 16 years of age who also had AD. Our study was conducted in the Gastroenterology-Hepatology and Pediatric Nutrition Unit of the Pediatrics Department of the Mohamed VI Hospital and University Center in Oujda, Morocco, during a seven-year period between January 2017 and January 2024.

RESULTS

We studied 60 patients with CD in our study. Eight patients (13%) had an associated AD. Their average age was eight years, with extremes varying between two and 15 years. AD was diagnosed before CD in six cases (75%), in parallel with CD in one patient (12.5%), while in only one case, it was diagnosed after CD (12.5%). All our patients had a single AD associated with CD. These ADs were mainly type 1 diabetes in seven cases and autoimmune thyroiditis in only one case. All our patients followed a gluten-free diet in addition to specific treatment for associated AD. Nevertheless, despite regular medical follow-up and targeted dietary advice for the management of CD and associated AD, three patients encountered difficulties in following the recommended diet.

CONCLUSION

Younger patients with CD have an increased risk of hypothyroidism and insulin-dependent diabetes. These data necessitate improved surveillance to discover these illnesses as early as possible in order to optimize management and reduce related consequences.

Coexisiting type 1 diabetes and celiac disease is associated with lower Hba1c when compared to type 1 diabetes alone: data from the Australasian Diabetes Data Network (ADDN) registry

AIM

To compare HbA1c and clinical outcomes in adolescents and young adults with type 1 diabetes (T1D), with or without celiac disease (CD).

METHODS

Longitudinal data were extracted from ADDN, a prospective clinical diabetes registry. Inclusion criteria were T1D (with or without CD), ≥ 1 HbA1c measurement, age 16-25 years and diabetes duration ≥ 1 year at last measurement. Multivariable Generalised Estimated Equation models were used for longitudinal analysis of variables associated with HbA1c.

RESULTS

Across all measurements, those with coexisting T1D and CD had lower HbA1c when compared to those with T1D alone (8.5 ± 1.5% (69.4 ± 16.8 mmol/mol) vs. 8.7 ± 1.8% (71.4 ± 19.8 mmol/mol); p < 0.001); lower HbA1c was associated with shorter diabetes duration (B = - 0.06; 95% CI - 0.07 to - 0.05; p < 0.001), male sex (B = - 0.24; - 0.36 to - 0.11; p < 0.001), insulin pump therapy use (B = - 0.46; - 0.58 to - 0.34; p < 0.001), coexistence of T1D and CD (B = - 0.28; - 0.48 to - 0.07; p = 0.01), blood pressure (B = - 0.16; - 0.23 to - 0.09; p < 0.001) and body mass index (B = -- 0.03; - 0.02 to - 0.04; p = 0.01) in the normal range. At last measurement, 11.7% of the total population had a HbA1c < 7.0% (53.0 mmol/mol).

CONCLUSIONS

Across all measurements, coexisting T1D and CD is associated with lower HbA1c when compared to T1D alone. However, HbA1c is above target in both groups.

Accuracy of Serological Screening for the Diagnosis of Celiac Disease in Type 1 Diabetes Children

Background and Objectives: Patients with type 1 diabetes (T1D) are considered at high-risk for developing celiac disease (CD). The purpose of our study was to determine the prevalence of CD among children who were followed in our unit for T1D using the latest ESPGHAN guidelines, and avoiding intestinal biopsies in some of the children. Materials and Methods: We performed a prospective monocentric study, which included 663 T1D children between June 2014 and June 2016. We considered CD according to serological (tissue transglutaminase (TGAs) and endomysium antibodies) results. Children were included either at the time of T1D diagnosis or during their follow up. We looked for clinical and biochemical signs of CD, and for T1D characteristics. Results: The children's ages ranged from 11 months to 18 years. CD was confirmed in 32 out of 663 patients with T1D, with a prevalence of 4.8%. CD was excluded in 619 children and remained uncertain for 12 children, who had positive TGAs without the required criteria. We found that 95% of T1D children express HLA-DQ2 and/or -DQ8, which was 2.4 times higher than in the general population. Conclusions: An intestinal biopsy could be avoided to confirm CD in the majority of T1D children. Silent forms of CD are frequent and screening is recommended for all patients. Importantly, repeated TGA assessment is required in HLA genetically predisposed T1D patients, while it is unnecessary in the 5% who are HLA-DQ2 and -DQ8 negative.

Anti-Islet Autoantibodies in Type 1 Diabetes

Anti-islet autoantibodies serve as key markers in immune-mediated type 1 diabetes (T1D) and slowly progressive T1D (SPIDDM), also known as latent autoimmune diabetes in adults (LADA). Autoantibodies to insulin (IAA), glutamic acid decarboxylase (GADA), tyrosine phosphatase-like protein IA-2 (IA-2A), and zinc transporter 8 (ZnT8A) are currently employed in the diagnosis, pathological analysis, and prediction of T1D. GADA can also be detected in non-diabetic patients with autoimmune diseases other than T1D and may not necessarily reflect insulitis. Conversely, IA-2A and ZnT8A serve as surrogate markers of pancreatic β-cell destruction. A combinatorial analysis of these four anti-islet autoantibodies demonstrated that 93-96% of acute-onset T1D and SPIDDM cases were diagnosed as immune-mediated T1D, while the majority of fulminant T1D cases were autoantibody-negative. Evaluating the epitopes and immunoglobulin subclasses of anti-islet autoantibodies help distinguish between diabetes-associated and non-diabetes-associated autoantibodies and is valuable for predicting future insulin deficiency in SPIDDM (LADA) patients. Additionally, GADA in T1D patients with autoimmune thyroid disease reveals the polyclonal expansion of autoantibody epitopes and immunoglobulin subclasses. Recent advancements in anti-islet autoantibody assays include nonradioactive fluid-phase assays and the simultaneous determination of multiple biochemically defined autoantibodies. Developing a high-throughput assay for detecting epitope-specific or immunoglobulin isotype-specific autoantibodies will facilitate a more accurate diagnosis and prediction of autoimmune disorders. The aim of this review is to summarize what is known about the clinical significance of anti-islet autoantibodies in the pathogenesis and diagnosis of T1D.

Sweet but sour: Impaired attention functioning in children with type 1 diabetes mellitus

Children diagnosed with type 1 diabetes mellitus (T1DM) are at risk for neurocognitive sequelae, including impaired attention functioning. The specific nature of the cognitive deficit varies; current literature underscores early age of diabetes diagnosis and increased disease duration as primary risk factors for this neurocognitive decline. Forty-three children with T1DM were evaluated for Attention Deficit/Hyperactivity Disorder (ADHD) symptomatology using the MOXO continuous performance test (MOXO-CPT) performed during a routine outpatient evaluation. The study cohort demonstrated a significant decline in all four domains of attention functioning. The effect was most pronounced with early age at T1DM diagnosis, a longer disease duration and with poorer glycemic control (represented by higher HbA1c values). With increased disease duration (of 5 plus years), acute hyperglycemia was associated with inattention in the real-time setting. These findings highlight the need for routine screening of neurocognitive function in children with T1DM so that early intervention can be employed during this crucial period of cognitive development.

