January 2014 Issue

Living Gluten Free With Type 1 Diabetes
By Karen Meadows, MA, MS, CDE
Today’s Dietitian
Vol. 16 No. 1 P. 34

Celiac disease is common in patients with type 1 diabetes. Understand the genetic link between these conditions and ways to counsel clients and patients.

A type 1 diabetes diagnosis demands major lifestyle changes that include dietary modifications, regular physical activity, and a strict medication regimen. A celiac disease diagnosis also requires significant lifestyle changes that involve eating a gluten-free diet.

Each disease is tough to manage on its own, but if both are diagnosed, either simultaneously or years apart, life for clients and patients can become even more complicated. However, RDs can help clients manage their diabetes and celiac disease as they follow a healthful gluten-free lifestyle.

Type 1 Diabetes and Celiac Disease
The American Diabetes Association (ADA) reports that about 1% of the US population has celiac disease, while an estimated 10% of individuals who have type 1 diabetes also have celiac disease. Several studies have explored the possible connection between these two disorders.

A 2002 study by Barera and colleagues published in Pediatrics investigated the prevalence of celiac disease in 274 children and adolescents at the onset of type 1 diabetes and the occurrence of new cases during a six-year follow-up. The researchers found that the prevalence of celiac disease in patients with type 1 diabetes was approximately 20 times higher than in the general population. “The overall prevalence of biopsy-confirmed celiac disease in the entire cohort of patients was 6.2%,” the authors wrote. They concluded that “sixty percent of [celiac disease] cases are already present at diabetes onset, mostly undetected, but an additional 40% of patients develop celiac disease a few years after diabetes onset.”1

Research suggests that celiac disease and type 1 diabetes share a common genetic etiology. The National Institutes of Health reported in a February 2013 article, “Research Finds Shared Genetic Susceptibility for Celiac Disease and Type 1 Diabetes — Celiac Disease Awareness Campaign,” that “a growing body of research suggests type 1 diabetes is triggered by exposure to gluten … adding even more weight to the theory that the two disorders share common genetic causes.”

The article referred to results of a British study published in the December 25, 2008, issue of The New England Journal of Medicine. According to those researchers, “Two inflammatory disorders, type 1 diabetes and celiac disease, cosegregate in populations, suggesting a common genetic origin.” They concluded that “a genetic susceptibility to both type 1 diabetes and celiac disease shares common alleles [sites on a chromosome]. These data suggest that common biologic mechanisms, such as autoimmunity-related tissue damage and intolerance to dietary antigens, may be etiologic [causal] features of both diseases.”2

The German BABYDIAB study, published in the October 2003 issue of The Journal of the American Medical Association, followed newborns from 1989 to 2003 and examined whether early introduction of gluten-containing foods influenced the risk of developing type 1 diabetes and celiac disease autoantibodies. The researchers found that food supplementation with gluten-containing foods before the age of 3 months significantly increased the risk of type 1 diabetes autoantibodies, but that early exposure to gluten didn’t significantly raise the risk of developing celiac disease–associated autoantibodies.3

The Environmental Determinants of Diabetes in the Young (TEDDY) study, begun in 2002, is tracking nearly 8,000 children in Europe and North America, investigating possible triggers for type 1 diabetes, including celiac disease. Jill Norris, PhD, MPH, chair of the Colorado School of Public Health department of epidemiology and one of the study investigators, says the TEDDY study is screening for celiac autoimmunity because of the risk of type 1 diabetes in those diagnosed with celiac disease. She also believes that type 1 diabetes and celiac disease share a genetic marker and says the TEDDY study is looking for shared environmental factors, including dietary factors.

Is There a Link With Type 2 Diabetes?
While research suggests an association between type 1 diabetes and celiac disease, there doesn’t appear to be a link between celiac disease and type 2 diabetes, as the latter isn’t an autoimmune disorder and doesn’t share genes with celiac disease. According to the Celiac Sprue Association, individuals can be genetically predisposed to type 2 diabetes, but those genes don’t increase the risk of celiac disease.

