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Episode 3: What Came First Celiac, or Type 1 Diabetes?

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Course Credit

The following credits are available for this course:

AMA PRA Category 1 Credits™ (MD, DO, NP, PA)0.75 hours
ASWB ACE Continuing Education Credits (Social Worker)0.75 hours
Contact Hours (Nurse)0.75 hours
CDR CPEUs (Registered Dietitian)0.75 hours

(Note: a course evaluation is required to receive credit for this course.)

Vanessa Weisbrod

Director, Celiac Disease Program

Janis Arnold headshot

Janis Arnold, MSW, LICSW

Clinical Social Worker, Division of Gastroenterology, Hepatology, and Nutrition

Katherine Garvey, MD, MPH

Clinical Chief, Diabetes; Director, Diabetes Program; Attending Physician, Division of Endocrinology

Assistant Professor of Pediatrics, Harvard Medical School

Sharon Weston, MS, RD, CSP, LDN

Senior Clinical Nutrition Specialist; Lead RD Optimal Wellness for Life Clinic, Division of Gastroenterology, Hepatology, and Nutrition

In this episode, Dr. Katherine Garvey describes the current protocols for screening for celiac disease in patients with type 1 diabetes. Furthermore, Dr. Garvey and Sharon Weston, MS, RD, CSP, LDN identify common challenges of the gluten-free diet for patients with a dual diagnosis of celiac disease and type 1 diabetes. Sharon Weston also explains common school lunch foods that are suitable for a patient with celiac disease and type 1 diabetes.

Learning Objectives: 

At the conclusion of this educational program, learners will be able to:

  1. Describe the current protocols for screening for celiac disease in patients with type 1 diabetes
  2. Identify common challenges of the gluten-free diet for patients with a dual diagnosis of celiac disease and type 1 diabetes
  3. Explain common school lunch foods that are suitable for a patient with celiac disease and type 1 diabetes

In support of improving patient care, Boston Children’s Hospital is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physicians

Boston Children’s Hospital designates this live activity for a maximum of 0.75 AMA PRA Category 1 Credits ™. Physicians should claim only credit commensurate with the extent of their participation in this activity.

Nurse
Boston Children’s Hospital designates this activity for 0.75 contact hours for nurses. Nurses should only claim credit commensurate with the extent of their participation in the activity.

Social Work
As a Jointly Accredited Organization, Boston Children’s Hospital is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. Boston Children’s Hospital maintains responsibility for this course. Social
workers completing this course receive 0.75 ACE CE continuing education credits.

Dietician
Boston Children’s Hospital designates this activity for 0.75 contact hours for dieticians. Dieticians should only claim credit commensurate with the extent of their participation in the activity.

Disclosures

Boston Children’s Hospital adheres to all ACCME Essential Areas, Standards, and Policies. It is Boston Children’s policy that those who have influenced the content of a CME activity (e.g. planners, faculty, authors, reviewers and others) disclose all relevant financial relationships with commercial entities so that Boston Children’s may identify and resolve any conflicts of interest prior to the activity. These disclosures will be provided in the activity materials along with disclosure of any commercial support received for the activity. Additionally, faculty members have been instructed to disclose any limitations of data and unlabeled or investigational uses of products during their presentations.

The following planners, speakers, and content reviewers, on behalf of themselves, have reported the following relevant financial relationships with any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on patients: 

Vanessa Weisbrod

None

Janis Arnold, MSW, LICSW

None

Sharon Weston, MS, RD, CSP, LDN

Consultant/Advisory Board Member to Nutricia, Kate Farms. Own individual stock in Takeda.

Katherine Garvey, MD, MPH

None

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Vanessa Weisbrod:

Welcome to Raising Celiac, a podcast dedicated to raising the standard of education, awareness, and research on celiac disease and related autoimmune conditions. I’m Vanessa Weisbrod, the education director of the Celiac program at Boston Children’s Hospital. And each month on the podcast, we will invite leading experts to dive into a condition related to celiac disease and look at how it impacts a patient family, the latest research and offer suggestions for health providers to manage these complex cases. Every episode of the Raising Celiac Podcast is accredited by the Boston Children’s Hospital Continuing Education Department for physicians, nurses, social workers, and dieticians. To claim your credits for listening to today’s episode, please visit dme.childrenshospital.org/raisingceliac. Let’s get started with this month’s Raising Celiac patient story.

