What is the link between coeliac disease and Type 1 diabetes?

Coeliac disease and dermatitis herpetiformisUsually shortened to DH, this is a form of coeliac disease where the skin is affected with small blisters. (DH) are more common in people with some other autoimmuneA reaction to a trigger which causes the body to attack itself. diseases, such as Type 1 diabetes mellitus (Type 1 DM).

The association is probably because both diseases have a common genetic predisposition. HLA-DQB1 is the gene present in the majority of people with both conditions (1,2). 

There is no increased risk of coeliac disease in people with Type 2 diabetes mellitus (3).    

How common is Type 1 diabetes in coeliac disease?

Type 1 DM affects about 0.75% and coeliac disease affects 1% of people in the general population. The National Institute for Health and Clinical Excellence (NICENational Institute for Health and Clinical Excellence - an independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health. NICE had produced a clinical guideline on the recognition and assessment of coeliac disease.) guideline on the recognition and assessment of coeliac disease notes that 2-10% of people with coeliac disease will also have Type 1 DM (4).  

Presentation and symptoms of coeliac disease in diabetes

In most cases (about 90%), Type 1 DM is diagnosed before coeliac disease (5). This may be because Type 1 DM generally has an acute onset and the symptoms are more easily identified.

The symptoms of coeliac disease vary from person to person and range from mild to severe. Coeliac disease can be missed as the symptoms of ill health can be attributed to the diagnosed diabetes. 

It has been shown that when coeliac disease is diagnosed before diabetes, the clinical presentation of diabetes is more severe and there is a higher prevalence of multiple autoimmune diseases (6).

Malabsorption commonly occurs in people with undiagnosed coeliac disease and Type 1 DM. Recurrent hypoglycaemia has been reported as a sign of coeliac disease in individuals with Type 1 DM (7). Unstable diabetes and growth failure in children with diabetes may indicate the presence of coeliac disease (8).

How to diagnose coeliac disease?

The NICE guideline recommends that anyone with Type 1 DM should be screened for coeliac disease.  

Immunoglobulin A (IgA) tissue transglutaminase (tTGA) and endomysial antibody (EMAEndomysial antibody - an antibody that is measured in the blood as part of the diagnosis process for coeliac disease. Depending on the laboratory performing the test, one or more antibodies may be measured (see Tissue Transglutaminase)) tests are sensitive diagnostic markers for coeliac disease.

The presence or absence of IgA deficiency has been reported in a group of patients with Type 1 DM. People with IgA deficiency should have IgG tTGA and/or EMA tests to confirm or rule out coeliac disease (10,11).

It is possible to have a negative blood testBlood is taken from someone who is being tested for coeliac disease. yet still have coeliac disease. Some patients with Type 1 DM may be negative for coeliac disease antibodiesExist in the blood and are used by the immune system to attack viruses or bacteria. early in their diagnosis but may become antibody positive at a later stage. There have been reports suggesting that coeliac disease can be missed if testing for coeliac disease only happens at diagnosis (12,13).

Therefore, people with Type 1 DM should be monitored for coeliac disease (11). Research currently available does not support specific guidelines on how frequently to retest for coeliac disease. However, as a precaution, Coeliac UK recommends that everyone with Type 1 DM is tested for coeliac disease every three years.

What are the benefits of diagnosis of coeliac disease in diabetes?

In people with coeliac disease and Type 1 DM following a gluten-freeWhen a food has less than 20 parts per million (ppm) of gluten so it is safe for people with coeliac disease to eat. diet can result in short and long term improvements.

Benefits of diagnosis and the glutenA protein that is found in the cereals wheat, barley and rye. -free diet include:

• normal growth in children (14,15)
• reduces the risk of anaemia and long term problems like osteoporosisA condition where your bones lose bone mass and become brittle.
• improves absorption of nutrients including iron, folate, calcium and carbohydrate
• improvements in HbA1c and diabetic control (7,14).