In the May 2013 issue of Gastroenterology, researchers published results of a 2012 study by Kabbani and colleagues that compared the charts of 840 patients who had celiac disease with 840 controls to determine the association between celiac disease and type 2 diabetes, hypertension, hyperlipidemia, hyperglycemia, or a high BMI. Study results showed that the prevalence of type 2 diabetes and metabolic syndrome in patients with celiac disease was significantly lower compared with controls and the US population.4

“Researchers have done epidemiologic studies that look at whether certain traits, like having celiac disease, are higher in a particular population, such as those with type 2 diabetes. These studies have found that there doesn’t appear to be an association between celiac disease and type 2 diabetes,” says Erika Gebel Berg, PhD, an associate editor of Diabetes Forecast.

Berg says a 2002 to 2008 study from Dicle University Medical School in southeastern Anatolia, Turkey, “looked at antibodies for celiac disease in people with type 1, type 2, and no diabetes.” According to the results, Berg says, there was a statistically significant presence of antigliadin antibodies (AGA-IgA) in patients with type 1 diabetes compared with healthy controls. And there was no statistically significant presence of AGA-IgA in patients with type 2 diabetes compared with healthy subjects. (Positive AGA-IgA is one indication of celiac disease.)5

Celiac Disease Complications
Clients and patients with celiac disease have an increased risk of developing vitamin and mineral deficiencies, including folate, iron, and vitamins B6, B12, and D. When people with celiac disease consume gluten, their immune systems respond by damaging the fingerlike villi of the brush border in the small intestine, which results in malabsorption of these vital nutrients. Deficiencies in untreated celiac disease may lead to anemia, osteoporosis, reproductive problems, and intestinal cancer, further complicating the health and quality of life of people with type 1 diabetes.6

Lara Rondinelli-Hamilton, RD, CDE, who contributed to Gluten-Free Recipes for People With Diabetes, encourages everyone with type 1 diabetes to be tested for celiac disease “because it is so important to eat gluten free if you have celiac disease. Eating gluten free is the only treatment for celiac disease. It’s life changing, but people will feel better and get better.”

Gluten’s Effects on Blood Sugar
Type 1 diabetes patients with celiac disease who eat a gluten-free diet won’t only feel better, but they’ll also experience more stable blood sugar readings. In those with celiac disease, gluten prevents the absorption of carbohydrates in the intestines, which often causes unexplained blood sugar highs and lows, explains Linda Reineke, RD, CDE, who works with patients with type 1 diabetes and celiac disease as part of the University of New Mexico Hospital diabetes program. Other food components also affect blood sugar fluctuations when combined with carbohydrate intake. For example, fat slows digestion. “Sometimes foods are absorbed, sometimes not, depending on how mixed the meal is,” she explains.

Reineke, while counseling a client with type 1 diabetes over the course of several years, found herself constantly addressing variable blood glucose levels. A colleague on her health care team suggested the patient might have celiac disease. “He was tested and had positive antibodies for celiac disease,” Reineke recalls. “Once he started to eat gluten-free foods, his blood glucose got much better.”

Gluten-Free Foods and Blood Sugar
It’s important to remember that even after a celiac disease diagnosis and transition to a gluten-free diet, clients and patients still may experience blood sugar fluctuations. Their intestines are beginning the healing process, and carbohydrates are being readily absorbed. In addition, if clients and patients are eating processed gluten-free products that tend to be low in protein and fiber and high in carbohydrates, they may experience blood sugar increases.

Most clients with type 1 diabetes have been taught how much insulin they need to take to coincide with carbohydrate intake. But the formula they use may not be appropriate once they begin eating gluten-free foods, so they’ll need to reassess insulin needs and frequently check blood sugar levels.

In a July 2002 study published in Diabetes Spectrum, Schwarzenberg and Brunzell stated, “It seems likely that a malabsorptive disease could create opportunity for hypoglycemia in diabetes, particularly in patients under tight control. Serological testing for GSE [gluten-sensitive enteropathy] in patients with type 1 diabetes, with early diagnosis of GSE, may reduce this risk by allowing patients to be diagnosed in a pre-symptomatic state. It also seems prudent to closely monitor insulin needs and blood glucose control during the early phase of instituting a gluten-free diet.”7

Challenges of Avoiding Gluten
Eliminating all gluten-containing foods from the diet can complicate most aspects of living with type 1 diabetes, though. Patients with type 1 diabetes count carbohydrates before eating meals and snacks and then balance them with the correct insulin dosage. They also consider their protein and dietary fiber intake. This poses a challenge because many processed gluten-free foods are high in carbohydrates but low in protein and fiber.