Janis Arnold:

Sophia was a happy and vibrant four-year-old who loved hosting tea parties with her stuffed animals, especially Bella, her rainbow unicorn. She made all her family members join the parties, even her two older brothers who rolled their eyes every time she asked. She always asked her mom to fill the tea cups with pink lemonade to match the pink of the circus animal sprinkled cookies she served on her white tea plates. As the tea parties went on, Sophia’s mom started to notice that her dainty sips of tea shifted to gulping down the liquid and quickly refilling the cup. Her brothers joked she was addicted to the sugary lemonade, but was she?

Vanessa Weisbrod:

Type one diabetes is an autoimmune disease. Doctors don’t know the exact cause, but believe it is triggered by a combination of genetic and environmental factors. In a patient with type one diabetes, the body’s immune system attacks and destroys the cells in the pancreas that make insulin. As a result, the body is unable to produce enough insulin, a hormone that regulates the amount of sugar in the blood. Type one diabetes can cause blood glucose to be too high, which can cause long-term damage to the kidneys, eyes and nerves.

Janis Arnold:

Drinking too much lemonade during tea parties wasn’t the only thing that seemed off. Sophia’s preschool teacher reached out to her mom because she started asking for water very frequently. She was drinking her entire water bottle by 9:00 AM and refilling it multiple times during the day. She was using the bathroom several times an hour and falling asleep at the table during lunch. Mom made an appointment with the pediatrician where they learned Sophia had lost nearly three pounds since her last well child visit. Sophia’s doctor ordered lab work, including a blood sugar test, hemoglobin A1c, an autoantibodies panel, as well as a urine test. All came back indicating type one diabetes.

Vanessa Weisbrod:

There is a well-established link between type one diabetes and celiac disease that was first discovered over 60 years ago. The estimated prevalence of celiac in patients with type one diabetes is approximately 8% compared to about 1% in the general population. Due to the significantly higher prevalence of celiac disease in diabetes patients, many physicians recommend getting screened for celiac after a diagnosis of type one diabetes and vice versa.

Janis Arnold:

And this is exactly what Sophia’s endocrinologist did at her first appointment even though Sophia reported no obvious symptoms of celiac disease. The test was positive. Sophia’s parents felt helpless and overwhelmed. In a matter of a few weeks, they went from having few worries in the world to having a daughter with two autoimmune diseases, both that required major lifestyle changes. How would they manage a strict gluten-free diet on top of constant blood sugar monitoring and giving insulin? It all seemed like too much to handle.

Vanessa Weisbrod:

The goal of type one diabetes treatment is to control glucose levels and prevent the patient’s blood sugar from being too high. The ideal diabetes management regimen includes insulin therapy, glucose and ketone monitoring, regular active exercise and healthy eating. Understanding how food impacts blood glucose is critically important for the management of type one diabetes. Food causes blood glucose to go up. Insulin causes blood glucose to go down. Too much food with not enough insulin can cause blood glucose to go too high. Not enough food with too much insulin can cause blood glucose to go too low. And the amount and type of food affects how much and how quickly the glucose levels go up.

Janis Arnold:

Sophia’s family attended a getting started class at their local hospital to learn about balancing food and insulin. They studied food labels and started having Sophia try out new foods that were richer in fiber and whole grain. But as they started perusing the gluten-free isles of the grocery store, they quickly noticed a problem with many starchy gluten-free products like bread, crackers, cereal, pasta. They were all higher in carbohydrate content than their gluten containing counterparts and contained highly refined starches and sugars. A quick internet search told them these refined ingredients were used in gluten-free foods to mimic the mouth feel and texture of gluten. Yikes. Now what?