Does a Gluten-Free Diet Affect BMI and Glycosylated Hemoglobin in Children and Adolescents with Type 1 Diabetes and Asymptomatic Celiac Disease? A Meta-Analysis and Systematic Review

Background: Children diagnosed with type 1 diabetes mellitus (T1DM) are more prone to having celiac disease (CD) than the normal population. Moreover, patients with this dual diagnosis who are also on a diabetic and gluten-free diet (GFD) risk faltering growth and uncontrolled blood glucose levels. This review aims to assess the efficacy and effectiveness of managing patients with T1DM screened for CD with GFD to prevent complications associated with these chronic pathologies in childhood and adulthood. Materials and Methods: We abided by the PRISMA guidelines in this meta-analysis and used multiple databases and search engines. We included case−control studies. The primary outcomes were changes in the standard deviation score, body mass index (SDS BMI), and glycosylated hemoglobin (HA1C) after being on a GFD for at least twelve months. Results: The pooled data from the six studies included showed that there was neither a statistically significant difference in the mean SDS BMI (−0.28 (95% CI −0.75, 0.42)) (p = 0.24) nor in the mean of HA1C (mean −0.07 (95% CI −0.44, 0.30)) (p = 0.36) for the same group. HDL cholesterol improved significantly in patients on a strict GFD (p < 0.01). Conclusions: In children with T1DM and asymptomatic CD, being on a GFD had no significant effect on BMI or HA1C. However, it can have a protective effect on the other complications found in both chronic pathologies.

Screening for complications and associated conditions in children, adolescents and young adults with Type 1 diabetes mellitus in the Netherlands: Big differences in a small country

INTRODUCTION

Children, adolescents and young adults with Type 1 diabetes mellitus need to be screened for chronic complications and associated (autoimmune) diseases. There are no Dutch national guidelines for screening available but the International Society for Pediatric and Adolescent Diabetes (ISPAD) gives recommendations in its guidelines. The ISPAD guidelines from 2014 were updated in 2018.

OBJECTIVES

The adherence of the Dutch pediatric diabetes clinics to the international guidelines as stated by the ISPAD.

METHODS

A questionnaire about screening method and frequency was send to all members of the Dutch national committee for pediatric diabetes. The screening policies of the pediatric diabetes clinics were compared to the ISPAD guidelines of 2014 and 2018.

RESULTS

Sixty-two percent of all diabetes clinics filled out the questionnaire. None of the diabetes clinics followed all recommendations of the ISPAD. The majority of the clinics had a higher frequency of screening, performed extra blood tests and did not personalize their policy to the individual patient. Approximately one third of the diabetes clinics still commenced screening for chronic complications at the age of 10 years, as recommended in the previous version of the ISPAD guideline.

CONCLUSIONS

Dutch pediatric diabetes clinics screen their patients on chronic complications and associated conditions very differently and not according to the international (and most recent) guidelines. A more individualized approach with respect to the newest ISPAD guidelines will diminish the burden for the patient and medical costs as well.

Insulin therapy in childhood type 1 diabetes: Knowledge and practice in Senegal

INTRODUCTION

Childhood type 1 diabetes (T1D) is a chronic condition with serious repercussions on both the quality of life of the child and the family. Insulin therapy is the cornerstone of optimal blood sugar control. The main objective of our study was to assess the level of knowledge of physicians about insulin therapy in diabetes.

METHODS

This was a multicenter survey over a period of 5 months (from March 5 to August 2, 2018). It took place in five reference university hospital centers in the Dakar region.

RESULT

The number of doctors interviewed in our study was 82, 47.6% of whom were confirmed pediatricians or pediatricians in the process of specialization. The number of years of experience in the field of diabetes was on average 3 years. Fast-acting regular insulins were recommended by 75.6% of doctors and mixtures of insulin (intermediate and rapid-acting) by 50% of doctors. Overall, 91% of doctors recommend a variation in insulin injection sites. The "basal bolus" treatment regimen with insulin analogs was recommended by 50% of doctors, while 31.7% recommended it with human insulin. Regarding adapting insulin doses for leisure and sports activities, more than half (54.9%) of the doctors had to reduce the doses.

CONCLUSION

This study enabled us to assess the level of knowledge of insulin therapy among doctors caring for children with diabetes in Senegal, which proved to be limited. We recommend the reinforcement and follow-up of training on the management of T1D for providers at the different facilities.

Low prevalence of maternal microchimerism in peripheral blood of Japanese children with type 1 diabetes

AIM

To clarify the prevalence and degree of maternal microchimerism in Japanese children with type 1 diabetes, as well as its effect on phenotypic variation.

METHODS

We studied 153 Japanese children with type 1 diabetes, including 124 children positive for β-cell autoantibodies, and their 71 unaffected siblings. The number of circulating microchimeric cells per 10⁵ host cells was estimated by the use of quantitative-polymerase chain reaction targeting non-transmitted maternal human leukocyte antigen alleles. The results were compared to previous data from white European people. Phenotypic comparison was performed between maternal microchimerism carriers and non-carriers with diabetes.

RESULTS

Maternal microchimerism was detected in 15% of children with autoantibody-positive type 1 diabetes, 28% of children with autoantibody-negative type 1 diabetes, and 16% of unaffected siblings. There were no differences in the prevalence or levels of maternal microchimerism among the three groups or between the children with type 1 diabetes and their unaffected siblings. Furthermore, maternal microchimerism carriers and non-carriers exhibited similar phenotypes.

CONCLUSIONS

Maternal microchimerism appears to be less common in Japanese children with type 1 diabetes than in white European people. Our data indicate that maternal microchimerism is unlikely to be a major trigger or a phenotypic determinant of type 1 diabetes in Japanese children and that the biological significance of maternal microchimerism in type 1 diabetes may differ among ethnic groups.

Prevalence of celiac disease in a large cohort of young patients with type 1 diabetes

BACKGROUND

Serological screening for celiac disease (CD) allows the identification of individuals genetically predisposed, as type 1 diabetes mellitus (T1DM). However, the diagnosis is confirmed by intestinal biopsy. The aim was to determine the prevalence of immunoglobulin-A anti-tissue transglutaminase antibodies (IgA-tTG) and CD in a large cohort of young T1DM patients.

METHODS

Screening for CD was randomly conducted in 881 T1DM by IgA-tTG and total IgA. Individuals with positive antibodies were referred to endoscopy/duodenal biopsy.

RESULTS

The age of the cohort at the screening was 14.3 ± 5.9 years and at T1DM onset was 7.9 ± 4.4 years. The prevalence of positive serology was 7.7%. Median IgA-tTG levels were 117.7 U/mL (interquartile range [IQR] 35.7-131.5 U/mL). Of the 62 duodenal biopsy, CD was diagnosed in 79.0%, yielding an overall prevalence of 5.6%. The mean age of CD patients was 15.6 ± 6.5 years and, at T1DM onset was 6.3 years (4.0-9.9 years). The modified Marsh-Oberhuber histological classification was 22.5% (3a), 36.7% (3b), and 40.8% (3c). In the biopsy-proven patients, T1DM onset occurred at slightly younger ages (6.3 vs 9.7 years, P = 0.1947), gastrointestinal (GI) manifestations, predominantly abdominal pain and distension, were more prevalent (71.4% vs 38.5%, P = 0.027) and higher IgA-tTG titers (128.0 vs 26.3 U/mL, P = 0.0003) were found than in those with negative-biopsies.

CONCLUSION

Our results demonstrate the prevalence of 7.7% of IgA-tTG and 5.6% of CD in T1DM patients in South Brazil and, emphasize the importance of the screening in high-risk individuals. Furthermore, the presence of GI manifestations and higher IgA-tTG titers strongly suggest the diagnosis of CD.

