Juvenile Diabetes (Type 1 Diabetes Mellitus)

What Is Juvenile Type 1 Diabetes Mellitus?

[dropcap]J[/dropcap]uvenile diabetes is type I diabetes mellitus that begins in childhood or before the age of 25 years. It is an inherited inflammatory autoimmune disease of the pancreas in which anti-islet autoantibodies destroy the islet cells of the pancreas that secrete insulin hormone, resulting in a lack of insulin.

Loss of insulin production results in failure to metabolize glucose. Glucose is a simple sugar that is a required source of energy for the body, especially the brain and muscles.

Juvenile diabetes is characterized by sustained fasting blood glucose levels above 126 mg/dL (hyperglycemia) with subsequent loss of glucose from the body by removal through the urine (glucosuria) as the body attempts to lower blood glucose, and cell starvation that follows.

That is, while glucose accumulates in blood, the body cannot access it. Without insulin treatment, this disorder quickly produces coma and ultimately results in death. In fact, it is 5th leading cause of death in the United States.

Q: How does insulin work?

A: Insulin moves glucose from the bloodstream into body cells where it is used or reformulated for high energy storage. For example, muscles can use glucose for immediate work or store it in the form of glygogen for later work, depending on need. Healthy insulin production keeps an 8 hour fasting blood glucose level to less than 100 mg/dL. Upon eating carbohydrate food, glucose is digested and absorbed from the small intestine into the bloodstream which then raises blood glucose levels. The elevated level is controlled by prompt action of insulin to lower it to below 140 mg/dL  within 2 hours of eating.

Insulin does not work alone. The islets of Langerhans manage glucose in the body. The islets are specialized formations located on the outer surface of the pancreas. The islets are composed of two different types of cells known as alpha and beta cells. These cells make the competing hormones that keep blood glucose within a healthy range.

Alpha cells secrete glucagon to raise blood glucose levels by triggering the body to release stored energy in the form of glycogen. In the opposite, beta cells secrete insulin to lower blood glucose by opening body cells so that glucose in blood can enter. Without insulin, glucose cannot enter cells but remains in the bloodstream where it accumulates.

Insulin is also needed to move magnesium into cells from the bloodstream. On the other side, magnesium is needed to produce insulin. Insulin has other functions such as building muscle and helping regulate cholesterol which directly impacts the sex hormones, estrogen, progesterone, and testosterone.

Onset of symptoms usually occurs over a period of days or weeks, although beta cell destruction can begin years earlier. The SEARCH for Diabetes in Youth multicenter study, funded by the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH), has determined that based on data from 2002 to 2003, a total of 15,000 youth in the United States were newly diagnosed with type 1 diabetes each year. Non-Hispanic white youth had the highest rate of new cases of type 1 diabetes according to NIH.

Type 1A diabetes mellitus has become one of the most intensively studied autoimmune disorders. It is now possible to predict its development, beginning with HLA-encoded genetic susceptibility, followed by the development of a series of anti-islet autoantibodies.¹

What Is Juvenile Diabetes In Celiac Disease and/or Gluten Sensitivity?

• Relationship between juvenile diabetes and celiac disease. Juvenile diabetes is an associated autoimmune glandular disorder in celiac disease. The association between celiac disease and other immune disorders may be due to the sharing of a common genetic background, such as HLA antigens (genetic markers). However, in a very large study, involving 909 patients with celiac disease, Ventura and his associates found that the development of immune disorders in Celiac Disease was clearly related to the duration of exposure to gluten.²
• Relationship between juvenile diabetes and celiac antibodies. There is an excellent correlation between IgA anti-EMA and IgA anti-tTG antibodies (celiac test), and celiac disease is most often present before the onset of diabetes.
• Relationship between juvenile diabetes and silent celiac disease.  Silent celiac disease has a high incidence in children with type 1 diabetes and their siblings. Celiac disease was diagnosed in five children before diabetes onset. A further 12 children were diagnosed after diabetes onset, without any gastrointestinal symptoms, and 11 of these had anti-tTG at the onset of diabetes, with the remaining child showing seroconversion within 6 months. Hence, all the children with both diseases had anti-tTG at or before diabetes diagnosis, and the prevalence of coeliac disease was 10.1%. Moreover, 6.8% of the siblings and 3.1% of the control children had elevated levels of anti-tTG. None of the siblings reported any coeliac-related symptoms, despite being positive for anti-tTG, and celiac disease has so far been biopsy confirmed in 4.5%.³
• Relationship between juvenile diabetes and atypical celiac disease. Anti-tTG antibodies (celiac test) should alert pediatricians to the atypical forms of celiac disease which are the most common forms in type 1 diabetes mellitus.
• Relationship between juvenile diabetes and early onset in celiac disease. Celiac disease-positive patients had earlier onset of diabetes and decreased growth and weight gain.⁴
• Relationship between juvenile diabetes and giving gluten food to infants. A study investigating breastfeeding, food supplementation, or age at introduction of gluten-containing foods in newborns of parents with type 1 diabetes mellitus demonstrated that reduced total or exclusive breastfeeding did not significantly increase the risk of developing islet autoantibodies.Giving gluten-containing foods before age 3 months, however, was associated with significantly increased islet autoantibody risk.⁵

How Prevalent Is Juvenile Diabetes In Celiac Disease and/or Gluten Sensitivity?