Vanessa Weisbrod:

Carbohydrates are an important source of energy. They are also the main nutrient the body turns into blood sugar. It’s important to eat good for you carbohydrates that are high in fiber like whole grains, fruits and vegetables. These carbohydrates slow digestion and help make you feel full for longer. High fiber foods also reduce spikes in blood glucose after eating. Many gluten-free foods at grocery stores are considered processed carbohydrates. They’re low in fiber and if not closely monitored, can raise blood sugars too high. So how does a family with a child with a dual diagnosis of celiac disease and type one diabetes manage the dietary considerations of both conditions? Does going on a strict gluten-free diet help with managing diabetes? How do these patients manage their nutritional needs when eating outside of the home, like at school or in a restaurant? We’ll discuss this and more on today’s episode of Raising Celiac.

Today we talk about celiac disease and type one diabetes with two leading experts. First, we talk to Dr. Katharine Garvey, the Clinical Chief of Diabetes and the Director of the Diabetes Program at Boston Children’s Hospital. Then we’ll be joined by Sharon Weston, a Senior Clinical Nutrition Specialist at Boston Children’s Hospital who runs the nutrition education classes for patients with celiac disease and type one diabetes. Welcome to Raising Celiac.

Dr. Garvey:

Thank you so much. I’m so happy to be here.

Vanessa Weisbrod:

So Dr. Garvey, we know that celiac disease and type one diabetes share several common risk factors including genetics, environment and immune dysregulation. Can you tell our listeners more about these commonalities and why the conditions are so closely related?

Dr. Garvey:

Yes, of course. So I think the major predominant driving factor is absolutely genetic commonalities. The fact of the matter is that there is a shared genetic susceptibility with certain alleles that we call HLA haplotype. Specifically, there’s an HLA, I think it’s DQ2 and DQ8 that are found in celiac disease and in most individuals with type one diabetes. And in fact, it’s common enough when you have type one diabetes to have those alleles that we don’t even recommend necessarily screening the genetics to determine that because you’re going to find it. And approximately 5% to 10% of people with type one diabetes have positive antibodies for celiac. And I think it’s around 5% or so, maybe a little higher of people who have biopsy-proven celiac disease. And so it’s a pretty significant chunk and significant enough that we do execute routine screening for people with type one diabetes to check if they have celiac.

Vanessa Weisbrod:

Is there an understanding of which disease comes first or does one cause the other?

Dr. Garvey:

Yeah, that’s a really good question and it’s a little bit confounded by the fact that we routinely screen people with type one diabetes for celiac. And as we might get to later, most people with type one diabetes who are diagnosed with celiac are not coming in leading with celiac symptoms and so would’ve had no reason to be screened prior. And so maybe it’s not surprising given that the vast majority in research as we currently understand it have diabetes diagnosed first. I think in most studies, somewhere on the order of 80% to 90%, but I have patients who were diagnosed with celiac first. We definitely see it, just not as commonly.

Vanessa Weisbrod:

So are all kids diagnosed with type one diabetes automatically screened for celiac disease? Is this a standard protocol?

Dr. Garvey:

Yeah, that’s a great question too. So we follow the American Diabetes Association screening recommendations and the current guidelines are to screen soon after the diagnosis of type one diabetes and that’s tough. If we just think about that. We don’t screen exactly at the moment of diagnosis at our center, although some centers do. We screen for that first time about six to eight weeks out from diagnosis. But still, they’re adjusting to the new world of having type one diabetes and everything that comes with that and everything that carries. And then we’re going to add celiac disease to that? It’s really important to consider what the screening may bring. However, the recommendations are to do it soon after the diagnosis and then if it’s negative, two years later. And if it’s a negative then, five years later, so diagnosis two years and five years. And then after that, if it’s negative at that five year mark, I think the recommendation is if people have any signs or symptoms or we may change the plan if they have a first through degree relative who also has celiac.

Vanessa Weisbrod:

So the biopsy to confirm a celiac diagnosis is still the gold standard in North America. Do kids with type one diabetes also need the biopsy to confirm a celiac diagnosis?

Dr. Garvey:

Yeah, so people with type one diabetes who screen positive are sent to gastroenterology who would help them explore whether or not biopsy is right for them. And I know there are the European guidelines where if your tTG is 10 times above the upper limit or whatever it is, they may not need a biopsy. And as far as I know, the recommendation would be the same in people with type one, where biopsy is the gold standard, but if it’s so obvious based on their antibody results and other criteria that they may be offered to proceed without it. Many people with type one diabetes don’t have classical symptoms of celiac. And so just given the huge significance and challenge of implementing a gluten-free diet, I think it does make sense to go after a biopsy just to make sure it’s truly necessary. As with the European guidelines, I think many people would potentially want to forego it if their results are that high for screening.