Practice Variance in Thyroid Screening of Youth with Type 1 Diabetes Mellitus

BACKGROUND

Variance between current American Diabetes Association (ADA) and International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines and in clinical practice exists for the use of thyroid antibody and thyroid function screening in pediatric patients with new-onset type 1 diabetes (T1D).

METHODS

North American Pediatric Endocrine Society (PES) members were surveyed regarding their thyroid screening practices of euthyroid youth with T1D. An institutional analysis of the ability of antithyroid peroxidase (aTPO) and antithyroglobulin antibodies (aTG) to predict the subsequent use of levothyroxine was performed.

RESULTS

Forty-eight percent of 374 survey respondents tested both aTPO and aTG at diagnosis of T1D, but 35% performed no baseline antibody testing. If antibodies were positive, 89% of the respondents would perform annual thyroid function testing, but if antibodies were negative, 62% would follow thyroid function annually and 29% biannually. Institutionally, aTPO had significantly greater sensitivity (p = 0.04) but lower specificity (p = 0.008) than aTG for predicting the use of levothyroxine.

CONCLUSIONS

Variance exists among North American PES members regarding thyroid disease screening for pediatric patients diagnosed with T1D, and this appears to reflect differences between ADA and ISPAD guidelines. A prospective multicenter observational study which shares electronic medical record data and compares aTPO and TSH as primary screening tests may allow for more uniform guidelines and address the possibility of using TSH alone.

Screening for coeliac disease in 1624 mainly asymptomatic children with type 1 diabetes: is genotyping for coeliac-specific human leucocyte antigen the right approach?

OBJECTIVES

To investigate the frequency of coeliac disease (CD)-specific human leucocyte antigen (HLA) genotypes in paediatric patients with type 1 diabetes (T1D), who are known to have a higher prevalence of CD than the general population, and to evaluate whether HLA genotyping is a suitable first-line screening method for CD.

STUDY DESIGN

The study was a multicentre observational analysis of patients with T1D aged <20 years of whom a subgroup had undergone HLA genotyping. Patient data were retrieved from the Diabetes Prospective Follow-up database, a large diabetes follow-up registry. The present analysis included data from 439 centres throughout Germany, Austria, Switzerland and Luxembourg.

RESULTS

In March 2017, the database contained 75 202 patients with T1D (53% male, mean age (SD) 14.6 (4.1) years, mean age at diagnosis 8.8 (4.3) years and mean diabetes duration 5.8 (4.3) years). 1624 patients had undergone coeliac-specific HLA genotyping, of whom 1344 (82.8%) were positive for HLA-DQ2, HLA-DQ8 or both, while 17.2% had no coeliac-specific HLA-markers. 26.6% of at-risk patients had a clinical suspected diagnosis of CD, and 3.6% had biopsy-proven CD.

CONCLUSIONS

Genotyping for HLA-DQ2, HLA-DQ8 or both is positive in the vast majority (>80%) of patients with T1D. Therefore, screening for coeliac-specific HLA genotypes as a first-line test is not a suitable method to exclude CD in T1D. Regular screening for coeliac-specific antibodies in T1D is still recommended.

Prevalence and characteristics of celiac disease in South African patients with type 1 diabetes mellitus: Results from the Durban Diabetes and Celiac Disease Study

BACKGROUND AND AIM

The aim of this study was to assess the prevalence and characteristics of celiac disease (CD) in all patients with type 1 diabetes mellitus attending a tertiary adult diabetes clinic in Durban, South Africa.

METHODS

This was a cross-sectional observational study that screened 202 patients; of these, 56.4% were African (Black), 31.7% Asian Indian, 4.5% White, and 7.4% mixed race. Demographic data, symptoms, and anthropometry were documented. Blood tests included anti-tissue transglutaminase antibody (tTG), anti-endomysial antibody (EMA), and anti-gliadin antibody (AGA). Endoscopy and duodenal biopsy were performed in patients with celiac antibodies. Diagnosis of CD was based on the modified Marsh classification.

RESULTS

Mean age and mean duration of diabetes were 26.4 ± 11.4 and 10.7 ± 9.1 years, respectively. Celiac antibodies were found in 65 (32.2%) patients: EMA 7.4%, tTG immunoglobulin A (IgA) 8.4%, tTG immunoglobulin G 1.9%, AGA IgA 18.3%, and AGA immunoglobulin G 21.8%. Histological evidence of CD was found in 5.9% (n = 12/202): 2.5% were classed as definite CD (Marsh 3) and 3.4% as potential CD (Marsh 1). None of the patients with CD were symptomatic. The sensitivity of AGA IgA, EMA, and tTG IgA antibodies for detecting histologically proven CD was 66.7%, 50.0%, and 41.7%, respectively.

CONCLUSION

The prevalence of CD was similar to reports from western countries. No ethnic specific differences were noted. CD was silent in all patients in this study. The sensitivity of EMA and tTG antibodies was poor and merits further evaluation as screening tools for CD in South African patients with type 1 diabetes mellitus.

Celiac Disease and Celiac Antibodies in DM1 Patients: When Are Screening and Biopsy Recommended?

INTRODUCTION

The prevalence of celiac disease (CD) is increased in diabetes mellitus type 1 (DM1) patients. In most cases, CD is diagnosed in asymptomatic patients and hence periodic screening tests are recommended, but the timing, frequency of tests and indication for duodenal biopsy is unclear. The purpose of this study was to investigate the dynamics of CD serology in DM1 and identify risk factors for CD.

METHODS

Celiac serology and duodenal biopsy results from 1990 until 2015 were collected from patients with DM1. The outcome of positive celiac serology, the incidence and risk factors for CD in DM1 patients were investigated.

RESULTS

A total of 314 DM1 patients who had celiac serology were identified, with follow-up period up to 23 years. Of 31 patients (9.9%) with positive celiac serology, 11(35.4%) had spontaneous normalization after various time periods. Eighteen patients were diagnosed with CD (58.1% of positive celiac serology, 5.73% of the study cohort). Age under 4.5 years was a risk factor for CD, but not family background of autoimmune diseases or gender. All patients with CD diagnosis were diagnosed during the first 6 years following DM1 diagnosis.

CONCLUSION

Screening asymptomatic DM1 patients for CD beyond 6 years after diagnosis is not recommended. Spontaneous normalization of CD serology occurs, and hence, serologic follow-up may be performed. In children with DM1 diagnosis under the age of 4.5 years or with positive CD serology at DM1 diagnosis, there is an increased risk for CD and therefore positive serology should lead to biopsy.

Safety Evaluation of the MiniMed 670G System in Children 7-13 Years of Age with Type 1 Diabetes

OBJECTIVE

To evaluate the safety of in-home use of the MiniMed™ 670G system with SmartGuard™ technology in children with type 1 diabetes (T1D).

METHODS

Participants (N = 105, ages 7-13 years, mean age 10.8 ± 1.8 years) were enrolled at nine centers (eight in the United States and one in Israel) and completed a 2-week baseline run-in phase in Manual Mode followed by a 3-month study phase with Auto Mode enabled. Sensor glucose (SG), glycated hemoglobin (HbA1c), percentage of SG values across glucose ranges, and SG variability, during the run-in and study phases were compared. Participants underwent frequent sample testing with i-STAT® venous reference measurement during a hotel period (6 days/5 nights) to evaluate the system's continuous glucose monitoring performance.

