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Diabetes and Celiac Disease
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| 5/31/1999 |
Celiac Disease is an autoimmune disease treated with diet alone. Type I diabetes,
traditionally called Insulin Dependent Diabetes Mellitus, is an autoimmune
disease treated not only with diet but also with injected insulin. An autoimmune
disease involves an attack by the individual's immune system on some part of the
body.
In Celiac Disease (CD), ingestion of gluten causes the sensitive
individual's immune system to attack the tissue of the small intestine. The
attack destroys the villi lining the small intestine, which absorb nutrients
from food, and results in malabsorption and subsequent medical problems.
The damage usually is not permanent. Once the individual starts a
gluten-free diet, the small intestine begins to heal and eventually returns to
normal or near normal. The GF diet must be continued for life.
In Type I
diabetes, the immune system attacks the insulin-producing beta cells in the
islets of Langerhans in the pancreas. The beta cells are destroyed, resulting in
a loss of insulin-producing capabilities. Insulin is a vital hormone that
permits glucose, a simple sugar that is the body's main source of energy, to
enter into and be used by the body's cells to sustain life.
The damage
to the islets of Langerhans is permanent. People with Type I diabetes must have
injections of insulin for life. These injections are coordinated with the timing
and amount of food the individual eats, so diet is a prime concern of the
diabetic for life.
The connections between Celiac Disease and Type I
diabetes go beyond autoimmunity and diet. Both diseases have genetic and
environmental origins. This means an individual is more at risk of developing
either problem when a close relative also has it.
On the genetic side,
development of one reveals the pre-existing and larger risk that the genes for
the other may be present. At least two genes and gene locations are connected
with each disease. One gene for each disease is near one gene for the other on
the same chromosome. Nearby genes are more likely to pass together to offspring.
However, while the genes are necessary, they are not sufficient to
produce the diseases. On the environmental side, researchers know gluten is
needed to produce Celiac Disease, but they also know it's not the only
environmental cause. With diabetes, the environmental causes are being
extensively studied for prevention and cure.
Roughly ten percent of
celiacs either have Type I diabetes or might develop Type II diabetes (more
later). Estimates differ, but at least five percent of those who have Type I
diabetes are or will become celiac. Where the two diseases occur in one
individual, in almost all cases, the diabetes is diagnosed first.
Diabetes, which has several forms, is much better known and much more
prevalent than Celiac Disease. According to the American Diabetes Association
(ADA), eight million Americans have been diagnosed with diabetes. The
organization says another eight million have the disease, but have not been
diagnosed.
Of the 8 million who are diagnosed, 800,000 are Type I. If at
least five percent of those are also celiac, that means there are 40,000 celiacs
-- most likely undiagnosed -- among the already-diagnosed diabetic population.
Most cases of Type I are obvious, unlike the more common Type II, which
can remain hidden for years.
Type I diabetes is much more serious than
CD. Without self-regulating insulin levels, people with Type I walk a tightrope:
too low a blood sugar level can lead to potentially deadly "insulin reaction";
too high a blood sugar level can lead to long-term complications that involve
the eye, kidney, heart, nerves or vascular system. These complications are
minimized with better control of blood sugar.
Often diagnosis of gluten
sensitivity in a person with Type I diabetes improves management of the
diabetes. As the individual's intestine heals on the gluten-free diet, the rate
of food absorption becomes more predictable, and insulin requirements gradually
increase as more carbohydrate is absorbed. So it's important that people with
diabetes who are also gluten sensitive be properly diagnosed and treated with
the gluten-free diet to help them achieve better control of their blood sugar.
Those with diabetes are also at risk for digestive problems that can
occur because of nerve damage to the gastrointestinal tract. Called
gastroparesis, the damage may involve the intestines, where the nerves that
actually wave the villi to move food along can be damaged, and/or the stomach,
where the damage can cause incomplete mixing of food, delayed emptying into the
small intestine, incomplete absorption of food, nausea and vomiting. Unlike
celiac gastrointestinal damage and distress, gastroparesis is not reversible by
diet, but may improve with strict control of the blood sugar and some forms of
drug treatment. Type I diabetes, which strikes quickly and irreversibly, mostly
affects the young; in fact it is sometimes called Juvenile-Onset Diabetes,
although it can be diagnosed for the first time in older individuals. Compared
to Celiac Disease, which can occur at any age, diagnosis is usually quite easy.
The Type I individual presents with a better defined form of
malnourishment than does the celiac: hyperglycemia (high blood sugar), weight
loss, extreme thirst, excessive urination laden with unmetabolized sugar and
protein, a "fruity" smell to the breath and little or no insulin in the blood.