Vanessa Weisbrod:

Absolutely. So you mentioned that kids with both conditions might not have the classic symptoms like diarrhea, vomiting, weight loss, and growth issues. What are the symptoms that you see in the kids with type one diabetes, if any?

Dr. Garvey:

Yeah, so many children with type one diabetes and celiac do not have the classical symptoms that you mentioned. Some do, but the most common thing that I see clinically is more of an after the fact. They don’t have any obvious symptoms, but after the fact will notice that some things have improved. And in fact, one of those is glucose variability. So just to take a step back and remind listeners that in type one diabetes what we’re dealing with is essentially an absolute insulin deficiency, and it’s normal to some extent to have glycemic variability or glucose variability because we’re giving back insulin with a very imperfect method by putting it under the skin and injections. But much of the way we do that is by matching carbohydrate intake and trying to quantify a carbohydrate intake and insulin and saying, okay, if you are eating something, let’s say it’s an apple, actually let’s say bread because we’re talking about celiac disease, so if we say two slices of bread has 30 grams of carbohydrate and your prescribed carbohydrate ratio is one unit for 15 grams, then you’ll take two units of insulin for that bread.

Now, if you have unpredictable erratic absorption of your nutrients because you have undiagnosed celiac disease, then you might not digest that bread the way that you did yesterday or the way you will tomorrow. It all depends on what part of the small bowel it’s hitting, and it’s quite possible that we would give the insulin and then the food would not be appropriately digested and that would result in a low glucose. Maybe we would change the carb ratio to accommodate for that variability, but then the next time you try it, your glucose will be high after. And so we see a lot of unpredictable glucose measurements, recurrent lows, overall poor control with the diabetes management. And often when we find out that they have celiac disease and appropriately treat that, we find that it’s much easier to control the diabetes.

Vanessa Weisbrod:

So that’s a good outcome, but then toss in the changes of gluten-free ingredients and it might go the other way. So how does the gluten-free diet really impact the treatment for a child with type one diabetes?

Dr. Garvey:

Exactly. So on the one hand, you have an improvement from a healed gut and improved intestinal absorption of nutrients. But on the other hand, you have gluten-free carbohydrates, which can be extremely challenging. And I know that you’ll be talking with Sharon Weston, who is an absolute expert, and I defer all things to Sharon on this, but many of the carbohydrates used in gluten-free diet are very high glycemic index, so rapidly digested things that are used instead of gluten to try to provide the texture and the experience of eating things like bread. So these might have ingredients such as tapioca starch or rice flour or things that are going to hit hard and create a potentially rapid increase in glucose.

And that’s really challenging to manage with insulin. Also, it can be really challenging to manage if you mix it with fat. So if you mix a gluten-free carbohydrate such as pizza crust with cheese, the cheese is going to delay the absorption maybe for a long time and then it will all hit hours later. How do you cover that with insulin if you already gave the insulin when you ate it? So it’s very complicated and it’s more predictable once they’re diagnosed. But covering gluten-free carbohydrates with insulin is much harder than standard.

Vanessa Weisbrod:

All the more need for a really good dietician when you’re managing both conditions.

Dr. Garvey:

Exactly. Critical part of the team.

Vanessa Weisbrod:

So a recent study assessed quality of life in patients diagnosed with both type one diabetes and celiac disease and found lower scores than in matched patients with diabetes alone, especially in respect to social functioning and general health perception. As you heard from Sophia’s family, it was a challenging emotional adjustment for them. How do you help families cope with these major life changes?

Dr. Garvey:

Yeah, what an important point. I think that data are somewhat contradictory in this area. Studies like the one you cited have shown results in adults who have decreased quality of life with a dual diagnosis. In children, there are some other studies showing that there is a minimal impact of the double diagnosis, although parents felt that their children function lower socially. I’m not sure the data in this area really capture how incredibly challenging the dual diagnosis is. I personally think the studies are small, there aren’t enough pediatric studies, and we need more data to really help us understand and bring a voice to the immense challenge. You’re taking an incredibly burdensome condition with type one diabetes where you have to calculate and give insulin three, four, five, up to 10 times a day on top of intensive glucose monitoring adjustments for exercise and different dietary content. And then you add to that the restrictions and the challenges of gluten-free.