RESULTS

Auto Mode was used a median of 81% of the time. From baseline to end of study, overall SG dropped by 6.9 ± 17.2 mg/dL (P < 0.001), HbA1c decreased from 7.9% ± 0.8% to 7.5% ± 0.6% (P < 0.001), percentage of time in target glucose range (70-180 mg/dL) increased from 56.2% ± 11.4% to 65.0% ± 7.7% (P < 0.001), and the SG coefficient of variation decreased from 39.6% ± 5.4% to 38.5% ± 3.8% (P = 0.009). The percentage of SG values within target glucose range was 68.2% ± 9.1% and that of i-STAT reference values was 65.6% ± 17.7%. The percentage of values within 20%/20 of the i-STAT reference was 85.2%. There were no episodes of severe hypoglycemia or diabetic ketoacidosis during the study phase.

CONCLUSION

In-home use of MiniMed 670G system Auto Mode for 3 months by children with T1D, similar to MiniMed 670G system use by adolescents and adults with T1D, was safe and associated with reduced HbA1c levels and increased time in target glucose range, compared with baseline.

Incidence and risk of celiac disease after type 1 diabetes: A population-based cohort study using the health improvement network database

OBJECTIVE

To determine the incidence of and risk factors for development of celiac disease (CD) in individuals with type 1 diabetes.

METHODS

Cohort study using The Health Improvement Network (THIN), a UK primary care database of >13 million people. Individuals with incident type 1 diabetes diagnosed at 1 to 35 years of age between 1995 and 2015 with no previous diagnosis of CD were included. Cox regression was used to identify risk factors for CD, including age at diabetes diagnosis and sex, while adjusting for year of diagnosis to control for potential rising incidence in CD over time.

RESULTS

Subjects (n = 9180; 43% female) had a median observation time of 5.1 years (interquartile range 2.0-10.1). CD was diagnosed in 196 (2%) during follow up. Median time to diagnosis was 2.1 years, but 25% were diagnosed more than 5 years after diabetes diagnosis. Incidence (per 10 000 person-years) was greater in females (43.0 [95% confidence interval [CI] 35.2-52.0]) vs males (26.8 [95% CI 21.5-32.9]). In multivariable Cox regression stratified by childhood- vs young adult-onset diabetes, younger age at diabetes diagnosis within childhood (hazard ratio [HR] 0.91 [95% CI 0.88-0.94]) and female sex among the adult-onset diabetes group (HR 3.19 [95% CI 1.39-7.34]) were associated with greater risk of CD.

CONCLUSIONS

As expected, incidence of CD was higher in individuals with childhood-onset diabetes vs those with adult-onset diabetes. However, individuals with diabetes are at risk of developing CD throughout childhood and adulthood, and prolonged screening after diagnosis may be warranted. Prospective studies are needed in order to guide risk-stratified approaches to screening.

Screening for autoimmune thyroiditis and celiac disease in minority children with type 1 diabetes

BACKGROUND

Hashimoto's thyroiditis (HT) and celiac disease (CD) are commonly associated with type 1 diabetes (T1DM). There is no consensus on screening, however, the American Diabetes Association (ADA) and the International Society for Pediatric and Adolescent Diabetes (ISPAD) recommend testing for thyroid function (TFT), thyroid antibodies and anti-tissue transglutaminase antibodies (TTG) IgA soon after diagnosis. TFT should be repeated every 1-2 years while TTG IgA should be tested for within 2 and 5 years. We hypothesize that the rate of HT and CD in our T1DM children is lower, so screening may need to be revised to reflect their underlying risk.

METHODS

An Institutional Review Board (IRB)-approved retrospective chart review was conducted on children with T1DM in the past 10 years. Age, sex, race, A1C, TFT, thyroid and celiac antibodies were obtained. t-Tests, the Wilcoxon-Mann-Whitney test and stepwise regression were performed.

RESULTS

Of 222 children with T1DM, with a mean age of 15.8±5.53 years, followed for 6.1±4.0 years, 53% female, mean A1C 11.1±1.9% and 87% African American (AA). Three had Graves' disease (1.3%), three had HT (1.3%) and 97% were euthyroid. TFT were assessed on average every 1.3 years and thyroid antibodies every 2.5 years. Positive thyroid antibody was found in 11%, negative in 57% and unknown in 32%. The positive antibody group had higher mean A1C and TSH. No biopsy confirmed cases of CD (0%) were found when screened every 2.3 years.

CONCLUSIONS

The number of individuals who screened positive for hypothyroid HT and CD was lower than expected in our population. Further studies are needed to assess the optimal screening frequency for HT and CD in minority children with T1DM.

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

BACKGROUND

Celiac disease (CD) is common in patients with type 1 diabetes (T1D) and effects of CD on growth in children with T1D remain unclear.

METHODS

We analyzed heights, weights, and body mass index (BMI) in 215 matched pediatric CD/control pairs in the T1D Exchange Clinic Registry. CD was defined by a clinic-reported diagnosis and positive celiac serology (n = 80) and/or positive small bowel biopsy (n = 135). Cases and controls were matched by age (mean: 14 years), diabetes duration (median: 7 years), sex (57% female), and clinic site. There were 5569 height/weight measurements.

RESULTS

Gluten was restricted for varying periods of time in 61% of females and 51% of males with CD. Females with CD were shorter than female controls at all ages (P = 0.01). Weight z-scores were initially lower in preschool females with CD but similar to controls by middle childhood. Males with CD were initially shorter but adult heights were similar. Height in both sexes and weight in males were lower in CD participants diagnosed at younger age. Growth in T1D children with biopsy-proven CD, 76% of them were gluten-restricted, was comparable to that of T1D controls.

CONCLUSION

Concurrent CD impairs linear growth in T1D females at all stages of development and in young T1D males. Young females with CD have lower weights, but both sexes have similar weights by middle childhood. Children younger at CD onset remain shorter throughout childhood; males younger at CD onset have persistently lower weights. Long-term gluten restriction may restore weight gain and linear growth in children with CD and T1D.

Endocrinopathies in celiac disease: When the endocrinologist sees what is invisible to the gastroenterologist

Celiac disease (CD) is a systemic, immune mediated and genetically determined small intestinal disorder characterized by intolerance to dietary gluten that generally presents with gastrointestinal symptoms in young children and extra-intestinal manifestations. Furthermore, there is close association between CD and endocrine diseases, including diabetes, autoimmune thyroid diseases, growth and pubertal disorders, etc. probably due to the presence of a common genetic predisposition. The present review aims to highlight and give more insight to the endocrine changes in CD, especially when there are few or no gastrointestinal symptoms and to emphasize on screening opportunities in some endocrine diseases. (www.actabiomedica.it)

Coexistence of celiac disease & type 1 diabetes mellitus in children

BACKGROUND & OBJECTIVES

Type 1 diabetes mellitus (T1DM) and celiac disease (CD) tend to co-exist due to similar underlying genetic predisposition. Failure to recognize CD in patients with T1DM predisposes them to complications. The present study was aimed to assess children with T1DM for the presence of CD.

METHODS

This was a retrospective analysis of the records of children with T1DM attending paediatric endocrinology clinic at a tertiary care hospital in north India from January 2006 to May 2014. All children were screened for CD at the time of diagnosis of T1DM using IgA anti-tissue transglutaminase (anti-tTG) levels in serum. Seropositive children were subjected to upper gastrointestinal endoscopy and duodenal biopsy for histopathological confirmation. The children also underwent thyroid function testing (TFT); those with deranged TFT were evaluated for thyroid-specific antibodies.

