Gluten-Free Diet in Co-Existent Celiac Disease and Type 1 Diabetes Mellitus: Is It Detrimental or Beneficial to Glycemic Control, Vascular Complications, and Quality of Life?
Abstract
:1. Celiac Disease and Type 1 Diabetes Mellitus: The Association
2. Epidemiology and Screening
3. Effect of Gluten Free Diet
3.1. Gluten Free Diet for CeD in T1DM Patients
3.2. Glycemic Control and Glycemic Index in T1DM and CeD
3.3. Effect of Gluten Free Diet on Body Mass Index in Patients with T1DM and Celiac Disease
3.4. Bone Mineral Density in Patients with T1DM and Celiac Disease
4. Micro- or Macroangiopathic Complications in Coexistent T1DM and Celiac Disease
5. Quality of Life
6. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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References | Main Objective | Study Design | Study Population | Results | Comments and Study Limitations |
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Taler et al. 2012 | Study the effect of CeD on glycemic control and growth in T1DM patients, and the influence of dietary adherence to GFD on these parameters. | Observational case–control study | 68 T1DM patients and CeD | No significant differences in glycemic control or frequency of severe hypoglycemia or diabetic ketoacidosis between the study patients and controls. Standard deviations of Body mass index, height, and HbA1c values were not significantly higher in the control than the study group and similar in subjects with CeD regardless of degree of adherence to a GFD. | The numbers were small to make clear conclusions. |
Acerini et al. 1998 | Study the clinical characteristics and response to GFD in CeD in children and adolescents with T1DM | Screening for CeD | 167 children and adolescents with T1DM (97 males; age 1.9–22 years) in a pediatric diabetic clinic | By 24 months, there was a trend towards increased BMI standard deviation score 1.31 (0.47 to 2.29), p = 0.248) and to reductions in HbA1c (8.1 (6.4–10.8), p = 0.697). The therapeutic benefits of dietary therapy in asymptomatic CeD remain uncertain. | No comment |
Saadah et al. 2004 | Study the effect of GFD on growth and diabetic control in children with T1DM and CeD. | Weight, height, Hb-A1c, and insulin requirements were measured before and for 12 months after the diagnosis and treatment of CeD. Dietary adherence and awareness were measured by structured questionnaire. | 21 children with T1DM, and subsequent diagnosis of CeD. | BMI increased after GFD. Insulin dosage at diagnosis was less in CeD patients than in controls), but was similar to controls once a GFD had been established. It seemed that there was a relation between dietary adherence/awareness and growth parameters. | The small number of patients prevented relevant analysis. |
Kaukinen et al. 1999 | Study the effect of a GFD on metabolic control of diabetes in patients with T1DM and CeD. Additionally analyzed whether the diabetic control changes after reinforcement of GFD | Retrospective and controlled prospective survey. Published as a letter to the editor. | 45 adults; 22 patients. | Retrospective analysis: there were no statistically significant differences in metabolic control, BMI, or hypoglycemic events before and after the introduction of the GFD. Prospective analysis: the mean HbA1c was 8.7% before and 8.8% after 1 year in patients with CeD. The mean daily insulin dosage was 0.6 U/kg in patients with CeD, and 0.7 U/kg in those with only T1DM. No differences were found in metabolic control, insulin dosage, BMI, and hypoglycemic events in CeD patients at the beginning and at the end of the study. | Very limited number of patients included. |
Abid et al. 2011 | Study the short-term effects of GFD in a T1DM and CeD. | Data were collected at baseline and 12 months after GFD. | 468 children with T1DM; 23 patients were diagnosed with CeD | Almost 50% showed improvement in GI symptoms, while 75% of patients had no further severe hypoglycaemic events. There was no significant change in score for height, weight, and BMI or the mean HbA1c and before and after GFD. The mean insulin requirement increased. | The duration of study was short |
Creanza et al. 2018 | To study whether in T1DM patients the concomitant presence of CeD treated with a GFD influences glycemic control and the prevalence or severity of microvascular complications. | An observational case–control study | 34 patients with T1DM and CeD and 66 patients with T1DM alone matched for age, gender, and T1DM duration | HbA1c level was similar in T1DM + CeD and T1DM alone; insulin requirement was significantly higher in T1DM + CeD compared with T1DM. | Observational and cross-sectional study design which prevented evaluation of the changes of renal function over time. Patients were followed up in a tertiary care center with periodic clinical assessment of both T1DM and CeD. Therefore, results may not be fitting to those who may not undergo a strict monitoring. |