And to me, it’s a no-brainer that this is tremendously impactful on patient and family experience. And I think many children who have a dual diagnosis would say that the celiac is the harder of the two, which is so important and interesting, and it’s something I think we need to understand better, just the social impact of celiac and how incredibly hard that is. So in terms of how I help them cope, I think first of all, just by bringing voice to this experience and when you’re in a diabetes visit, it’s very easy to focus only on diabetes and to really get into the weeds of the numbers and the ratios and the insulin doses and the rates and what they’re doing and how we can improve the glucose trends. And sometimes it’s very matter of fact about celiac. Oh yeah, these gluten-free carbs are harder to cover.

But just to take a pause and say, “What you’re dealing with, the challenges of this dual diagnosis, this is really hard. And the fact that you are doing it, that you are doing the gluten-free diet is huge and you deserve a lot of credit for that. And it’s not just an additional line on your problem list. It is a really big accomplishment to be doing it.” So I try to bring voice to that. I try to send people back to nutrition and also encourage them to take advantage of mental health resources and community resources for these conditions. The other point I wanted to make is just that there are data showing that as challenging as quality of life is in a dual diagnosis, it’s even lower in people who have a dual diagnosis but don’t treat the celiac. And I think that’s a really important situation that I do see in my clinical practice.

And I don’t think it’s as noted in the celiac program because they don’t come. They’re not coming to the celiac program because they’re not treating their celiac disease. And I do have families who say, “You know what? We can’t deal with the gluten-free diet on top of diabetes management.” And I think there are data that tell us this is concerning for quality of life, it’s concerning for bone health, it’s concerning for diabetes control. There are a lot of reasons to treat celiac disease. And I just try to encourage those people to come back and keep having open conversations with gastroenterology and really make sure that their eyes are wide open in terms of knowing what they’re doing by not treating the celiac.

Vanessa Weisbrod:

That’s a really good point. And we’ve heard so many of the same things from families coming into the Celiac Kids Connection, and we now have a couple of parents who serve as the diabetes liaisons to really make sure that those families have an extra layer of support with families who are going through the experience of a dual diagnosis too. And I agree, it’s really challenging.

Dr. Garvey:

Oh, that’s so wonderful. Yeah, I think it’s really wonderful to have peer mentors and family mentors because I think the dual diagnosis is so overwhelming. And if you think about things like celiac camp or gluten-free conventions where you go and stop at all the tables that have gluten-free things and a lot of them are desserts or gluten-free bakeries, which are all so incredible for people living with celiac, those things are an absolute nightmare for insulin management. And it’s just important to own that and try to help people come up with strategies. Not that their kids can’t have that stuff, but how do we plan for it and how do we address it? Because it is really difficult, a whole other can of worms.

Vanessa Weisbrod:

And that’s how the whole diabetes liaison came to be was families coming to the holiday party for the Celiac Kids Connection and saying, “Oh my goodness, there’s frosting and cookies and cupcakes everywhere, and this is really hard to add into the day.” And so I think we’re a lot more conscious of that now and making sure that we’re thinking about those things in advance and having food items that work for everybody, and also giving parents the nutritional information ahead of time so that they can prepare for those types of events.

Dr. Garvey:

I think that’s a great idea. And then are there any ways, and I’d be really curious to hear what Sharon says about this, that there are some lower glycemic options that are still really satisfying to the patient and the child living with this, and that’s not easy to find in celiac, but it is out there.

Vanessa Weisbrod:

Well, thank you so much Dr. Garvey, for all of this wonderful information. We’re going to take a quick break and when we come back we’ll have our Boston Children’s Hospital dietician, Sharon Weston here to talk to us about nutritional considerations for patients with a dual diagnosis.

Dr. Garvey:

Thank you so much.

Speaker 4:

The Global Autoimmune Institute works to empower solutions in the diagnosis and treatment of autoimmune diseases through research, education, and awareness while supporting multidisciplinary approaches to health. We are thrilled to support the production of this educational podcast.

