Associated conditions of celiac disease

  1. Associated conditions of celiac disease

Evidence suggests that individuals with other autoimmune conditions may have an increased risk of developing celiac disease [1]. The prevalence of autoimmune conditions in individuals with celiac disease may be as high as 14% compared to a rate of 2.8% in the general population. This increase prevalence of celiac disease in other autoimmune conditions warrants screening of these populations.

A list of conditions associated with celiac disease is provided below. Celiac disease has been reported to have an increased prevalence amongst patients with autoimmune thyroid disease (up to 7%), irritable bowel syndrome (up to 7%), and type 1 diabetes (8 - 10%), Downs syndrome (5 - 12 %), Turners syndrome (4 - 8 %), and Williams syndrome (8.2%) (1). Screening of all children, even those who are asymptomatic, in these at risk groups is recommended by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) after three years of age [2].

Celiac disease may also have an increased prevalence in the following conditions

  • Addison’s Disease

  • Autoimmune liver conditions

  • Autoimmune myocarditis

  • Chronic thrombocytopenia purpura

  • Depression/bipolar disorder

  • Epilepsy

  • Lymphoid malignancy

  • Polyneuropathy

  • Sjögren’s Syndrome

  • Sarcoidosis

  • Turner Syndrome

  • Unexplained subfertility

Type 1 diabetes

Type 1 diabetes

Celiac disease and type 1 diabetes often occur together. About 10% of Type 1 diabetics develop celiac disease. Celiac disease is often found on a routine screening, as many diabetics with celiac disease are asymptomatic. Celiac disease is also frequently found in first-degree relatives of type 1 diabetics. In the vast majority of patients celiac disease diagnosis follows the diagnosis of type 1 diabetes.

Genetic similarities
The joint occurrence of the two diseases appears to be linked by the presence of histocompatibility genes specifically the occurrence of HLA-DQ2 and HLA-DQ8.

Screening for celiac disease in  type 1 diabetics
Similarly to celiac disease, the incidence of type 1 diabetes is rising, with a reported increase of 3% annually [2]. Less than 10% of patients with type 1 diabetes and celiac disease report gastrointestinal symptoms [3], therefore, routine screening  for celiac disease in  this patient group is strongly recommended. Annual screening of type 1 patients is recommended by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) [2]. Current ESPGHAN guidelines recommend screening every 2 to 3 years [3].

Impact of a dual diagnosis
Evidence suggests that children with both type 1 diabetes and celiac disease have lower weight and height standard deviation scores. Furthermore, good adherence to a gluten free diet appears to result in steady improvement in height and weight while poor adherence is likely to result in continued growth impairment [6]. Among adults newly diagnosed with celiac disease, glycaemic control has been shown to be significantly worse than amongst those with type 1 diabetes alone [7], although this effect may be reduced over time as the gluten free diet becomes well established [5,8]. Malabsorption of carbohydrates secondary to mucosal damage may explain the observation that episodes of hypoglycaemia are more common in patients with type 1 diabetes and celiac disease in the six months before and after celiac diagnosis. Once again, this finding is not repeated upon longer term follow up of patients, indicating gut recovery on a gluten free diet [9].

Long term risk
Unfortunately the prevalence of longer term complications associated with diabetes appear to be significantly greater for patients with both conditions, compared to those with diabetes and/or celiac disease alone. Both risk of retinopathy [10] and subclinical atherosclerosis [11] is increased for those with a dual diagnosis in the longer term. Overall mortality risk after the first 5 years post celiac diagnosis also appears to increase over time for those with both type 1 diabetes and celiac disease [12].

Dietary therapy for diabetes and celiac disease
A strict gluten free diet is required in order to maintain glycaemic control and reduce the short and long term complications of both diseases. The dietary management of both conditions is based on general healthy eating principles that apply to the population as a whole for the purpose of disease risk reduction and promotion of optimal health. Weight control and exercise are also paramount to glycaemic control.

References

  1. Fasano, A., Catassi, C. (2012). Clinical practice. Celiac disease. N Engl J Med.;     20; 367(25):2419-26. doi: 10.1056/NEJMcp1113994.
  2. Celiac disease: past, present, and future challenges: dedicated to the memory of our friend and colleague, Prof David Branski (1944-2013). Heyman MB. J Pediatr Gastroenterol Nutr. 2014 Jul;59 Suppl 1:S1. doi:10.1097/01.mpg.0000450390.38403.22
  3. Dabelea D, Mayer-Davis EJ, Saydah S et al. Prevalence of type 1 and type 2 diabetes among children and adolescents from 2001 to 2009. JAMA 2014; 311:1778-1786
  4. Scaramuzza AE, Mantegazza C, Bosetti A, Zuccotti GV. Type 1 diabetes and celiac disease: The effects of gluten free diet on metabolic control. World J Diabetes 2013; 4: 130-134
  5. Husby S, Koletzko S, Korponay-Szabó IR et al. European Society for Pediatric Gastroenterology, Hepatology, and Nutrition guidelines for the diagnosis of coeliac disease. J Pediatr Gastroenterol Nutr 2012; 54: 136-160
  6. Fröhlich-Reiterer EE, Kaspers S, Hofer S, et al. Anthropometry, metabolic control, and follow-up in children and adolescents with type 1 diabetes mellitus and biopsy-proven celiac disease. J Pediatr 2011; 158: 589-593.
  7. Akirov A, Hirsch G, Boyko V, et al. Celiac in type 1 diabetes children and youth–prevalence, metabolic control and growth parameters. Tel Aviv: Israel Society of Clinical Pediatrics, 2010
  8. Leeds JS, Hopper AD, Hadjivassiliou M, Tesfaye S, Sanders DS. High prevalence of microvascular complications in adults with type 1 diabetes and newly diagnosed celiac disease. Diabetes Care 2011; 34: 2158-2163
  9. Hansen D, Brock-Jacobsen B, Lund E, et al. Clinical benefit of a gluten-free diet in type 1 diabetic children with screening-detected celiac disease: a population-based screening study with 2 years’ follow-up. Diabetes Care 2006; 29: 2452-2456
  10. Mohn A, Cerruto M, Iafusco D, et al. Celiac disease in children and adolescents with type I diabetes: importance of hypoglycemia. J Pediatr Gastroenterol Nutr 2001; 32: 37-4
  11. Mollazadegan K, Kugelberg M, Montgomery SM, et al. population-based study of the risk of diabetic retinopathy in patients with type 1 diabetes and celiac disease. Diabetes Care 2013; 36: 316-321
  12. Pitocco D, Giubilato S, Martini F, et al. Combined atherogenic effects of celiac disease and type 1 diabetes mellitus. Atherosclerosis 2011; 217: 531-535
  13. Mollazadegan K, Sanders DS, Ludvigsson J, Ludvigsson JF. Long-term coeliac disease influences risk of death in patients with type 1 diabetes. J Intern Med 2013; 274: 273-280