Söderström et al. 2022 | Examing the effects of diet on glycemic control. Additionally examined adherence to GFD and effects on QoL | Non-randomized feasibility study | 23 children with recent diagnosis of T1DM. A GFD (n = 14) or a normal diet (n = 9) for 12 months. | Children on a GFD had a statistically significant lower HbA1c at 6 months compared with those on a normal diet. Glycemic control was improved in the GFD group at 6 and 12 months. Adherence to a GFD was satisfactory. At inclusion, the GFD group had poorer QoL and there was no significant difference for QoL between groups throughout the study. | Small samples resulted in low statistical power. Participants were not randomized. The authors discussed these and other limitations extensively. |
Mozzillo et al. 2022 | Evaluate the influence of GFD on growth, metabolic control and QoL in young patients with T1DM and CeD. | Systematic review | Studies published in recent 15 years. Studies included were those having moderate-high quality of evidence and reporting objectively adherence to GFD | Studies showed no significant differences in growth parameters, HbA1c, number of hypoglycemic episodes, total daily insulin doses comparing youth with T1DM + CeD on GFD to those with T1DM only. Studies assessing the effect of GFD introduction showed stable BMI and HbA1c. Two studies assessed QoL, which was not different between T1DM + CeD versus T1DM only, as well as pre- and post-CeD diagnosis and introduction of GFD. | Heterogeneity of the analyzed studies regarding sample size, duration of follow-up, and methods. |
Mahmud et al. 2020 | Studied changes in HbA1c over 12 months after GFD | Randomized clinical trial | Fifty-one participants | 51 patients were randomized to a GFD (n = 27) or Gluten containg diet (n = 24). No HbA1c differences were seen between the groups, although greater postprandial glucose increases emerged with a GFD. | Small sample size and heterogeneity of patients characteristics |
Kaur et al. 2020 | Assess the effect of GFD on T1DM and subclinical CeD | Prospective open label randomized controlled trial | 320 T1DM patients. Thirty eligible patients were randomized to receive GFD (n = 15) or a normal diet (n = 15) | There is a decrease in hypoglycemic episodes and better glycemic control in patients on a GFD. Further, the mean HbA1c decreased in the GFD group and increased in the group following a normal diet. | - |
References | Main Objective | Study Design | Study Population | Results | Study Limitations |
---|---|---|---|---|---|
Bakker 2013 | To study 1. the glycemic control at CeD diagnosis and after initiating a GFD in T1DM patients. 2. the prevalence of complications in T1DM patients with CeD. | Retrospectively collected HbA1c levels before CeD diagnosis, at CeD diagnosis, and the latest HbA1c levels as well as the presence of nephropathy and retinopathy. | 31 patients; median duration of T1DM and CeD of 27 years (IQR 14–37) and 3 years (IQR 1–8), respectively. | Prevalence of retinopathy was lower in T1DM + CeD group compared with controls, (38.7 vs. 67.4%, p < 0.05), no difference in the prevalence of nephropathy was found between the groups (p = 0.09). | A retrospective, observational study, and therefore associations may not reflect causality. |
Picarelli 2013 | Evaluating whether the presence of CeD in a group of T1DM patients is associated with a different expression of hemostatic factors and with a different manifestation and/or progression of microvascular complications of T1DM in comparison with patients with only diabetes | Laboratory assessment of blood and urine samples | 94 adult T1DM patients were included and subsequently screened for CeD. | The metabolic control and the hemocoagulative parameters were significantly different between the two groups: T1DM + CeD patients had significantly lower concentrations of HbA1c, cholesterol, triglycerides, factor VII antigen, factor VII coagulant activity (FVII:c), and prothrombin degradation fragments, as well as higher values of activated C protein. Neither retinal abnormalities nor signs of renal damage were observed in T1DM + CeD patients. | - |
