Symptomless celiac disease in type 1 diabetes: 12‐year experience in Estonia

Background: We aimed to determine the prevalence and characteristics of celiac disease in children with type 1 diabetes in Estonia, a country with a formerly low frequency of both diseases. Methods: Altogether, 271 patients with diabetes were studied over 12 years (1995–2006): 122 at diagnosis and 149 patients 0.1–14.8 years after diagnosis. In addition, 73 patients were followed up over 1–6 years. Immunoglobulin A type endomysium and tissue transglutaminase antibodies were determined. Patients with antibodies and/or with celiac‐disease‐related symptoms were invited for a small‐intestinal biopsy. Results: At the primary screening, celiac disease was histologically confirmed in nine patients (all without symptoms), that is, in 3.3% (95% confidence interval: 1.63–6.42) of type 1 diabetes cases. At follow up, celiac disease was additionally detected in two (2.7%) of 73 diabetic patients, that is, in 0.016 (95% confidence interval: 0–0.072) celiac disease cases per follow‐up year. Conclusion: The prevalence of celiac disease among type 1 diabetes patients in Estonia is similar to that in countries with a high incidence of celiac disease and type 1 diabetes. As celiac disease is mostly symptomless, all children with type 1 diabetes, irrespective of their geographic origin, should be regularly screened for celiac disease.     

Prediction of silent celiac disease at diagnosis of childhood type 1 diabetes by tissue transglutaminase autoantibodies and HLA

Abstract: Aims: The aims were to estimate the diagnostic sensitivity and specificity of autoantibodies to tissue transglutaminase (IgA‐ and IgG‐tTG), gliadin (AGA) and endomysium (EMA) in relation to human leukocyte antigen (HLA)‐DQB1 alleles to identify silent celiac disease at diagnosis of type 1 diabetes. Methods: IgA‐ and IgG‐tTG were measured in radioligand binding assays in 165 type 1 diabetic patients. Data on HLA‐DQB1 were available for 148 patients and on both AGA and EMA for 164 patients. For patients considered positive for AGA or EMA, or both, an intestinal biopsy was suggested. HLA‐DQB1 typing was carried out by polymerase chain reaction and hybridization with allele specific probes. Results: Three patients, left out from further study of antibodies, but not from HLA‐DQB1 analysis, had treated celiac disease at diagnosis. Out of the other 162 type 1 diabetic patients tested, nine had IgA‐tTG, six IgG‐tTG, eight EMA, and 11 AGA. Biopsy was suggested for nine patients, of whom six showed villous atrophy, one did not and two refused to participate. Thus, silent celiac disease was probable in 8/162 and biopsy‐verified in 6/162, where five patients were AGA‐positive and six either EMA‐, IgA‐tTG‐ or IgG‐tTG‐positive. Of the 11 patients with celiac disease (three with treated and eight with silent celiac disease), 10 were HLA‐DQB1‐typed, of whom 65% (13/20) had the DQB1*02 allele, compared with 36% (100/276; p = 0.011) of those without celiac disease. IgA‐tTG levels were higher in patients having either *02 or *0302 (0.6; ?1.3–112.4 RU) compared with those not having these alleles (0.4; ?0.7–3.4 RU; p = 0.023). Conclusion: IgA‐tTG are HLA‐DQB1*02‐associated autoantibodies with high sensitivity and specificity for silent celiac disease at diagnosis of type 1 diabetes.     

Incidence of enteropathy-associated T-cell lymphoma in celiac disease: implications for children and adolescents with type 1 diabetes

Abstract: The long-term consequences of screening for celiac disease in diabetic children are not known. Routine screening is not practiced in our pediatric diabetic population. This study of the incidence of the most severe and specific long-term complication of untreated celiac disease, i.e., enteropathy-associated T-cell lymphoma (EATCL) and its association with diabetes, is done in order to justify our strategy not to practice routine screening. In the first phase of this study, a questionnaire was sent to all Swiss pathologists. The second phase consisted of a search in the cancer registry of the canton of Zurich. The incidence of EATCL in the general population of a Swiss region and the theoretical risk for a diabetic patient to develop this type of lymphoma were calculated.
Ten cases of EATCL were found. Five had a long history of malabsorption, three of them since childhood. The mean age of the patients was 61.9 yr. None suffered from diabetes mellitus. The incidence of EATCL was 0.07/100 000 inhabitants/year. The expected risk for EATCL in patients with type 1 diabetes is 12.4/100 000 diabetic patients over a period of 60 yr.
The data suggest that the risk for EATCL is small in diabetic patients. Therefore, we restrict the investigation for celiac disease to patients with typical and atypical symptoms, but do not perform routine screening.     