RESULTS

Positive serology for CD was present in 43 of 126 children with T1DM whose records were reviewed [34.1%; 95% confidence interval (CI): 25.9-43.1]. Confirmed CD was diagnosed in 17 (13.5%; CI: 8.1-20.7) of the children screened and 17 of 40 (42.5%; CI: 27.1-59.1) seropositive participants. Four out of 17 children with coexisting CD and T1DM also had autoimmune thyroiditis with overt hypothyroidism. The children with confirmed CD were more likely to have short stature [odds ratios (OR)-3.16; 95% CI: 1.09-9.20, P<0.05] and hypothyroidism (OR-6.4; 95% CI: 1.52-26.90, P<0.05).

INTERPRETATION & CONCLUSIONS

Our study showed a higher proportion of CD in children with T1DM as compared to that reported in general population. Regular screening of children with T1DM for CD is needed to improve metabolic control and prevent long-term complications.

Diabetes in Childhood and Adolescence

BACKGROUND

The incidence of type 1 diabetes mellitus in childhood and adolescence is steadily rising and now stands at 22.9 new cases per year per 100 000 persons up to age 15.

METHODS

This review is based on pertinent publications retrieved by a selective literature search, with special attention to the current German S3 guideline on diabetes in childhood and adolescence.

RESULTS

Polydipsia, polyuria, and weight loss are the characteristic presenting symptoms of diabetes mellitus. The acutely presenting patient needs immediate stabilization because of the danger of rapid metabolic decompensation (risk of keto - acidosis, 21.1%). Long-term insulin therapy can be delivered either by subcutaneous injection or by an insulin pump. The goals of treatment are the near-normalization of glucose metabolism (HbA1c <7.5%), the avoidance of acute complications (hypoglycemia and ketoacidosis), the reduction of diabetes-specific sequelae (retinopathy, nephropathy, neuropathy, hypertension, and hyperlipidemia), unrestricted participation in age-appropriate everyday activities, and normal physical and psychosocial development. Children and adolescents with diabetes need individualized treatment with frequent adjustments and holistic overall care so that these goals can be effectively met.

CONCLUSION

Every physician must be able to diagnose the initial presentation of diabetes and to initiate the first steps in its management. The patient should be referred as soon as possible to a diabetes team that has experience in the treatment of children and adolescents.

ATP4A autoimmunity in pediatric patients with type 1 diabetes and its relationship to blood count, iron metabolism, and vitamin B12

OBJECTIVE

We aimed to assess the prevalence of autoantibodies against the 4A subunit of the gastric proton pump (ATP4A) in pediatric type 1 diabetes (T1D) patients and explore the relationship between ATP4A positivity and blood cell count, iron turnover, and vitamin B12 concentration.

SUBJECTS

The study included 94 (59% female) T1D children (aged 12.5 ± 4.1 years, T1D duration 4.2 ± 3.6 years, HbA1c 7.3 ± 1.5% (57 ± 12.6 mmol/mol) with no other autoimmune diseases.

METHODS

ATP4A antibodies were measured in T1D patients using a radioimmunoprecipitation assay. Blood cell count, iron concentration, total iron binding capacity, ferritin, transferrin, hepcidin, and vitamin B12 concentration were measured in all the study participants.

RESULTS

A total of 16 (17%) children were ATP4A positive. Serum concentrations of ferritin were significantly lower in ATP4A positive than in antibody negative subjects (P = .034). Overall the levels of ATP4A antibodies (ATP4A Index) correlated positively with the age at T1D diagnosis (r = 0.228, P = .026) and negatively with ferritin levels (r = -0.215, P = .037). In ATP4A positive patients, the ATP4A Index correlated positively with age at diagnosis (r = 0.544, P = .032) and negatively with vitamin B12 levels (r = -0.685, P = .004).

CONCLUSIONS

ATP4A antibodies were present in a significant proportion of children with T1D. Higher ATP4A levels in T1D children are associated with lower, yet still fitting within the normal range, levels of vitamin B12, and ferritin. Routine screening of T1D children for gastric autoimmunity (ATP4A) should be considered with follow-up of those positive for vitamin B12 and iron deficiency.

Thyroid Disease and Type 1 Diabetes in Dutch Children: A Nationwide Study (Young Dudes-3)

OBJECTIVE

To investigate the prevalence of overt thyroid disease in children in The Netherlands with and without type 1 diabetes mellitus (T1DM).

STUDY DESIGN

Nationwide, retrospective cohort study in The Netherlands. Using the national registry of both healthcare reimbursement and pharmaceutical care, data of all Dutch children (aged 0-14 years) with a diagnosis of T1DM, or a diagnosis of hypothyroidism or hyperthyroidism in the period 2009-2011.

RESULTS

The prevalence of thyroid disease was 0.15% in children without T1DM, and 3.43% in children with T1DM (rate ratio 23.59; 95% CI 19.92-27.93; P < .001). Both hyperthyroidism and hypothyroidism were 24 times more likely in children with T1DM than in those without. Thyroid disease was more common in girls than in boys, both in children with T1DM (rate ratio of girls vs boys 3.07; 95% CI 2.10-4.49) and in children without T1DM (rate ratio 1.59; 95% CI 1.49-1.69). This sex difference was more pronounced for hypothyroidism than for hyperthyroidism.

CONCLUSIONS

Children with T1DM in The Netherlands are 24 times more likely to develop thyroid disease than their peers without diabetes. Girls with T1DM were more prone to thyroid disease, particularly hypothyroidism.

Prevalence of Celiac Disease in 52,721 Youth With Type 1 Diabetes: International Comparison Across Three Continents

OBJECTIVE

Celiac disease (CD) has a recognized association with type 1 diabetes. We examined international differences in CD prevalence and clinical characteristics of youth with coexisting type 1 diabetes and CD versus type 1 diabetes only.

RESEARCH DESIGN AND METHODS

Data sources were as follows: the Prospective Diabetes Follow-up Registry (DPV) (Germany/Austria); the T1D Exchange Clinic Network (T1DX) (U.S.); the National Paediatric Diabetes Audit (NPDA) (U.K. [England/Wales]); and the Australasian Diabetes Data Network (ADDN) (Australia). The analysis included 52,721 youths <18 years of age with a clinic visit between April 2013 and March 2014. Multivariable linear and logistic regression models were constructed to analyze the relationship between outcomes (HbA_1c, height SD score [SDS], overweight/obesity) and type 1 diabetes/CD versus type 1 diabetes, adjusting for sex, age, and diabetes duration.

RESULTS

Biopsy-confirmed CD was present in 1,835 youths (3.5%) and was diagnosed at a median age of 8.1 years (interquartile range 5.3-11.2 years). Diabetes duration at CD diagnosis was <1 year in 37% of youths, >1-2 years in 18% of youths, >3-5 years in 23% of youths, and >5 years in 17% of youths. CD prevalence ranged from 1.9% in the T1DX to 7.7% in the ADDN and was higher in girls than boys (4.3% vs. 2.7%, P < 0.001). Children with coexisting CD were younger at diabetes diagnosis compared with those with type 1 diabetes only (5.4 vs. 7.0 years of age, P < 0.001) and fewer were nonwhite (15 vs. 18%, P < 0.001). Height SDS was lower in those with CD (0.36 vs. 0.48, adjusted P < 0.001) and fewer were overweight/obese (34 vs. 37%, adjusted P < 0.001), whereas mean HbA_1c values were comparable: 8.3 ± 1.5% (67 ± 17 mmol/mol) versus 8.4 ± 1.6% (68 ± 17 mmol/mol).

