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.

Current Perspectives on the Role of Very-Low-Energy Diets in the Treatment of Obesity and Type 2 Diabetes in Youth.

In both developed and developing countries, pediatric obesity and type 2 diabetes are an increasing public health concern: globally 5.6% of girls and 7.8% of boys aged ≥5 years have obesity. The incidence of type 2 diabetes has increased in youth in recent decades and disproportionately affects those from ethnic/racial minority groups and disadvantaged backgrounds. For the treatment of both conditions, conventional lifestyle intervention is frequently ineffective, access to bariatric surgery is very limited and many young people are unsuitable or unwilling to undergo surgery. A very-low-energy diet (VLED) provides a viable alternative and may be effective for weight reduction and improved glycemic control in youth, based on one systematic review. In particular, in the treatment of type 2 diabetes, a chart review and a pilot study both demonstrated that a VLED can reduce the requirement for medications, including insulin, and lead to the remission of diabetes. However, long-term follow-up and safety data remain limited and therefore a VLED is inconsistently recommended by clinical practice guidelines for the treatment of pediatric obesity and type 2 diabetes. In clinical practice, VLED use in children and adolescents is uniquely challenging due to intolerance of expected side effects, difficulty adhering to the highly restrictive diet and difficulty with behaviour change within the current social context and environment. Ultimately, more research, including larger, longer-term trials with comprehensive safety monitoring are required to strengthen the evidence base. This would inform clinical practice guidelines, which may facilitate more widespread utilization of VLED programs in the management of obesity and type 2 diabetes in youth.

Abnormal Cortical and Trabecular Bone in Youth With Type 1 Diabetes and Celiac Disease.

OBJECTIVE: This study compared bone health in youth with type 1 diabetes and celiac disease (CD) versus type 1 diabetes alone. RESEARCH DESIGN AND METHODS: This was a case-control study of 42 youth with coexisting type 1 diabetes and CD and 40 with type 1 diabetes matched for age, sex, diabetes duration, and HbA1c. Bone mineral density (BMD), bone mineral content (BMC), and BMC-to-lean tissue mass (LTM) ratio were measured using DXA and reported as z-scores for height. Total, trabecular, and cortical bone and muscle parameters were measured using peripheral quantitative computed tomography (pQCT) and reported as z-scores for age. RESULTS: Mean age at assessment was 14.3 ± 3.1 years; diabetes duration, 8.0 ± 3.5 years; HbA1c, 8.2 ± 1.5% (66 ± 5 mmol/mol); and 25-hydroxy vitamin D, 71 ± 21 nmol/L. Comparing youth with coexisting CD versus type 1 diabetes alone, DXA showed lower BMC-to-LTM ratio (0.37 ± 1.12 vs. 0.73 ± 2.23, P = 0.007) but no difference in total BMD. Youth with coexisting CD also had lower BMC-to-LTM ratio versus the general population (P = 0.04). Radial pQCT showed lower total BMC (-0.92 ± 1.40 vs. -0.26 ± 1.23, P = 0.03) despite similar bone and muscle cross-sectional area. In multivariable linear regression, lower BMC was associated with higher insulin dose (P = 0.03) but not HbA1c. CONCLUSIONS: Youth with both type 1 diabetes and CD have lower BMC relative to LTM and lower BMC, indicating abnormal trabecular and cortical bone development despite similar bone and muscle size. These findings suggest that the two conditions confer a lower bone turnover state. We recommend further examination of bone health in this population; future research should examine early interventions to improve bone health.

Greater postprandial glucose excursions and inadequate nutrient intake in youth with type 1 diabetes and celiac disease.

The gluten free diet (GFD) has a high glycemic index and low-fiber content, which potentially influences glycemic excursions in type 1 diabetes (T1D) and celiac disease (CD). Participants in this case-control study of youth with T1D+CD (n = 10) and T1D only (n = 7) wore blinded continuous glucose monitoring systems for six days. Blood glucose levels (BGLs) were compared between groups for each meal, including pre-meal, peak, 2-hour postprandial and time-to-peak. Participants consumed a test-breakfast of GF cereal and milk for three days and kept weighed food diaries; nutrient intake was analyzed and compared to national recommendations. Youth with T1D+CD had shorter time-to-peak BGL (77 vs 89 mins, P = 0.03), higher peak (9.3 vs 7.3 mmol/L, P = 0.001) and higher postprandial BGLs than T1D (8.4 vs 7.0 mmol/L, P = 0.01), despite similar pre-meal BGLs (9.2 vs 8.6 mmol/L, P = 0.28). Regarding test breakfast, greater pre and post-meal BGL difference correlated with longer CD duration (R = 0.53, P = 0.01). Total energy and macronutrient intake didn't differ between groups; however the majority of participants collectively had inadequate intake of calcium (76%), folate (71%) and fiber (53%), with excessive saturated fat (12%) and sodium (>2,000 mg/day). The GFD is associated with greater glycemic excursions and inadequate nutritional intake in youth with T1D+CD. Clinical management should address both glycemic variability and dietary quality.

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.

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.