Vanessa Weisbrod:

Welcome back, everyone. I’m now excited to welcome Sharon Weston, our dietician to the podcast. Welcome, Sharon.

Sharon Weston:

Thank you.

Vanessa Weisbrod:

So many of our listeners are very familiar with the gluten-free diet, but just in case, can you tell them what it means to be gluten-free?

Sharon Weston:

Sure. Well, first off, we know that adhering to a gluten-free diet is the only currently known treatment for celiac disease. And a gluten-free diet really means that we’re avoiding all sources of gluten, which show up in wheat, barley, rye, and oats and oats, especially, we have to focus on because we want to make sure that we’re just choosing oats that are gluten-free. Following a gluten-free diet means carefully reading food labels for all ingredients and also avoiding cross-contamination from foods that contain gluten.

Vanessa Weisbrod:

So now we add in a diagnosis of type one diabetes. Tell our listeners how the added diagnosis changes things nutritionally.

Sharon Weston:

Yeah, so when we add in the diagnosis of type one diabetes, now we have to not only think about choosing foods that are gluten-free, but we also really need to pay attention to how the foods eaten impact blood glucose levels. So looking at the macronutrients, which are our carbohydrates and protein and fat, and understanding how different types of carbohydrates impact blood glucose levels plays an important role nutritionally.

Vanessa Weisbrod:

Sophia’s family felt quite overwhelmed when they went to the grocery store for the first time to look at gluten-free food. How do you counsel patients newly diagnosed with both type one diabetes and celiac disease on approaching food choices, especially the carb-heavy products?

Sharon Weston:

Yeah, so first off, I try to encourage families to take advantage of all the naturally gluten-free foods that are out there, so focusing on fruits and vegetables, meat, poultry, fish, milk, yogurt, cheese, nuts and seeds and nut butters, and those gluten-free whole grains. And these are not only wholesome food choices, but they also tend to be lower in carbohydrates, especially high glycemic carbohydrates, and that can help moderate blood glucose levels or blood glucose spikes. Choosing less highly processed carbohydrates, even if they are gluten-free, will help to decrease the intake of those fast acting carbohydrates, increase fiber intake, and also increase the quality nutrition wise.

Vanessa Weisbrod:

For sure. I mean, it can be a lot to think about for families. So as you’re working with these families, what are the key elements that you tell them they always have to think about when they’re cooking meals for their child with the dual diagnosis?

Sharon Weston:

Yeah, so I just really try to keep it simple. I like to focus on the basics. The main messages are really to encourage balanced meals, choose paired snacks, and that means really snacks that are a balance of carbohydrates and protein or fat and minimize juice and sugary drinks, gluten-free balanced plate model, which promotes half the plate being fruits and vegetables balanced with a quarter of the plate as protein and a quarter of the plate as gluten-free carbohydrates. It’s just a simple model to think about. And healthy fats can also round out that balanced plate model, gluten-free paired snacks, balance, again, carbohydrates with some protein or fat, like I said, are very helpful to satisfy appetite in between meals, acting like a bridge between two meals. It provides a balanced source of fuel and that can help moderate blood glucose rise and falls and act as a more sustaining source of food fuel.

And then also encouraging water or plain milk or plain milk alternatives that are gluten-free can also help maintain hydration and also provide key nutrients without excess sugar. Another key element to helping families follow these main messages is to just help with planning and planning ahead for meals and snacks, and using an organized grocery shopping list that goes along with a game plan for meals can lead to success and minimize the need to fall back on takeout food or fast food and learning to prepare home cooked gluten-free meals and they don’t have to be fancy. Also, it just helps with minimizing the risk for cross-contamination. And also, we know that improves nutritional quality just in terms of eating more fruits and vegetables and less sodium and just less junk.

Vanessa Weisbrod:

So getting away from the junky snacks that we think of that little kids love, what are some snacks that you recommend for kids with celiac and diabetes? Just some practical everyday snacks.