• A pooled analysis, based on 26,605 patients with type 1 diabetes, found a prevalence of biopsy-confirmed celiac disease of 6.0%.  More than one in twenty patients with type 1 diabetes have biopsy-verified celiac disease. “This prevalence is high enough to motivate screening for celiac disease among patients with type 1 diabetes.”⁶
• Prevalence of celiac disease in children with juvenile diabetes in Wisconsin is at least 4.6%.⁷
• Prevalence of juvenile diabetes in a nationwide German study was 6.7%.⁸
• In a French study, prevalence was 3.9%, and 82% of those were already positive for anti-tTG antibodies (celiac) at type 1 diabetes mellitus onset.⁴
• The risk of type 1 diabetes was significantly associated with a positive family history for type 1 diabetes mellitus and celiac disease.⁹

What Are The Symptoms Of Juvenile Diabetes In Celiac Disease and/or Gluten Sensitivity?

Juvenile diabetes is marked by earlier onset of diabetes and poor diabetic control.

• Excessive urination
• Excessive urination at night.
• Thirst,and dehydration result from the action of kidneys to rid the blood of high blood glucose levels.
• Decreased growth and weight loss result from inability to use glucose as an energy source because the body has to breakdown fat and muscle for the energy it requires.¹⁰

How Does Juvenile Diabetes Develop In Celiac Disease and/or Gluten Sensitivity?

• Juvenile diabetes in celiac disease results from a linked autoimmune mechanism with celiac disease.

Does Juvenile Diabetes Respond To Gluten-Free Diet?

Yes. Diabetes control in children improves on gluten free diet.¹¹

6 Steps To Improve Juvenile Diabetes In Celiac Disease and/or Gluten Sensitivity:

• [dropcap]1[/dropcap]Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:

[box type=”shadow” ]Treatment. This condition responds to the complete elimination of gluten, which is the required treatment that improves both diabetes and gut health.

• Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
• A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
• Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.

Correct Your Individual Nutritional Needs.

• Eat foods that can replenish missing nutrients. Find them under NUTRIENT DEFICIENCIES.
• Take nutritional supplements as needed. Find them under NUTRIENT DEFICIENCIES.

Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the  absorbing cells that make up the surface lining of your small intestine are better able to function.

• Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
• Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.¹²
• The intestinal lining may take up to a year to heal.[/box]

• [dropcap]2[/dropcap] Reduce Inflammation. Foods to Eat and Foods Not to Eat:

Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).

[box type=”shadow” ]Here Are Major Inflammatory Food Types That Reduce Healing:

• Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.¹³
• Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
• Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.¹³
• Fats. Limit deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.¹³.
• Excessive Refined White Flours (bran layer removed). Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.¹³
• Refined Sugars.  Includes white sugar, corn fructose and high fructose corn syrup.
• Certain Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.¹³
• Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.¹³
• Cocoa and Black Tea increase blood sugar.
• Rosemary. Increases blood sugar levels and should not be used by persons with insulin resistance or diabetes.[/box]

[box type=”shadow” ]Here Are Important Anti-Inflammatory Food Types to Promote Health:

• Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens.
• Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes green leafy vegetables such as lettuce and kale, also onion, broccoli, garlic, and others.
• High Quality Complex Carbohydrates. Provide vitamins, minerals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
• Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
• Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources includes tuna, salmon, cod, and others. Plants sources include flax, chia seeds, canola oil, and others.
• Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
• Prebiotics/ High Fiber Foods.  Food with fiber keeps our population of colonic microbes healthy.
• Protective Herbs and Spices.  See below #6 below for examples.[/box]

• [dropcap]3[/dropcap] Information Sheet You Can Take to Your Doctor or Other Health Professional:

Click here.

• [dropcap]4[/dropcap] Manage Your Medications Safely:

[box type=”shadow” ]

Insulin depletes magnesium and this causes digestive problems such as slow motility and constipation. Ask your doctor or pharmacist about this possible adverse effect and how to supplement. Do not stop prescribed medications without supervision.

Other medications that deplete magnesium which is required for insulin use in the body include:

This is not a complete listing.