To address this, Rondinelli-Hamilton says clients and patients should eat naturally gluten-free whole foods such as vegetables, fruits, lean meats, legumes, and quinoa. Not only are these foods better sources of carbohydrates, but they also contain more protein and fiber than processed foods.

Meeting Goals, Not Guidelines
Ultimately, there are no specific dietary guidelines for patients with celiac disease other than to eat gluten-free foods. Also, as noted by an ADA position statement, there aren’t any specific guidelines for those with type 1 diabetes either.8

The position statement says nutrition interventions should emphasize minimally processed, nutrient-dense foods in appropriate portion sizes that support metabolic control. For individuals with type 1 diabetes, the statement recommends meal plans based on either flexible insulin therapy using carbohydrate counting or fixed daily insulin doses with consistent carbohydrate consumption. Meal plans are created using the MyPlate method, carbohydrate counting, and the glycemic index. The ADA recommends that dietitians administer medical nutrition therapy based on their patients’ individual needs.8 “Dietitians need to consider individual lifestyle factors to craft appropriate dietary guidelines,” Reineke says. “The basis is diabetes control, and you alter that for celiac disease.”

However, there are certain goals the ADA recommends that all type 1 diabetes patients should meet. They should aim to keep their average blood sugar, blood pressure, and cholesterol within a target range. The association’s 2013 goals for most adults with diabetes (excluding pregnant women) are as follows:

• average blood sugar below 7% or 150 mg/dL;

• blood pressure below 140/80;

• LDL cholesterol below 100;

• HDL cholesterol higher than 40 for men and higher than 50 for women; and

• triglycerides below 150.

More or less stringent glycemic goals may be appropriate for each individual. Blood glucose targets are individualized based on duration of diabetes, age/life expectancy, comorbid conditions, known cardiovascular disease or advanced microvascular complications, hypoglycemia unawareness, and individual patient considerations.9

Dietary Basics
To help clients and patients adjust to the lifestyle changes that accompany a dual diagnosis of type 1 diabetes and celiac disease, dietitians can, for example, teach those who occasionally eat processed gluten-free products to count carbohydrates and especially pay close attention to carbohydrates in gluten-free grains, says Shelley Case, BSc, RD, author of Gluten-Free Diet: A Comprehensive Resource Guide.

RDs also must show patients how to adjust portion sizes and read labels to spot hidden sources of gluten. “Gluten-derived ingredients are found in almost every processed food,” Case says, “so careful label reading is essential.”

Grains such as wheat, barley, and rye contain gluten, but it also can be found in bulgur, durum, semolina, spelt, kamut, einkorn, faro, triticale, couscous, farina, malt, and seitan. Moreover, gluten may be hidden in ingredients such as vegetable protein/hydrolyzed vegetable protein, starch/stabilizer/vegetable starch, modified starch/modified food starch, natural or artificial flavors, caramel color, seasonings or flavorings, dextrin and maltodextrin, and oats. Oats often are contaminated with gluten as they grow or are harvested, stored, or processed, so it’s important for clients and patients to buy those that are labeled gluten free.

To increase their fiber intake, clients can add nuts to gluten-free cold cereals and flax to gluten-free oatmeal. Case also recommends adding kidney beans, black beans, or chickpeas to gluten-free pizza or baked potatoes.

Gluten also can be found in prepared food products such as soy sauce, ice cream, candy, herbal teas, canned soups, lunchmeats, and salad dressings. It’s found in personal care products such as toothpaste, mouthwash, lip balm, and lipstick and is used as a filler in many oral medications and over-the-counter products. Some varieties of these products are gluten free, so clients and patients should look for labels indicating this or contact manufacturers, speak with a pharmacist, or go online for needed information.

Patient Education
Ultimately, education is the key to living successfully with type 1 diabetes and celiac disease. Clients and patients need to become knowledgeable about both diseases and how to manage them through physical activity, medications, and nutritious gluten-free foods that fit into a diabetes-friendly meal plan.

“Knowledge is power,” Reineke says. “Celiac disease is a tough diagnosis because, like type 1 diabetes, it adds one more thing people have to consider every day. The number of grams of carbohydrates in gluten-free choices often are different, so this diagnosis will be easier [to manage] for those already carbohydrate counting. Others will need to learn.”