CONCLUSIONS

CD is a common comorbidity in youth with type 1 diabetes. Differences in CD prevalence may reflect international variation in screening and diagnostic practices, and/or CD risk. Although glycemic control was not different, the lower height SDS supports close monitoring of growth and nutrition in this population.

Thyroid and Islet Autoantibodies Predict Autoimmune Thyroid Disease at Type 1 Diabetes Diagnosis

CONTEXT

Screening of autoimmune thyroid disease in children with type 1 diabetes is important but varies between clinics.

OBJECTIVE

To determine the predictive value of thyroid autoantibodies, thyroid function, islet autoantibodies, and HLA-DQ at diagnosis of type 1 diabetes for autoimmune thyroid disease during follow-up.

SETTING

Forty-three Swedish pediatric endocrinology units.

DESIGN, PATIENTS, AND MAIN OUTCOME MEASURES

At diagnosis of type 1 diabetes, autoantibodies against thyroid peroxidase (TPOAb), thyroglobulin (TGAb), glutamic acid decarboxylase (GADA), insulin, insulinoma-associated protein-2, and 3 variants of zinc transporter 8 (ZnT8W/R/QA) HLA-DQA1-B1 genotypes and thyroid function were analyzed in 2433 children. After 5.1 to 9.5 years, information on thyroxine treatment was gathered from the Swedish National Board of Health and Welfare's Prescribed Drug Register.

RESULTS

Thyroxine was prescribed to 6% of patients. In patients <5 years of age, female sex [hazard ratio (HR) = 4.60; P = 0.008] and GADA (HR = 5.80; P = 0.02) were predictors. In patients 5 to 10 years old, TPOAb (HR = 20.56; P < 0.0001), TGAb (HR = 3.40; P = 0.006), and thyroid-stimulating hormone (TSH) (HR = 3.64; P < 0.001) were predictors, whereas in 10 to 15 year olds, TPOAb (HR = 17.00; P < 0.001) and TSH (HR = 4.11; P < 0.001) predicted thyroxine prescription.

CONCLUSION

In addition to TPOAb and TSH, GADA at diagnosis of type 1 diabetes is important for the prediction of autoimmune thyroid disease in children <5 years of age.

Lower dose basal insulin infusion has positive effect on glycaemic control for children with type I diabetes on continuous subcutaneous insulin infusion therapy

OBJECTIVE

The aim of our study was to explore a possible relationship between proportion of basal insulin dose (%BD/T) and glycaemic control in children with type I diabetes on continuous subcutaneous insulin infusion (CSII) therapy.

METHODS

All patients under the age of 18 with type I diabetes mellitus, treated in a general hospital in Utrecht, The Netherlands, who were on CSII therapy between 2000 and 2011 were selected for inclusion. All data as recorded during outpatient visits were retrospectively collected from patients' charts. Analyses were performed using R Statistical Software.

RESULTS

Data of 847 outpatient visits of 78 patients [31 males (39.7%) and 47 females (60.3%)] were analyzed. Mean age at diagnosis was 7.1 ± 3.7 yr, mean age at start of pump therapy 10.1 ± 3.8 yr. Mean HbA1c before pump start was 8.3 ± 1.0%, median BMI standard deviation score for age and gender was 0.64 (-1.89-3.79). Median follow-up time per patient was 29 months with an average of 10 visits (range: 3-25). Multivariate analysis revealed that a change of 10% in %BD/T resulted in a decrease or increase of HbA1c of 0.22% [95% confidence interval (CI): 0.15-0.29). No significant effect was observed from SDS BMI, sex, or duration of diabetes.

CONCLUSION

Low dose basal insulin infusion as a percentage of total insulin dose has a positive effect on metabolic outcome as expressed in HbA1c-levels. A change of 10% in %BD/T results in a decrease or increase of HbA1c of 0.22%. This supports the tendency to aim at the lowest basal insulin requirements in pump setting strategy.

Pattern of thyroid, celiac, and anti-cyclic citrullinated peptide autoantibodies coexistence with type 1 diabetes mellitus in patients from Southwestern Saudi Arabia

Objectives:

To investigate the seroprevalence of coexisting autoantibodies among type 1 diabetes mellitus (T1DM) patients, and to look for possible correlations with age at diagnosis, diabetes duration, and glycemic control.

Methods:

This is a cross-sectional study conducted at Aseer Central Hospital, Abha, Kingdom of Saudi Arabia from March 2013 to June 2014. A total of 202 T1DM patients were screened for serum anti-thyroglobulin (TG), anti-thyroid peroxidase (TPO), anti-tissue transglutaminase (aTTG), anti-endomysial (EMA), and anti-cyclic citrullinated peptide (anti-CCP) antibodies along with glycated hemoglobin, and biometric data.

Results:

From the 202 T1DM patients (96 males, and 106 females) (mean age: 11.3 years), 33 (16.3%) were positive for thyroid autoantibodies. Specifically, 19 (9.4%) were positive for TG and 25 (12.8%) were positive for TPO, and 11 were double positive. There were 21 (10.4%) patients that showed a double positive for both aTTG-IgA and EMA, and only one case of T1DM was positive for anti-CCP. No significant correlations were noticed between the presence of autoantibodies and the age at diagnosis, diabetes duration, body mass index, and glycemic control.

Conclusion:

The prevalence of thyroid and celiac disease autoantibodies is high among T1DM patients, while anti-CCP remains low and might be weakly associated with T1DM in the southwestern region of Saudi Arabia. No significant correlation between the age at T1DM diagnosis, duration, and glycemic control, and the presence of autoantibodies was found.

The First Use of Bolus Calculator With Speech Analyzer

BACKGROUND

The insulin therapy in type 1 diabetes involves a wide array of restrictions in patients and their families. One of those is a difficulty in estimation of the insulin dose programmed for each meal. The purpose of the study is an assessment of functionalities related to the expert system VoiceDiab-a calculator of meal boluses.

METHODS

The sample group composed of 54 patients, aged 3-52, all suffering from type 1 diabetes, treated with the insulin pump, taking part in the clinics RCT (for adults and a pediatrician), with a randomized allocation to a surveyed group and cross-over. The research methodology was based upon questionnaires and open-ended questions.

RESULTS

40% of respondents recognized the application's usefulness as high (18 of 47), giving it 10 points, and easy to use (70%). Disadvantages of this app comprised lack of some products in the application database (n = 23), troubles with the mobile range ( n = 4), and no option of a manual data input for processing purposes (n = 23). Advantages, that have been mentioned the most frequently included facilitation of measurements (n = 7), enhanced life quality of the patient (n = 8), and a guarantee of prompt and thorough calculations (n = 22). Of the surveyed individuals, 50% reached their diet, while 100% gave a top grade to the application, claiming it had contributed to a more efficient metabolic control.

CONCLUSION

The pilot scheme of the expert system VoiceDiab has potential to become an application, facilitating dosing of the meal insulin and improving the comfort and safety of insulin administering. However, it needs to be modified, as mentioned by the users who have tested the system.

Quality of Life in Type 1 Diabetes and Celiac Disease: Role of the Gluten-Free Diet

OBJECTIVE

To evaluate quality of life (QoL) and glycemic control in youth with type 1 diabetes (T1D) and celiac disease vs T1D only. We hypothesized that QoL scores would be lower in youth with T1D and celiac disease and those nonadherent to the gluten-free diet (GFD).

