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Significance of Screening Detected Celiac Disease in Children with Type I Diabetes (A Case Control Study) 11/06/2007 - This study investigated the effect of screening detected celiac disease in type I diabetic children in a multi-center case-control fashion.  The research team consisted of B Rami, Z Sumni, E Schober et al from Austria, Czech Republic, and Slovenia, among other European countries.

The team compared 98 diabetics with silent celiac disease to 196 control diabetics without celiac matched for age, sex, diabetes duration.  Mean age at diabetes diagnosis was 6.5 yrs, celiac diagnosis was 10.0 yrs.  Celiac screening included yearly antibody testing and positive patients underwent biopsy.  Hemoglobin A1c, hypoglycemia, ketoacidosis, insulin dosage, body-mass index, and height did not differ between cases and controls at celiac diagnosis or after a mean follow-up of 3.3 years.  After diagnosis of celiac disease, weight gain was diminished in boys with celiac disease compared to their controls.

Although a clear link between type I diabetes and increased risk of celiac disease is established, the benefit of a gluten-free diet is unclear in these children.  This study followed 98 patients with diabetes and silent celiac for a mean of 3.3 years and compared them to 196 controls.  This is the largest, best designed case-control study to date and it did not demonstrate any significant differences between the two groups, except for a decreased Body Mass Index (BMI - though still greater than non-diabetic, control children) in males after diagnosis. 

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What is more intriguing is that at diagnosis, no significant differences in height, BMI, HbA1c, insulin need, or hypoglycemia events were seen, questioning the metabolic significance of silent celiac disease.  In this study, it is difficult to estimate the duration of silent celiac disease prior to diagnosis.  Although, given the fact that these patients were asymptomatic and their mean diabetes duration was 3.6 years, it likely implies that silent celiac disease was present for a few years.

The data regarding the benefit of a gluten-free diet in screening detected celiac disease in type I diabetic children is scant but is slowly increasing.  Numerous psychological (burden of gluten free diet in addition to diabetic diet), cost (of diet), and ethical issues (potential long-term benefits of gluten-free diet, compliance with diet) exist regarding these children and hopefully this question will be answered soon and with good, convincing data. 

Journal of Pediatric Gastroenterology and Nutrition, 41:317-321, 2005 welcomes your comments below (registration is NOT required).

4 Responses:

an unknown user
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said this on
11 Nov 2007 4:31:52 PM PST
I have a biochemistry degree and have worked with pharmaceutical research and the wording of this article made it difficult for me to follow how these children were diagnosed, if they were on a gluten-free diet, and if they had celiac disease before or after their diabetes diagnosis.

Colleen Karney
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said this on
11 Nov 2007 7:32:45 PM PST
I guess he's saying that, absent free health care assistance for celiac children, the medical community is reluctant to offer celiac screening to all children. A broad-based celiac disease screening program, he suggests, would raise psychological, cost, and ethical issues. On the other hand, leaving celiac children undiagnosed also raises psychological issues (celiac disease contributes to depression and other mental health effects), cost issues (greater expense associated with a decade or more of wrong medical treatments and possible hospitalization for celiac disease patients who are not diagnosed until their teenage or adult years), and ethical issues (is it ethical to tell undiagnosed celiac disease patients that their poor concentration is their own fault; that they just need to 'pull out' of their depression; that they need to eat more whole grains, like wheat, oats, and barley, to ease their constipation; that there is no known cause for their IBS, skin, or hair problems; or that their 'gas' problems are triggered by unidentifiable 'wrong' foods?). If the medical community is waiting until families can have a special celiac disease assistant available to help them find and cook gluten-free food, navigate the school cafeteria and restaurants, and obtain financial assistance, then the medical community should lobby for whatever help is needed to help doctors feel comfortable in telling families how to keep their children healthy. For celiac disease families, good health is not possible without the early screening that US doctors are so reluctant to provide.

Murali Jatla
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said this on
15 Nov 2007 11:42:00 AM PST
Thanks for the the above comments. As stated in the summary the celiac disease was diagnosed 3.5 years after diabetes. Celiac screening was performed yearly after diabetes diagnosis and all celiacs were recommended a gluten-free diet. The article has been modified to reflect these clarifications.

The trouble with silent celiac disease in diabetes does not lie in screening. Screening is recommended for all type 1 diabetic children--it is recommended by major pediatric societies and must be performed. Making a diagnosis is not difficult, from a pediatric gastroenterologist's perspective. The true challenge lies in appropriately counseling an asymptomatic diabetic child's family when they are diagnosed with silent celiac disease. It is challenging to adjust to another condition that requires further dietary modification. The benefits of treating silent celiac disease in type 1 diabetic children is unknown and this largest, best-performed study found no significant improvements. Perhaps a follow-up period longer than 3.3 years is required to see any true effects.

A separate, perhaps more important, question is whether type I diabetes was secondary to silent celiac disease and whether it may have been prevented by celiac screening at an earlier age. It is unethical to perform a trial where we test a group of children at infancy and randomize them to regular diet or gluten-free diet and look 15 years later to see how many develop diabetes in the two groups. The question of universal screening is a very important one that will hopefully be settled soon. However, there should be no question regarding screening for celiac disease in type I diabetes, although the data supporting treatment is in evolution.

Scott Adams
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said this on
16 Nov 2007 1:56:55 PM PST
Thank you for the clarifications Dr. Jatla!

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