When providing medical nutrition therapy to patients, Reineke advises dietitians to discuss the different food groups, spend time listening to patients, take their individual eating patterns and lifestyles into consideration, and substitute nutritious gluten-free options for the foods they normally eat.

With a dietitian’s guidance, patients with type 1 diabetes and celiac disease can make healthful gluten-free food choices. Effective dietary counseling should result in better nutrition and better diabetes management. Dietitians are in the best position to help these patients establish a foundation for gluten-free living by providing patients with educational materials and scheduling follow-up appointments so they can achieve optimal health.

— Karen Meadows, MA, MS, CDE, is a freelance writer in New Mexico who lives successfully with type 1 diabetes and celiac disease.

 

Modifying Familiar Recipes
Patients with type 1 diabetes and celiac disease still can enjoy their favorite recipes by making the following modifications:

• Use gluten-free bread crumbs when preparing meatloaf.

• Choose corn, rice, or multigrain gluten-free tortillas instead of wheat tortillas.

• Eat polenta instead of pasta.

• Include quinoa, millet, and buckwheat as part of meals.

• Wrap a turkey burger in lettuce rather than a bun.

• Thicken sauces with arrowroot, cornstarch, guar gum, kuzu, or tapioca starch.

• Experiment with gluten-free flours. (Our May 2013 E-News Exclusive provides some information on using gluten-free flours: www.todaysdietitian.com/enewsletter/enews_0513_01.shtml.)

— KM

 

Sample Gluten-Free Meal Plan

Breakfast
1 cup hot brown rice cereal
1 slice whole grain, gluten-free toast with nut butter
1 egg
Snack
Corn muffin with cream cheese

Lunch
Quinoa salad with zucchini, bell pepper, scallions, and toasted almonds
Bouillon or miso soup
1 orange or kiwi

Snack
1/2 avocado with black bean salsa

Dinner
1 cup lentil sweet potato stew
1 baked chicken breast, skinless
Green salad with gluten-free dressing

— KM

 

Resources
• American Diabetes Association (www.diabetes.org)

• Celiac Disease Foundation (www.celiac.org)

• Diabetes Care, which publishes clinical practice recommendations every January (http://care.diabetesjournals.org)

• Gluten-Free Drugs (www.glutenfreedrugs.com)

• Kupper C, Higgins LA. Combining diabetes and gluten-free dietary management guidelines. Practical Gastroenterology. (www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/KupperArticle.pdf)

• National Digestive Diseases Information Clearinghouse (http://digestive.niddk.nih.gov/ddiseases/pubs/celiac)

• University of Chicago Celiac Disease Center (www.cureceliacdisease.org)

 

References
1. Barera G, Bonfanti R, Viscardi M, et al. Occurrence of celiac disease after onset of type 1 diabetes: a 6-year prospective longitudinal study. Pediatrics. 2002;109(5):833-838.

2. Smyth DJ, Plagnol V, Walker NM, et al. Shared and distinct genetic variants in type 1 diabetes and celiac disease. N Engl J Med. 2008;359(26):2767-2777.

3. Ziegler AG, Schmid S, Huber D, Hummel M, Bonifacio E. Early infant feeding and risk of developing type 1 diabetes–associated autoantibodies. JAMA. 2003;290(13):1721-1728.

4. Kabbani TA, Kelly CP, Betensky RA, et al. Patients with celiac disease have a lower prevalence of non–insulin-dependent diabetes mellitus and metabolic syndrome. Gastroenterology. 2013;144(5):912-917.

6. Celiac disease — complications. Mayo Clinic website. http://www.mayoclinic.com/health/celiac-disease/DS00319/DSECTION=complications. May 22, 2013. Last accessed November 2013.

7. Schwarzenberg SJ, Brunzell C. Type 1 diabetes and celiac disease: overview and medical nutrition therapy. Diabetes Spectrum. 2002;15(3):197-201.

8. Evert AB, Boucher JL, Cypress M, et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care. 2013;36(11):3821-3842.

9. Checking your blood glucose. American Diabetes Association website. http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/checking-your-blood-glucose.html. Last edited July 19, 2013. Accessed November 2013.