STUDY DESIGN

This case control study included 35 youth with T1D and 35 with T1D  and  celiac disease matched for age, sex, diabetes duration, and hemoglobin A1c level. QoL was assessed in participants and parents using the Pediatric Quality of Life Inventory Generic Core Scale, Pediatric Quality of Life Inventory Diabetes Module. and the General Well-Being Scale; youth with T1D and celiac disease also completed the celiac disease-specific DUX questionnaire and parents completed the Pediatric Quality of Life Inventory Family Impact Scale. Questionnaires were scored from 0 to 100; higher scores indicate better QoL or well-being. Scores were compared between T1D vs T1D with celiac disease, with subgroup analysis by GFD adherence vs nonadherence and therapy (continuous subcutaneous insulin infusion vs multiple daily injections).

RESULTS

Youth with T1D  and celiac disease reported similar generic and diabetes-specific QoL to T1D only. GFD nonadherent vs adherent youth reported lower diabetes-specific QoL (mean score 58 vs 75, P = .003) and lower general well-being (57 vs 76, P = .02), as did their parents (50 vs 72, P = .006), and hemoglobin A1c was higher (9.6% vs 8.0%, P = .02). Youth with T1D  and  celiac disease using continuous subcutaneous insulin infusion vs multiple daily injections had similar generic and diabetes-specific QoL and A1C (8.6 vs 8.2%, P = .44), but were less happy having to follow a lifelong diet (59 vs 29, P = .007).

CONCLUSIONS

Youth with T1D  and celiac disease who do not adhere to the GFD have lower QoL and worse glycemic control. Novel strategies are required to understand and improve adherence in those with both conditions.

Feasibility of screening for T1D and celiac disease in a pediatric clinic setting

OBJECTIVE

Type 1 diabetes (T1D) or celiac disease (CD) develops in at least 2% of the general population. Early detection of disease-specific autoimmunity and subsequent monitoring would be possible if screening tests were more widely available. Currently, screening for islet autoimmunity is available only in a research setting, and CD-specific autoimmunity screening is limited to those in high-risk groups. This study assessed the feasibility of incorporating T1D and CD autoantibody screening into a pediatric practice.

METHODS

Patient engagement strategies, blood collection preference, blood sample volume, rate of autoantibody detection in the general population, and parental satisfaction were assessed. Over 5 weeks, research staff recruited 200 patients, aged 2-6 yr from two pediatric practices in the Denver area to be screened for islet autoantibodies (IAs) and the transglutaminase antibody.

RESULTS

Of the 765 parents approached, 200 (26%) completed the same-day screening. Of the 565 subjects who did not complete the screening, 345 expressed interest, but were unable to make a participation decision. A finger stick, compared with a venous draw, was the preferred method of sample collection. Both methods yielded sufficient blood volume for autoantibody determination. IAs or the transglutaminase antibody were detected in 11 subjects. Parents expressed satisfaction with all aspects of participation.

CONCLUSIONS

The results of this study suggest that it is feasible to conduct this type of screening in a pediatric clinic. Such screening could lead to increased disease awareness and the possible benefits that can result from early detection.

Prevalence of celiac disease in Indian children with type 1 diabetes

BACKGROUND

Type 1 diabetes (T1D) patients are at an increased risk of having celiac disease (CD). We evaluated the prevalence and clinical profile of CD in children and adolescents with T1D and reviewed the Indian literature to determine prevalence and reasons for variability.

METHODS

In this cross-sectional study, subjects with T1D were prospectively evaluated with a demographic and gastrointestinal (GI) questionnaire, human IgA-tissue transglutaminase (IgA-tTGA), and endoscopic duodenal biopsy in serology positive patients. Studies evaluating prevalence of CD in T1D from India were reviewed.

RESULTS

Fourteen (13.6 %) of the 103 (52 boys, 13 years [2-20]) T1D patients were IgA-tTGA (182 U [47-300]) positive and 3.8 % (4/103) had villous atrophy on histology. Subjects with T1D and CD (n = 4) were younger at onset of T1D (32.5 ± 12.6 vs. 110.5 ± 53.8 months; p < 0.005) and more often had GI symptoms (pain abdomen [2/4 vs. 6/89; p = 0.01], stool frequency of 2-3/day [3/4 vs. 38/89; p = 0.004]) than screen negative T1D (n = 89). Growth and glycemic control were not different between the groups. In the 7 Indian studies involving 915 children and adults, 13.8 % (8 % to 17.8 %) T1D were serology positive. Prevalence of CD was reported as 6.9 % (2.3 % to 11.1 %), but only 3.1 % (2.3 % to 4.2 %) had villous atrophy on histology.

CONCLUSIONS

Potential CD and CD were present in 13.6 % and 3.8 % children with T1D respectively. T1D with CD have onset of diabetes at younger age and were more often symptomatic than screen negative T1D.

Vascular risk factors in children, adolescents, and young adults with type 1 diabetes complicated by celiac disease: results from the DPV initiative

OBJECTIVE

Celiac disease (CD) is a common comorbidity of type 1 diabetes (T1D). Long-term consequences of CD are not completely understood, and adhering to a gluten-free diet is a burden for many patients. We investigated the effect of CD on vascular risk factors in a large cohort of T1D patients aged <20 yr.

RESEARCH DESIGN AND METHODS

Within the longitudinal Diabetes Patienten Verlaufsdokumentation (DPV)-diabetes registry, data were analyzed from 59,909 < 20-yr-old T1D patients treated at 392 centers in Germany and Austria. A total of 974 patients with biopsy-proven celiac disease (BPCD) were compared with 28,398 patients without CD with respect to blood pressure (BP), lipids, glycohemoglobin (HbA1c ), body mass index (BMI), and reported smoking behavior.

RESULTS

Patients with T1D and BPCD showed significantly lower high-density lipoprotein (HDL) cholesterol levels [median (interquartile range): 53.0 (43.0-62.6) mg/dL] than patients without CD [55.0 (45.0-66.0) mg/dL; p < 0.01; p < 0.001 after adjustment for confounding variables]. Systolic BP was lower in patients with CD [105.5 (100.0-112.5) mmHg] than in patients without CD [110.0 (102.0-117.0) mmHg; p < 0.0001; p < 0.001 after adjustment]. There were no significant differences regarding smoking behavior, BMI, or HbA1c . In a subgroup of 335 patients with BPCD, HDL cholesterol was measured 1 yr after diagnosis of CD:HDL increased by 8% (p < 0.01).

CONCLUSION

Young people with T1D and CD have lower HDL cholesterol values than patients without CD. As low HDL cholesterol is associated with vascular risk, our findings support screening for CD and monitoring of HDL cholesterol in young people with T1D.

Children and adolescents living with diabetes and celiac disease

Objective To understand the experience of children and adolescents living with type 1 diabetes and celiac disease. Method This is a qualitative exploratory-descriptive study. The participants were 3 children and 2 adolescents. The data were collected by means of semi-structured interviews between January and September 2012 at the participant's residence or at the diabetic outpatient clinic of the Hospital das Clinicas, Faculty of Medicine, University of Sao Paulo in São Paulo, Brazil. The content analysis technique was used to process the data. Results The key aspect of the illness experience of the patients was their diet, but with different meanings. The children had difficulty following the diet, while the adolescents reported that they had greater difficulty coping with the social and affective aspects of their diet. Conclusion The results reinforce the importance of nurses who seek strategies, together with the patients and their families, that help minimize the difficulties of these patients, especially with regard to managing the diet imposed by both diseases.