Both Type 1 DM and coeliac disease are associated with long-term complications so early diagnosis is important.

Dietary management of Type 1 diabetes and coeliac disease

Dietary management of the combined diseases requires professional guidance from a registered dietitianAn expert in food and nutrition. . 

The role of the dietitian is well documented in diabetes management and there are nutrition guidelines and recommendations for dietetic intervention in diabetes care (16).

The aim of dietary management is to improve blood glucose control as well as support people with the gluten-free diet. Children with coeliac disease and Type 1 DM should have their growth and development carefully monitored.

Coeliac UK has a leaflet on Type 1 diabetes and coeliac disease. This is available in the Members area of the website. Further information on the management of diabetes and coeliac disease is available on our website.

References

1 Martin-Villa JM (2001) Coeliac- and enteropathy-associated autoantibodies in Spanish insulin-dependent diabetes mellitus patients and their relation to HLA antigens.  Journal of Diabetes and its Complications.15: 38-43.

2 Hervonen K, Viljamaa M, Collin P, et al (2004) The occurrence of type 1 diabetes in patients with dermatitis herpetiformis and their first-degree relatives.  British Journal of Dermatology. 150(1): 136-8.

3. Page SR (1994) The prevalence of coeliac disease in adult diabetes mellitus.  QJM. 87: 631-37.

4. NICE (2009) Coeliac Disease: Recognition and assessment of coeliac disease. http://www.nice.org.uk/

5. Barera G, Bianchi C, Calisti L, et al (1991) Screening of diabetic children for coeliac disease with antigliadin antibodies and HLA typing.  Archives of Disease in Childhood. 66: 491-494.

6. Valerio G, Maiuri L, Troncone R, et al (2002) Severe clinical onset of diabetes and increased prevalence of other autoimmune diseases in children with coeliac diabetes diagnosed before diabetes mellitus.  Diabetologia. 45(12): 1719-22.

7. Hansen D, Bennedbaek FN, Hansen LK, et al (2001) High prevalence of celiac disease in Danish children with type 1 diabetes mellitus.  Acta Paediatrica. 90:1238-43.

8. Bradbury BL & Scarpello JHB (1999) Recurrent hypoglycaemia as the presenting symptom of coeliac disease in a patient with Type 1 diabetes mellitus.  Pract Diab Int 16: 89-90.

9. SIGN (2001) Management of diabetes. www.sign.ac.uk/pdf/sign55.pdf

10. Gillet PM, Gillett HR, Israel DM, et al (2001) High prevalence of celiac disease in patients with type 1 diabetes detected by antibodies to endomysium and tissue transglutaminase.  Canadian Journal of Gastroenterology. 15: 297-301.

11. Picarelli H (2005) Anti-endomysial antibody of IgG1 isotype detection strongly increases the prevalence of celiac disease in patients affected by type 1 diabetes mellitus.  Clinical and Experimental Immunology. 142(1): 111-15.

12. Jones H and Warner J (2010) NICE clinical guideline 86. Coeliac disease: recognition and assessment of coeliac disease. Archives of Disease in Childhood. 94: 312-313

13. Babiker A, Morris MA and Datta V (2010) Coeliac disease and type 1 diabetes: 7 years of experience versus NICE guidance 2009. Archives of Disease in Childhood. 95: 1068-1069.

14. Saadah OI, Zacharin M, O’Callaghan A, et al (2004) Effect of gluten-free diet and adherence on growth and diabetic control in diabetics with celiac disease.  Archives of Disease in Childhood. 89(9): 871-6. 

15. Smith CM (2000) Prevalence of celiac disease and longitudinal follow-up of antigliadin antibody status in children and adolescents with Type 1 diabetes mellitus.  Paediatric Diabetes. 1(4): 199-204.

16. Nutrition Subcommittee of the Diabetes Care Advisory Committee of Diabetes UK (2003) The implementation of nutritional advice for people with diabetes.  Diabetic Medicine. 20: 786-807.