Minimal other damage occurs beyond the destruction of the beta cells.
Normally the islets of Langerhans release insulin into the blood for
distribution to nearly all cells in the body. Insulin receptors on the surfaces
of cells are activated by the circulating insulin. Once insulin is bound there
to its receptor molecule, glucose can enter the cells for the "burning" that
produces energy.
Poisons build up quickly within the body in the absence
of insulin. Treatment consists of 2-4 subcutaneous injections of insulin a day
and control of carbohydrate intake.
The diet all Americans are
encouraged to follow today to maintain health and prevent disease is virtually
the same as the diet long recommended for people with diabetes to help them
control blood sugar levels. Basically, it includes less fat and protein and more
carbohydrates than what used to be the standard nutritionally recommended
American diet.
The diet features complex, that is less quickly
metabolized, carbohydrates to cut down the peak in blood glucose that occurs
about two hours after eating. Vegetables, especially starchy ones with fiber for
that "complex" factor, and fruit for dessert quickly become staples.
In
previous days, people with diabetes were told to avoid sugar. Today the
restriction on sugar is indirect. They control (that is measure the intake of)
total carbohydrate, adjusting where necessary when they consume direct sugar;
usually they eliminate something else that is probably less carbohydrate rich.
The dietary control of Type I diabetes is certainly more of a nuisance
than the dietary control of Celiac Disease (although celiacs who have been in
situations where there is nothing available to eat might disagree with me).
Types and amounts of carbohydrate should be controlled by weighing, estimating
portion size or by using food labels.
On the other hand, there is much
better information readily available to help those with diabetes monitor what
they eat. Food labels provide nearly adequate data to enable the individual to
control carbohydrate intake. Relatively inexpensive home-monitoring kits help
them keep track of their blood sugar level.
People with Type I diabetes
who exercise learn to adjust food and/or insulin to control blood glucose
levels. Exercise lowers blood sugar immediately and can continue to influence
blood sugar levels for as long as 12 to 24 hours.
So, what about
individuals with Type I diabetes who are also gluten sensitive? Their diet is
restricted on trace protein (gluten) and controlled on total carbohydrate. In
addition to avoiding grains and other foods that contain gluten, they carefully
monitor intake of gluten-free carbohydrates. As it does for most celiacs, this
leads to reliance on rice and corn.
But celiacs with Type I diabetes
also learn to rely on starchy vegetables, like potatoes, winter squash, peas,
beets, carrots, onions, and legumes, like black beans, lentils, dried peas, etc.
Legumes are especially useful because of their low "glycemic index," which means
they raise blood sugar less in proportion to their carbohydrate content than
many other foods.
And what about the celiac who is concerned about
developing diabetes? By current measure, one in 20 celiacs has Type I diabetes.
But unless you're young or have already been diagnosed, your odds of now
developing Type I diabetes are very slim.
However, you should be aware
of Type II diabetes, a non-autoimmune condition that is usually diagnosed in
adulthood. Diagnosed celiacs would have the same risk for Type II diabetes as
the general population, which is roughly five percent.
During onset,
Type II diabetes, like Celiac Disease, has confusing symptoms, so diagnosis can
be missed, creating a greater chance of irreversible damage. Symptoms can
include trembling or feeling faint or light-headed two hours after a meal of
"sweet" food with a high glycemic index. Others may just feel a lack of energy
that drives them to eat more and hence gain more weight -- the classic
overeating/underexercising problem.
Once diagnosed, Type II diabetes can
sometimes be controlled with weight loss, a very low fat diet, and exercise.
Most type IIs take pills; a few need insulin. Long-term complications are the
same as those for Type I.
A major but important goal that should be
taken on by both the celiac and diabetic communities would be better diagnosis
of gluten sensitivity among those with Type I diabetes. In fact, they make up
one of the most important high-risk groups that should be screened for gluten
sensitivity.
As mentioned, Type I diabetes carries with it the long-term
risk of serious complications. Undiagnosed gluten sensitivity ups the ante, not
only by playing havoc with blood sugar control but also by adding the usual
risks of undiagnosed gluten sensitivity: the possibility of osteoporosis from
poor calcium absorption, reproductive concerns, health problems caused by
whichever nutrients are malabsorbed and, of course, the increased risk of
cancer.
One way diagnosed celiacs can help the diabetes community is by
making the connection between the two diseases better known locally. We also
need to be especially positive in describing the mechanics of following the
diet, the variety of nutritious foods that are absolutely safe, and the feeling
of well-being that goes with being gluten-free.