The seroprevalence of immunoglobulin A transglutaminase in type 1 diabetic patients of South Indian origin

CONTEXT

Celiac disease (CD) is a commonly encountered autoimmune condition in patients with type 1 diabetes (T1D). There is sparse data on the seroprevalence of immunoglobulin A (IgA) transglutaminase (tTG) in T1D patients of South Indian origin.

AIMS

To detect the prevalence of IgA tTG in T1D patients of South Indian origin. To evaluate the relation between the presence of autoimmunity and metabolic control and complications of diabetes.

MATERIALS AND METHODS

We conducted a cross-sectional study on 258 T1D patients. All the patients were subjected to biochemical tests and evaluated for microvascular complications. IgA tTG was estimated by ELISA. IgA tTG levels >40 AU/ml was considered positive.

RESULTS

Of the 258 participants, 12 (4.65%) were found to be positive for IgA tTG antibodies. Distribution of IgA positivity was equal in both sexes. There was a significant negative correlation of IgA tTG positivity with hemoglobin and glycated hemoglobin (HbA1c).

CONCLUSIONS

The seropositivity of CD in South Indian patients with T1D has been observed to be 4.68%. This is much lower compared to studies from North India. This can be explained by both the genetic and dietary factors. The seropositivity correlated negatively with hemoglobin and HbA1c.

Young Age at Diagnosis of Type 1 Diabetes Is Associated with the Development of Celiac Disease-Associated Antibodies in Children Living in Newfoundland and Labrador, Canada

OBJECTIVES

The objectives of this study were to establish the prevalence of positive antibodies to endomysium (EMA) and tissue transglutaminase (tTG) in children with type 1 diabetes living in Newfoundland and Labrador (NL), and to examine clinical features associated with positive antibodies.

METHODS

Patients were recruited from the pediatric diabetes clinic. One hundred sixty-seven children with type 1 diabetes from the 280 children followed at the clinic were prospectively screened for celiac disease using EMA and tTG. The variables of Irish descent, age at onset of diabetes, duration of diabetes, sex, family history of celiac disease, hemoglobin A1C (A1C), ferritin, gastrointestinal symptoms, and body mass index were compiled for all patients. The group of patients with positive antibodies to EMA and/or tTG was compared to the group with negative antibodies.

RESULTS

The prevalence of patients with positive antibodies to EMA and/or tTG was 16.8% (n = 28). One patient had also been previously diagnosed with symptomatic celiac disease. The two statistically significant variables with positive antibodies were an earlier age at onset of diabetes (Mann-Whitney U two-tailed test: mean difference 3.2 years, 95% CI 1.7-4.8 years, p < 0.0001) and longer duration of diabetes (Mann-Whitney U two-tailed test: mean difference 2.9 years, 95% CI 1.3-4.4 years, p < 0.0001). Irish descent was associated with positive antibodies but did not reach statistical significance. On logistic regression analysis performed with these three variables together, only age at onset of diabetes remained significant.

CONCLUSIONS

There is a high prevalence of celiac disease-associated antibodies in children living in NL with type 1 diabetes. Unlike other clinical features, an earlier age at onset of diabetes was predictive for positive antibodies. As the majority of children with positive antibodies did not have signs or symptoms of celiac disease, routine screening for celiac disease in type 1 diabetes is recommended.

Celiac Disease Alone and Associated With Type 1 Diabetes Mellitus

OBJECTIVES

The aim of the study was to evaluate complication screening and follow-up patterns in a population with type 1 diabetes mellitus and celiac disease (T1D/CD) in relation to a matched cohort with celiac disease (CD) alone at our center.

METHODS

We retrospectively reviewed the health charts of 41 children with T1D and biopsy-proven CD and compared anthropometrics and complication of screening within 2 years from CD diagnosis. Follow-up patterns were determined 3 years postdiagnosis. This population was then compared with a population with both symptomatic and asymptomatic CD matched for age and sex.

RESULTS

In comparison with T1D/CD, patients with CD alone had a significantly lower height, weight and body mass index (BMI z score 0.01 vs 0.81, P = 0.001) and higher rates of screening for anemia (95% vs 71%, P = 0.003) and bone health (49% vs 29%, P = 0.05). Minimal rates of laboratory abnormalities were observed in either group, irrespective of symptoms at presentation, but CD alone more often presented with anemia than T1D/CD. Repeat serology testing was significantly more frequently performed in the T1D/CD group. Follow-up was equally variable with a median of 3 (range 0-4) visits with a gastroenterologist during the first 3 years postdiagnosis.

CONCLUSIONS

These results suggest that patients with T1D/CD represent a distinct and possibly milder phenotype from CD alone. Complication screening was variable and negative for the majority of the patients. Guidelines for follow-up may need to be tailored to specific groups to standardize evaluation and complication screening, especially with regard to bone health.

Screening for Celiac Disease in Type 1 Diabetes: A Systematic Review

BACKGROUND AND OBJECTIVES

Prevalence rates of type 1 diabetes (T1D) and celiac disease (CD) vary from 1.6% to 16.4% worldwide. Screening guidelines are variable and not evidence based. Our aim was to conduct a systematic review of CD in T1D.

METHODS

Medline, Embase, and the Cochrane Library were searched. Studies were limited to those in English and in humans. We selected longitudinal cohort studies screening for CD in T1D with at least 5 years of follow-up. Screening rates, characteristics, and prevalence of biopsy-proven CD in people with T1D were extracted.

RESULTS

We identified 457 nonduplicate citations; 48 were selected for full-text review. Nine longitudinal cohort studies in 11,157 children and adolescents with 587 cases of biopsy-proven CD met the inclusion criteria. Median follow-up was 10 years (range: 5-18 years). The weighted pooled prevalence of CD was 5.1% (95% confidence interval: 3.1-7.4%). After excluding 41 cases with CD onset before T1D, CD was diagnosed in 218 of 546 (40%) subjects within 1 year, in 55% within 2 years, and in 79% within 5 years of diabetes duration. Two studies (478 cases) reported higher rates of CD in children aged <5 years at T1D diagnosis. The duration of follow-up varied across the included studies. CD screening frequency progressively decreased with increased T1D duration.

CONCLUSIONS

Because most cases of CD are diagnosed within 5 years of T1D diagnosis, screening should be considered at T1D diagnosis and within 2 and 5 years thereafter. CD screening should be considered at other times in patients with symptoms suggestive of CD. More research is required to determine the screening frequency beyond 5 years of diabetes duration.

Diabetes and epilepsy in children and adolescents

Over the last years, there has been an increasing interest in the potential association between type 1 diabetes (T1D) and epilepsy. Both T1D and epilepsy are common conditions in children and adolescents, and therefore, their association might represent simply a coincidence or be related to common underlying mechanisms with a potential causal relationship. Few epidemiological studies have been performed in the pediatric population, and they have reached discordant conclusions, with some studies reporting an increased prevalence of epilepsy in children and adolescents with T1D, whereas others have not confirmed this finding. Several mechanisms could explain the occurrence of epilepsy in young people with T1D, such as metabolic abnormalities (hypo/hyperglycemia) and autoantibodies, along with a genetic predisposition and the presence of brain lesions/damage. Further studies are required to better define whether there is a causal relationship between the two conditions and to understand the underlying mechanisms.