Sharon Weston:

I think that some practical snacks are first, step one, choose a fruit or a vegetable. And then step two, really balance it with something that’s a good protein source or a protein source that has a little fat in it. An apple and a piece of cheese is a great paired snack or sliced carrots and cucumbers and hummus is a great snack. Just falling back on those fruits and vegetables as part of a snack is a great way and then adding in that protein will make that snack more longer-lasting.

Vanessa Weisbrod:

What about nut butters? Are those good things to add in?

Sharon Weston:

Sure. Nut butters are a great thing, and nut butter by itself is a great snack. If you just need something on the go and you have a jar of peanut butter in the car and a plastic spoon and just eat a spoonful of peanut butter, that’s a great long-lasting fuel that is a balance of carbohydrates that are gluten-free, protein and fat.

Vanessa Weisbrod:

What about baking for gluten-free? We know a lot of these gluten-free baking mixes are really heavy in white rice flour, corn starch. For these dual diagnoses, are there better flowers to use for baking?

Sharon Weston:

I think that when you look at the different ingredients for those boxed baked recipe ingredients, you’re going to look at the types of gluten-free flowers that are in there. And so almond flour is a great more sustainable fuel because it’s got that protein and that fat in it, as compared to things that are just fast-acting carbohydrates with no protein or fat. So when you look on the food label and you just look at the protein and fat content, not only the carbs, you can look at those choices that are a little more balanced.

Vanessa Weisbrod:

Great. So one of the things I’ve always been so impressed with you about is how you’ve worked with so many school food service providers to help them serve safe gluten-free meals to students with a dual diagnosis. Can you tell us about some of the challenges you’ve seen with school meal programs for these kids and how you’ve helped them overcome these?

Sharon Weston:

Yeah, that is a big challenge. And I think just educating the school’s food service team about the basics of glycemic index and the importance of balanced meals and paired snacks can help. And one challenge I’ve seen frequently really relates to just trying to stick to that balanced plate concept, especially for those meals that are the backup meal options for school, so the things that are served on like school bus trips when they’re going on a field day. So offering a gluten-free bagel and a higher sugar, gluten-free yogurt with applesauce and fruit chew gummies is something that’s gluten-free, but that carb amount and quality of those carbohydrates is not going to be ideal in preventing just a huge spike in blood sugar.

So some simple solutions to reduce high glycemic, gluten-free carbohydrates and balance them with protein and healthy fats includes just using gluten-free whole grain breads with maybe SunButter or cheese, or offering a hard-boiled egg, different types of deli meats, offering plain milk, lower sugar, Greek yogurts for simple protein sources, adding in fresh fruit instead of processed fruit, and even including some healthy fats like olives would be an easy way to just change that macronutrient profile of that easy meal.

And then breakfast is another challenge at school that I frequently see because higher sugar cereals are often used, and even things like gluten-free muffins that are high glycemic and low in fiber, adding in juice, adding in chocolate milk, those are all things that are used frequently. And again, educating the food service team to come up with easy guidelines to follow. So for example, offering a gluten-free cereal with six or less grams of sugar per serving and balancing that with plain milk and offering fresh fruit would help.

Vanessa Weisbrod:

So you heard Sophia’s family attended a nutrition class, which focused on carbohydrate counseling at their local hospital, but as you heard, many of the lessons they learned became more difficult to follow when they started the gluten-free diet. Can you tell our listeners about the class you’ve started at Boston Children’s Hospital for dual diagnosis patients and touch on how other dieticians might get a similar course up and running at their institution?

Sharon Weston:

Sure. So the class that we offer at Boston Children’s provides a comprehensive overview of learning the gluten-free diet, but in the context of type one diabetes. And so before instructing the details of the gluten-free diet, first I review the basics about glycemic index and we go over different ingredients, different grains, gums, et cetera, that show up in different gluten-free food labels and talk about how eating a gluten-free version of a food that they in the past had eaten, that gluten containing version, may now result in different unexpected changes in blood glucose levels. And so we talk about ideas for balanced meals. We talk, again, about paired snacks that are gluten-free, and we touch on strategies to think about with just modifying insulin delivery as well.

Vanessa Weisbrod:

So how did you get this class going and is it possible to be implemented elsewhere?

