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The DPV-Wiss database is a central registry for the documentation of
treatment processes and outcomes in children with type 1 diabetes
(T1DM) in Germany and Austria. Data are gathered and available for
analysis from 150 pediatric departments and 19,796 subjects (ages 0.1
to 19.9), representing approximately half the children with T1DM in
Germany. Kaspers et al report their findings regarding the
association between T1DM and celiac disease (CD) and anthropometrics
and metabolic control. Although there is no consensus for measuring
celiac and thyroid antibodies in children with diabetes, in Germany
these determinations are commonly performed every 1 to 2 years.
Three
groups of diabetic children were identified: Group 1 comprised no
clinical or biochemical signs of CD (n=18 470); Group 2 had 1 or
more significantly elevated CD-associated antibodies (IgG and IgA
antibodies to gliadin, endomysium, or tissue transglutaminase–IgA
antibodies), but no jejunal biopsy performed or recorded (n = 1
119); Group 3 exhibited biopsy-proven CD (n = 127). At least one CD
associated antibody elevation was present in 6.7% of the cohort,
while 0.6% had histologically confirmed CD. The mean age of diagnosis
of CD was lower than that of the Group 1 subjects (12.2 ± 4.6
years vs 13.4 ± 4.3 years, P< 0.05) and the onset of
T1DM was at an earlier age in Group 3 children (5.8 ± 4.0 vs
8.2 ± 4.0 years, P<0.001). The average age of
diagnosis of CD was 4.3 ± 3.8 years. In 13 children, CD was
diagnosed prior to the diagnosis of T1DM; 57% of Group 3 children
were female.
Standing height was significantly reduced in Group 3 children (–49 ±
1.1 vs –0.06 ± 1.0 height-SDS, P<0.001), and this difference increased over time. Growth of children less
than 11 years of age was more affected than that of older children.
BMI was also lower in the CD children and did not improve over time.
Daily insulin requirements, number of daily injections, and number of
severe hypoglycemic episodes did not differ among groups, but HbA1c
levels were significantly lower in the Group 3 children at CD
diagnosis (8.1% ±1.8% vs 8.8% ± 2.4%, P<0.001)
and remained lower during the observation period. The incidence of
thyroid disease was greater in the group with T1DM and CD (6.3% vs
2.7%, P<0.02).
The authors noted that the actual incidence of CD in their population may
be greater than recorded, since all children with positive antibodies
did not undergo jejunal biopsy. The failure of children with CD to
exhibit catch-up growth may have been the result of poor compliance
with the gluten-free diet. The growth reductions seen in these
children would account for a loss of 5.2 cm in final height. The
lower HbA1c values in the Group 3 children could have been the result
of malabsorption of nutrients or perhaps more meticulous attention to
carbohydrate amounts and source when using the gluten-free diet. The
authors concluded that the recommendations for regular screening of
children with T1DM for CD beginning at disease onset is both rational
and important, as untreated CD is associated with significant
long-term health risks such as osteoporosis and intestinal lymphoma.
Kaspers
S, Kordonouri O, Schober E, Grabert M, Hauffa B, Holl R and the
German Working Group for Pediatric Diabetology. Anthropometry,
metabolic control, and thyroid autoimmunity in type 1 diabetes with
celiac disease: A multicenter survey.J Pediatr. 2004:145:790-795.
First Editor’s
Comment: This paper presents important data
confirming the relationship between CD and T1DM; it lends evidence
for the need to screen children with T1DM for celiac associated
antibodies at the time of diagnosis and throughout childhood. The
findings of reduced height and BMI, not related to poor glycemic
control, are of concern. The implementation of a gluten-free diet is
difficult and compliance is even more difficult to assess than that
of the more routine carbohydrate-counting caloric recommendation diet
usually prescribed for children with T1DM. It will be important for
studies such as the current one to continue in order to assess the
long-term impact of living with both diseases. Information regarding
the development of osteoporosis and lymphoma in asymptomatic children
is especially important. The current database may assist in the
collection of such information.
Currently,
some third-party payors in the United States are reluctant to
reimburse for the laboratory determinations of celiac associated
antibodies in children with T1DM who do not exhibit typical symptoms
and signs of CD. The data from this German database can be used to
help justify such screenings.
William L. Clarke, MD
Second Editor’s
Comment: It is important to distinguish CD from
celiac autoimmunity (CA). The former presents with symptoms and
abnormalities on the intestinal mucosa and function which improve
with a gluten-free diet; the later presents no alterations other than
positive IgA transglutaminase antibodies and enodmysial antibody
immunofluorescence IgA. The natural history of CD is well known,
including chronic intestinal malabsorption and long-term risks of
osteoporosis and lymphoma. However, no such data exist for CA
patients who have no symptoms or alterations in jejunal morphology
and function; however, monitoring height and weight progression is
warranted. Since adherence to a gluten-free diet is poor even in the
CD patients, the added burden to diabetic individuals would need to
be considered before recommending it when CA is encountered. The
reader is referred to GGH1 for a review and commentary of
a paper by Hofferberg2 on the natural history of CA.
Fima Lifshitz, MD
Reference - (linked to  )
- Growth
Genet Horm. 2004;20:55-56.
- Hofferberg
EJ, Emery LM, Barriga KJ, et al. Pediatrics 2004;113:1254-1257.
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Current GGH - Vol. 24 No. 1
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