It is important that
gluten-sensitive people who also have diabetes not self-diagnose. It's also
critically important that their diagnosis include a biopsy. While this is true
in general, those with diabetes already face enough health concerns, without
adding the burden of misdiagnosis. Initially diabetic celiacs would probably
find a dietitian very helpful, although those who have experience in both
problems are few and far between. (see box to the right).
And finally,
if on a self-serving note, this thought to ponder: Since Type I diabetes gets
the respect from the medical community that celiacs long for, we can only hope
that more and more diagnosis of CD within the diabetic population will be one
very big step toward putting gluten sensitivity on the American health care map.
Better health for more people will certainly follow better dissemination of news
about gluten sensitivity.
A Celiac Expert Answers Questions about
Diabetes:
Joseph Murray, M.
D., is particularly concerned not only about properly diagnosing gluten
sensitivity and treating the patients, but also about identifying and treating
celiac diabetics. He has conducted several studies on the connections between
the two autoimmune problems. Gluten-Free Living asked him to answer a few
questions about this important issue.
Q. What would make a person with Type
I diabetes suspect Celiac Disease?
Symptoms would include lactose
intolerance, bloating, diarrhea, brittle diabetes, unexplained weight loss, or
anemia. However, I would advocate screening all people who have Type I diabetes
with the antibodies test at least once.
Q. What would make a celiac
suspect Type II diabetes?
This one is harder to suspect. Some signs
include getting up to urinate at night, thirst, weight gain, tiredness, vision
changes, numbness in the feet, or increased appetite. If there is a family
history of Type II diabetes, then the patient should be screened every now and
again.
Q. Are there any screening tests for Type II diabetes that a
person with Celiac Disease should be aware of?
Yes, fasting blood sugar,
blood sugar two hours after a meal, a formal glucose tolerance test and
measuring the hemoglobin A1C level. Of these, the last two are the most precise
and sensitive.
Q. Should gluten-sensitive children be screened for
diabetes and if yes, should the test be repeated from time to time?
This
question is much harder to answer. Typically, Type I diabetes has been regarded
as an obvious disease that presents suddenly. However, there may be a
pre-symptomatic period during which there is damage occurring to the islet
cells. If there is also a family history of Type I diabetes, then the family
members should be screened.
There is a major project currently underway
to study people at risk for Type I diabetes, but no data on studying those with
Celiac Disease. The diagnosis of Type I diabetes usually is made first. It is
much more uncommon for a diagnosis of Type I diabetes to be made years later in
celiac patients already on treatment.
Q. Any additional thoughts?
Work needs to be done to address the question of whether early diagnosis
of Celiac Disease may reduce the subsequent risk of another autoimmune disease
occurring later in life. One Italian group has reported preliminary work
suggesting that may be the case. Also, we don't know about non-Caucasian Type I
diabetes and the risk of Celiac Disease.
Diabetes Educator Offers Help to the Doubly
Diagnosed:
Catherine
Marschilok, MSN, RN, CDE, is one of those rare health care professionals who has
experience treating people with diabetes who are also gluten sensitive. A
diabetes educator, with both diseases in her family, she is especially concerned
that these individuals are properly diagnosed with Celiac Disease to preserve
their health, then given the guidance they need to stay healthy. But the usual
difficulties of diagnosing gluten sensitivity are compounded in people with Type
I diabetes. According to Ms. Marschilok, diabetics should suspect Celiac Disease
if they have any of these problems:
- Labile blood sugars that
include multiple episodes of unexplained high or low blood sugars.
- A diagnosis of
gastroparesis or delayed gastric emptying. In fact, she said, people with these
problems should be screened for Celiac Disease. Individuals who have diabetes
for more than five years and who have any kind of gastrointestinal complaint
often get the gastroparesis label pinned on them.
- Delay in growth, height or
weight in a child or young person. The delay may be very slow and gradual and
physicians might think of the problems as a result of poor diabetes control. But
they could be the result of Celiac Disease.
- All other obvious and
not-so-obvious signs of Celiac Disease. "If I had my choice, she said, "all
people with Type I diabetes would be screened yearly for Celiac Disease."
Ms. Marschilok is also concerned about the lack of
awareness in the medical community of the connections between CD and Type I
diabetes. "Endocrinologists generally screen diabetics every year for thyroid
disease, which is within their specialty area," she says, "But people with
diabetes are just as likely to have Celiac Disease as they are to have thyroid
disease. There is definitely not enough knowledge about the connection
anywhere."
Source: http://www.enabling.org/ia/celiac/dia-cd1.html
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