Sharon Weston:

The class we taught originally just focuses on going gluten-free, but we know that we have so many children now with the dual diagnosis that I just really incorporated principles that are related to type one diabetes in the class, and so we just offer it once a month. It’s done virtually by Zoom. It’s really important to just make it well-known among all of the providers, GI and endocrine, that there is a dual diagnosis class. And that, I think, is one of the challenges that we had getting it started, was just awareness that there is a class, but now most people know and I think that it’s actually better utilized now.

Vanessa Weisbrod:

That’s great. So many families have very busy afterschool schedules, especially if there are multiple kids in the family. What are some strategies to help families provide meals and snacks that work with both celiac and diabetes?

Sharon Weston:

Yeah, again, planning is such a key element to success, and so having a game plan for meals and snacks helps reduce frustration at meal and snack times. And some families decide to go gluten-free for everyone, some just do a combination of gluten-containing and gluten-free foods. And regardless, there are plenty of options for the whole family that are naturally gluten-free and also lower in sugar and lower in just using highly processed carbohydrates. I encourage families to take advantage of batch cooking so that when a gluten-free meal is made, some of it can be frozen or stored, so that is easy access to pull out for future meals when you’re rushed. And so cooking a larger batch of rice or making a double batch of gluten-free chili, having some gluten-free frozen nut-based cookies, for example, all in the freezer in individual containers or Ziploc bags, super easy to just pull those out from the freezer and use quickly when you’ve got these busy family schedules going on.

Again, remember that meals don’t have to be fancy, so just scrambling an egg or opening a can of tuna fish or using a gluten-free veggie burger are superfast easy options. And for go-to snacks, again, just keeping it simple will reduce stress. So like I said before, having a jar of peanut butter or some kind of nuts in the car, having some easy individually wrapped cheese sticks or just a bag of apples, easy things that are easy to grab and go and can be part of balanced meals and healthy snacks.

Vanessa Weisbrod:

For sure. And I love what you said about just being simple, that often simple is best both nutritionally and taste wise, especially when kids are involved. We recently had a dinner where there was somebody who had both celiac and type one diabetes, and I went as simple as I could come up with. And we had delicious grilled chicken. We had roasted broccoli, roasted sweet potatoes, which were delicious, my kids love sweet potatoes. And for dessert, I gave my kids both some options and we landed on just sliced strawberries with almond butter, which is sweet and satisfied everyone’s sweet craving, and also was good for everybody around the table.

Sharon Weston:

And you just pulled off a very balanced meal and a paired snack all in that.

Vanessa Weisbrod:

And dessert according to the kids.

Sharon Weston:

Yep.

Vanessa Weisbrod:

Well, thank you so much Sharon and Dr. Garvey for all the wisdom that you shared with our listeners today. And now my favorite part of Raising Celiac, let’s find out where Sophia is today.

Janis Arnold:

It’s been almost four years since Sophia was diagnosed with type one diabetes and celiac disease. Today, she is a thriving third-grader and loves playing soccer and the piano. She uses an insulin pump and continuous glucose monitor device that measures her blood sugar with a subcutaneous glucose sensor that reports a value every five minutes. Her mom gets the readings on a smartphone app so she can watch over her while she’s at school. Sophia’s school cafeteria has worked hard to include her in the normal lunch routine and serves foods like grilled chicken, hard-boiled eggs, cheese sticks, hummus, Greek yogurt, multi-grain crackers, gluten-free pretzels, and fresh cup vegetables. In her own words, “Sometimes it’s really hard to be gluten-free, but I know that eating good foods will keep me strong and healthy.”

Vanessa Weisbrod:

Thanks for listening to this episode of Raising Celiac. A special thanks to the generous contribution from the Global Autoimmune Institute to make this podcast possible. A reminder to all physicians, nurses, social workers, and dieticians, to claim your continuing education credits for listening to today’s episode, please visit dme.childrenshospital.org/raisingceliac and complete the short survey attached to this episode. If you like what you heard, be sure to write a review, like and subscribe wherever you get your podcasts. For more information, check us out on social at @BostonChildrensCeliac on TikTok, @ChildrensCeliac on Twitter, or @CeliacKidsConnection on Instagram. Join us next month when we discuss the relationship between celiac disease and eosinophilic esophagitis. Have a great month.