By Rachel Begun, MS, RD
November is National Diabetes Month and, in honor of raising awareness, this is Part 2 of a two-part blog series about the connection between celiac disease and type 1 diabetes.
Part 1 focused on the connection between celiac disease and type 1 diabetes, including prevalence statistics for having both diseases and what people with type 1 diabetes and their physicians should look for in terms of signs and symptoms for screening for celiac disease.
Because dietary management is important to both celiac disease and type 1 diabetes individually, this post is dedicated to managing the diet when having both conditions together. I have reached out to my esteemed colleague, a registered dietitian who specializes in diabetes, to answer the questions below.
Hope Warshaw, MMSc, RD, CDE, is a dietitian, diabetes educator, and author of Diabetes Meal Planning Made Easy and other books published by the American Diabetes Association (ADA). To learn more about Hope and her area of expertise, visit www.hopewarshaw.com.
Hope and I, as well as other dietitians specializing in celiac disease and/or type 1 diabetes, realize the importance of collaborating and sharing our knowledge with each other to help those diagnosed with both conditions manage a healthy lifestyle.
Rachel Begun: What are the key factors in the nutrition management of type 1 diabetes today?
Hope Warshaw: It’s important to reflect on the management of type 1 diabetes over time with the key year being 1921, when insulin was discovered and first used to treat type 1 diabetes. Only at this point was it possible for people with type 1 to be kept alive.
Today, more than 90 years later, numerous tools and devices help people with type 1 self-manage their disease. While still by no means an easy disease to manage, type 1 has become easier with longer-acting and more rapid-acting insulins, glucose meters, continuous glucose monitors and insulin pumps. With these tools and devices, the focus of nutrition management is on control of blood glucose levels along with control of blood lipids and blood pressure to delay the long-term complications of diabetes. Research shows that it is the control of all three levels that can keep people healthy, both short term and over time.
To control blood glucose levels within a safe and healthy range, about 70 to 150 mg/dl (before and after eating), people need to match their carbohydrate consumption with the insulin(s) they take. Research shows that it is the carbohydrate in foods that has the greatest impact on blood glucose levels, particularly several hours after eating. Over the years, and for this reason, carbohydrate counting has become the meal planning approach that most people with type 1 diabetes are taught to use today. This should not be translated to mean a low-carbohydrate diet.
The American Diabetes Association (ADA) recommends that people with diabetes consume between 45-65 percent of their calories as carbohydrate, the same as the general public. For frame of reference, Americans consume about 45-50 percent of their calories as carbohydrate. Consuming under 45 percent of calories as carbohydrate can result in inadequate amounts of fruits, vegetables, whole grains, low-fat dairy foods and dietary fiber. Some research in children and adults with celiac disease and type 1 diabetes shows that, in the attempt to control both diseases, there is a tendency to eat a diet higher in fat and protein and lower in carbohydrate than is recommended.
RB: If a person with type 1 diabetes is then diagnosed with celiac disease, are there consequences with taking gluten out of the diet?
HW: Following a healthy eating plan to manage type 1 diabetes and achieving blood glucose control is a continual challenge. The additional need to eliminate gluten from the diet due to a celiac disease diagnosis just adds to the complexity and challenges. However, people with type 1 diabetes and celiac disease have the same nutritional requirements as most healthy children and adults. A focus for managing both diseases should be on healthy eating, consuming basic unprocessed foods and nutritious meals and snacks (if they are needed).
RB: What tips do you recommend for people managing both diseases?
HW: People with type 1 diabetes and their family members should seek out a dietitian who has expertise in both diabetes and celiac disease. Children and young adults (under age 18) with type 1 diabetes are often followed by a pediatric endocrinologist who either works with or can refer people to dietitians with expertise in diabetes care. These individuals are knowledgeable about the nutrition management of the combination of diseases.
Adults diagnosed with type 1 diabetes and celiac disease should seek out the services of an adult endocrinologist who has expertise in diabetes care. Again, these providers should have access to dietitians with expertise in the management of both diseases.
People with type 1 diabetes and celiac disease should develop a long-term relationship with a dietitian because they will likely need assistance and counseling over time. To find a diabetes educator or diabetes education program in your neck of the woods, go to ADA’s Diabetes Education Recognition Programs and put in your zip code or search on the American Association of Diabetes Educator’s website for accredited programs in your area.
RB: What do you recommend with respect to consumption of gluten-free replacement foods?
HW: Due to the interest in following a gluten-free diet for the supposed reason(s) of managing a range of illnesses, we’ve seen an onslaught of gluten-free foods in the marketplace. The availability and healthfulness of some of these foods can help provide people with type 1 diabetes and celiac disease a wider range of food choices and options. Other gluten-free foods, which contain highly processed ingredients and limited nutrition, are unnecessary most of the time. However, they can come in handy for convenience when traveling or to satisfy particular food desires.
RB: In Part 1 of this blog series, I shared information that untreated celiac disease may also contribute to irregular blood glucose swings and that unexplained hypoglycemia, or low blood sugar, can be a sign of malabsorption related to celiac disease. Can you elaborate?
HW: Several studies show that people with celiac disease, treated or untreated, are more likely to have GI symptoms such as diarrhea, constipation, abdominal pain and bloating, nausea or vomiting and/or slowed movement of food through the GI tract. Any GI symptoms that interfere with the regular and expected absorption of nutrients, particularly carbohydrate, can result in blood glucose levels that are too high (above > 150 mg/dl after eating) or too low (defined by ADA as < 70 mg/dl).
These GI concerns and their impact on glucose levels should reinforce the importance of avoiding gluten when treating this combination of diseases. However, the increased possibility of hypoglycemia should further encourage people with type 1 diabetes and celiac disease to learn how to manage these situations and have a game plan to put into action should they occur. People with type 1 diabetes and celiac disease should always carry gluten-free treatments for hypoglycemia.
This is an issue we’ll be hearing more of as more people are diagnosed with both type 1 diabetes and celiac disease. Please share additional questions via the comment box below, as we are happy to continue the dialogue and share more information on this important topic.
Rachel Begun, MS, RD, is a registered dietitian and spokesperson for the Academy of Nutrition and Dietetics. She provides education, communications and consulting services to health organizations and the food industry. She also educates the public via speaking opportunities, online activities and writing for publications, including her own blog, The Gluten Free RD. You can connect with her on Facebook, Twitter, LinkedIn and Pinterest via her website at www.rachelbegun.com.