Diagnosing Celiac Disease in 2002: Who, Why, and How?

In this issue of Pediatrics, Barera et al¹ expand on the significant, recognized relationship between type 1 diabetes and celiac disease (CD). The authors confirm the increased prevalence of CD in type 1 diabetes and characterize the timing of the identification of CD relevant to the onset of type 1 diabetes. The study shows that the diagnosis of CD may be made before, at the same time, or several years after the diagnosis of type 1 diabetes. Although most cases in this study were identified within 5 years of diagnosis of type 1 diabetes, the number of subjects tested declined over the 5-year period so that by the sixth year only 10% were actually retested. It is possible, therefore, that over time even more cases of CD/type 1 diabetes will be identified. As in most populations where screening is done to detect CD, most of the patients in this series were either asymptomatic or had unrecognized symptoms.

Why should we be concerned about the identification of apparently asymptomatic CD in patients with type 1 diabetes? First, CD is characterized by small intestinal inflammation with mucosal atrophy. Therefore, absorption of nutrients could be variable or overt malabsorption could occur, altering insulin requirements and affecting diabetic control. Improvement in diabetic control and a decrease in hypoglycemic episodes have been observed in children with CD and type 1 diabetes after institution of a gluten-free diet.² Second, CD can affect growth as demonstrated by the increase in body mass index in the patients after treatment. In the study by Barera et al, this improvement could be attributed, in part, to management of type 1 diabetes as well. Third, CD is associated with other diseases or conditions that are reduced or eliminated when individuals with CD follow a gluten-free diet. These include …