Correlates of glycemic control and quality of life outcomes in adolescents with type 1 diabetes

Ingerski LM, Laffel L, Drotar D, Repaske D, Hood KK. Correlates of glycemic control and quality of life outcomes in adolescents with type 1 diabetes. Background: A major focus of pediatric multidisciplinary diabetes care is promoting glycemic control (A1c) while ensuring high quality of life (QOL). The current study investigated factors associated with A1c and QOL using a methodology that considered these variables as simultaneous outcomes. Method: A total of 261 adolescents (aged 13–18) with type 1 diabetes completed measures of blood glucose monitoring (BGM) frequency, diabetes‐specific QOL, negative affect, and depression. Caregivers completed measures of demographic and disease characteristics, depression, and family conflict. Results: A1c was negatively correlated with QOL (r = −0.18 to −0.29, p < 0.01) across all subscales. Based on clinical A1c goals and median QOL scores, adolescents fell into four glycemic control–QOL groups. Multinomial logistic regression determined correlates of group membership utilizing adolescents with suboptimal glycemic control–low QOL as the referent group. Adolescents with optimal glycemic control–high QOL reported increased BGM frequency (OR = 1.87), less negative affect (OR = 1.32), and were more likely to use CSII (OR = 5.41). Adolescents with optimal A1c–low QOL reported greater BGM frequency (OR = 1.91) and shorter disease duration (OR = 1.09). Adolescents with suboptimal glycemic control–high QOL reported greater BGM frequency (OR = 1.41), fewer depressive symptoms (OR = 1.13), and less negative affect (OR = 1.31). Conclusions: Results reveal disease, management, and psychosocial characteristics that differentiate glycemic control–QOL outcome groups and identify risk factors related to this relationship. Further appreciation of these characteristics may increase clinicians' understanding and attention to these important clinical outcomes and help tailor the most appropriate interventions (e.g., individual psychotherapy vs. family problem‐solving interventions) to help adolescents achieve glycemic control without sacrificing QOL.     

Quality of life in children with diabetes and celiac disease: minimal impact of the 'double diagnosis'

Sud S, Marcon M, Assor E, Daneman D and Mahmud FH. Quality of life in children with diabetes and celiac disease: minimal impact of the ‘double diagnosis'. Background: Despite the advent of sensitive testing to detect celiac disease (CD), screening in type 1 diabetes (T1D) remains controversial. Many diabetes clinics are apprehensive about the prospect of introducing a second illness requiring intensive lifestyle changes in patients and families already managing a chronic condition, especially in asymptomatic patients. Objective: To determine the impact of managing CD + T1D on quality of life in families, with attention to the effect of adherence with a gluten‐free diet (GFD) and metabolic control. Patients and Methods: Cross‐sectional assessment using a validated self‐reported quality of life measure: 28 children with biopsy‐proven CD + T1D were compared with 40 subjects with T1D aged 8–18 yr. Parental and child reports were assessed as well as symptoms at the time of CD diagnosis and adherence with a GFD at the quality of life assessment. Results: No significant differences in quality of life were observed between subjects with established CD + T1D and subjects with T1D alone. Parents of children with CD + T1D reported lower social functioning scores than parents of children with T1D (p = 0.03). In the CD + T1D group no differences in quality of life were observed with regard to age at CD diagnosis, CD duration, or on the basis of adherence with a GFD. Conclusions: The additional diagnosis of CD has minimal impact on quality of life in children with T1D; however, parents of CD + T1D children did express greater concern about their child's social functioning.     

Glycemic control and type 1 diabetes: the differential impact of model of care and income

Hatherly K, Smith L, Overland J, Johnston C, Brown‐Singh L, Waller D, Taylor S. Glycemic control and type 1 diabetes: the differential impact of model of care and income. Objective: To examine the effect of model of care (specialist care vs. shared care), and income, on glycemic control in a sample of young people with type 1 diabetes. Methods: A total of 158 children and young people with type 1 diabetes, aged 8–19 yr, and their families, were recruited independent of their source of care as part of a longitudinal, cross‐sectional exploratory study. At enrollment, participants completed a series of questionnaires and underwent a structured interview to gather data regarding the type of specialist and healthcare services attended, as well as demographic, healthcare, and self‐care information. Capillary sample was taken for HbA1c determination. Results: The mean HbA1c for the group as a whole was 8.6 ± 1.4%. There was no effect for model of care on glycemic control. However, young people living in households with a family income of less than AUS$83 000 (US$73 500) per year had a significantly higher mean HbA1c than their counterparts reporting a higher household income (8.8 ± 1.4% vs. 8.3 ± 1.1%; p = 0.019). Conclusion: Although no differences were found with respect to the short‐term impact of specialist vs. shared care, it is evident that more support is required to improve glycemic control in this sample of young people where the mean level of HbA1c was significantly higher than target. Further research is also indicated to determine the relationship between glycemic control and socioeconomic status.