Pitocco 2011 | To assess carotid intima-media thickness (c-IMT), in patients with T1DM, CeD or both (T1DM + CeD) compared with age- and sex-matched healthy individuals. | Observational single centre study. Clinical, metabolic and anthropometric data were collected. | 120 patients, 30 with T1DM, 30 with CeD, 30 with T1DM + CeD and 30 Healthy controls. | c-IMT was significantly greater in patients with T1DM + CeD than in those with T1DM or CeD, while no difference was found between T1DM and CeD. c-IMT was greater in CeD than in healthy controls. Glycemic control was similar between T1DM + CeD and T1DM alone. Lipid and anthropometric parameters were similar among groups. In a multivariate analysis, only age and disease type were significantly correlated with c-IMT. | Observational study |
Salardi 2017 | To evaluate lipid profiles, besides HDL-C, in children with T1DM associated with biopsy-proven CeD, and to investigate the influence of age and degree of adherence to GFD on lipid changes. | Retrospective multicenter study | 261 children with both T1DM and CeD were enrolled | At CeD diagnosis, children with T1DM + CeD showed higher LDL cholesterol (LDL-C) compared to children with T1DM alone. GFD failed to normalize LDL-C levels. HbA1c values were not affected by GFD. At diagnosis, the youngest children had lower levels of total cholesterol. These patients had a greater decrease in triglycerides levels after treatment. | No reliable data on complications, to relate them with lipid panel. Furthermore, The assessment of complications was not centralized. |
Rohrer 2015 | To investigate whether CeD associated with T1DM increases the risk of microvascular complications. | A Multicenter Longitudinal Analysis | Patients (n = 56,514) aged > 10 years with diabetes duration < 20 years from 392 centers in Germany and Austria, | Retinopathy and nephropathy occurred earlier in the presence versus absence of CeD: retinopathy was seen at mean age 26.7 years in 25% of patients with CeD vs. mean age 33.7 years in 25% without CeD. Microalbuminuria was documented at mean age 32.8 years vs. 42.4 years. The hazard ratio both retinopathy (1.263) and nephropathy (1.359) was higher in patients with T1DM and CeD versus those without CeD. After adjustment for confounders, CeD was found as an independent risk factor for microvascular complications. | - |
Leeds 2011 | Investigated the effect of a GFD on diabetes-related complications in CeD in adults with T1DM. | A case-control study conducted at a U.K. teaching hospital. | Patients with T1DM aged > 16 years (n = 1000) were assessed for CeD. HbA(1c), lipid profile, quality of life, retinopathy stage, nephropathy stage, and degree of neuropathy before and after 1 year on a GFD were assessed. | The prevalence of CeD was 3.3%. At diagnosis of CeD, adult T1DM patients had worse glycemic control, lower total cholesterol, lower HDL cholesterol, and a higher prevalence of retinopathy, nephropathy, and peripheral neuropathy. There was no difference in QoL (p > 0.1). After 1 year on a GFD, only the lipid profile improved, but in those adherent to GFD HbA1c and markers for nephropathy improved. | - |
Creanza 2018 | To study whether in T1DM patients the concomitant presence of CeD treated with a GFD influences glycemic control and the prevalence or severity of microvascular complications. | An observational case-control study | 34 patients with T1DM and CeD and 66 patients with T1DM alone matched for age, gender, and T1DM duration. | HbA1c level was similar in T1DM + CeD and T1DM alone; insulin requirement was significantly higher in T1DM + CeD compared with T1DM. | Observational and cross-sectional study design which prevented evaluation of the changes of renal function over time. Patients were followed up in a tertiary care center with periodic clinical assessment of both T1DM and CeD. Therefore, results may not be fitting to those who may not undergo a strict monitoring. |
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Eland, I.; Klieverik, L.; Mansour, A.A.; Al-Toma, A. Gluten-Free Diet in Co-Existent Celiac Disease and Type 1 Diabetes Mellitus: Is It Detrimental or Beneficial to Glycemic Control, Vascular Complications, and Quality of Life? Nutrients 2023, 15, 199. https://doi.org/10.3390/nu15010199
Eland I, Klieverik L, Mansour AA, Al-Toma A. Gluten-Free Diet in Co-Existent Celiac Disease and Type 1 Diabetes Mellitus: Is It Detrimental or Beneficial to Glycemic Control, Vascular Complications, and Quality of Life? Nutrients. 2023; 15(1):199. https://doi.org/10.3390/nu15010199
Chicago/Turabian StyleEland, Ingo, Lars Klieverik, Abbas Ali Mansour, and Abdulbaqi Al-Toma. 2023. "Gluten-Free Diet in Co-Existent Celiac Disease and Type 1 Diabetes Mellitus: Is It Detrimental or Beneficial to Glycemic Control, Vascular Complications, and Quality of Life?" Nutrients 15, no. 1: 199. https://doi.org/10.3390/nu15010199