Type 1 Diabetes and Celiac Disease: How Common a Connection?

We have recently had an upsurge in children with type 1 diabetes at our gastroenterology clinic for celiac screening. What is the incidence of celiac disease in children with this type of diabetes?

—— Valerie Bermel, RN, MS
Cleveland, Ohio

Celiac disease may be associated with abdominal symptoms, such as crampy diarrhea or bloating. Often, however, it is silent. Untreated celiac disease may result in poor growth, osteopenia or, rarely, intestinal lymphoma. These are no doubt related to the damage done to the small-bowel mucosa, which includes villous atrophy, crypt hyperplasia, and an influx of inflammatory cells. These changes are reversible with a gluten-free diet. The prevalence of celiac disease in children with type 1 diabetes is estimated to be 5% to 10%.¹ The prevalence may increase with age.

Celiac disease is usually silent in children with diabetes. However, it may interfere with glucose control, impede normal weight and height gain, and reduce bone mineral density. Screening for celiac disease is easily done by testing for the IgA class antibodies, either anti-endomysial or anti-tissue transglutaminase. Also measure total IgA; a few children may normally have very low IgA levels, and the rise in IgA antibodies that is a sign of celiac disease might not be detectable in them. Such children may need to be screened by the older method of testing for the less specific IgG class antibodies, such as antigliadin. All children with type 1 diabetes should be screened for celiac disease. If the results of a blood screening are positive, order a small-bowel biopsy to confirm the diagnosis. Even if biopsy results are initially negative, villous atrophy may develop later. Thus, biopsy should be repeated every 4 to 5 years on a lifelong basis in children with positive blood screening results but a normal initial biopsy.

Therapy for celiac disease consists of dietary restriction of wheat, rye, and barley protein. This can be accomplished within the context of a diabetic diet. Repeated small-bowel biopsy is not necessary unless GI symptoms persist.

—— David Wyatt, MD
Professor, Pediatric Endocrinology
Medical College of Wisconsin
Milwaukee