ANTACIDS / ULCER MEDICATIONS

• Pepcid®, Tagamet®, Zantac® deplete Magnesium.
• Magnesium and Aluminum Antacid preparations (Gaviscon®, Maalox®, Mylanta®) deplete Magnesium.
• Alka Seltzer®, Baking Soda deplete Magnesium.

ANTIBIOTICS disrupt intestinal permeability which complicates celiac disease.

•  Tetracyclines deplete Magnesium.

ANTI-INFLAMMATORIES disrupt intestinal permeability which complicates celiac disease.

• Corticosteroids (Prednisone, Medrol®, Aristocort®, Decadron) deplete Magnesium.

ANTIVIRAL AGENTS

• Foscanet depletes Magnesium.

BRONCHODILATORS

• Albuterol inhalers that are breathed in on a daily basis as a long term therapy and also for quick relief as rescue inhalers to open airways deplete Magnesium.

DIURETICS

• Thiazide Diuretics (Hydrochlorothiazide, Enduron®, Diuril®, Lozol®, Zaroxolyn®, Hygroton® and others) deplete Magnesium.
• Loop Diuretics (Lasix®, Bumex®, Edecrin®) deplete Magnesium.

FEMALE HORMONES disrupt intestinal permeability which complicate celiac disease.

• Oral Contraceptives (Norinyl®, Ortho-Novum®, Triphasil®, and others) deplete Magnesium.
• Oral Estrogen/Hormone Replacement (Evista®, Prempro®, Premarin®, Estratab® and others) deplete Magnesium.[/box]

• [dropcap]5[/dropcap]Nutritional Supplements To Help Correct Deficiencies:

[box type=”shadow” ]

The type and quantity of nutritional supplements that may be needed depend on which nutrients are deficient.

• Multivitamin/mineral combination that provides 100% once a day is useful to improve overall nutrient levels. This is a safe dose, but always check with your doctor to avoid interactions with medications.
• Chelated magnesium  as prescribed but do not take at same time as calcium because they compete for absorption.

Storage Note: Store container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet – not in the bathroom or on the kitchen table.[/box]

• [dropcap]6[/dropcap]Manage Natural Remedies: 

[box type=”shadow” ]Hydration:

• Eight glasses of water are recommended per day unless there is a contraindication such as kidney or heart disease. The Institute of Medicine recommends approximately 2.7 liters (91 ounces) of total water, from all beverages and foods, each day for women and 3.7 liters (125 ounces) daily of total water for men.
• If you are thirsty, drink water. Add fresh, squeezed lemon to water. Lemon is anti-inflammatory, alkalizing and provides vitamin C.
• Hydration Test: Urine should be pale yellow. Fingertips should be plump, without pruning but this may not be reliable when fingers are swollen with edema. Lips should be plump, without puckering. The feeling of thirst can be unreliable.
• What is wrong with soda, coffee, tea, and alcohol? These drinks are dehydrating, increase acid, and deplete nutrients.[/box]

[box type=”shadow” ]Carminatives. The following  anti-inflammatory plant sources called carminitives help heal the digestive tract. They also tone the digestive muscles which improves peristalsis, thus aiding in the expulsion of gas from the stomach and intestine to relieve digestive colic and gastric discomfort.

Carminative Food Remedies:

• Raspberry.
• Carrot is also a cleansing digestive tonic.
• Grape is also bile stimulating and a cleansing remedy for sluggish digestion and laxative.
• Redbeets also stimulate and improve digestion and are easily digested.
• Cabbage also stimulates and improves digestion and is also a liver decongestant.
• Lettuce also stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
• Potatoes are antispasmodic (due to atropine like properties) and a liver remedy.

Carminative Herb Remedies:

• Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa.  Drink as tea or use in cooking.
• Chamomile, lemon balm, and fennel, (as a tea) also help relieve nervous tension.
• Parsley also relieves indigestion.
• Thyme is also soothing remedy useful for stimulating digestion of rich, fatty foods.

Carminative Spice Remedies:

• Cloves are also antispasmodic.
• Nutmeg is also useful for indigestion.
• Ginger.[/box]

[box type=”shadow” ]Exercise Helps:

Exercise improves circulation and rids the body of toxins.

• Walking is aerobic exercise that reconditions the whole body to improve stamina. Read more about Exercise and Fitness.
• Weight training builds muscle. Read more about Exercise and Fitness.
• Stretching improves flexibilty. Read more about Exercise and Fitness.

Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal. [/box]

What Do Medical Research Studies Tell About Juvenile Diabetes In Celiac Disease and/or Gluten Sensitivity?

RESEARCH STUDY SUMMARIES

“Systematic review with meta-analysis: associations between coeliac disease and type 1 diabetes.” This study is a systematic review of English-language articles published in PubMed Medline between 2000 and May 2014. Search terms included ‘celiac disease’ or ‘coeliac disease’ and ‘diabetes mellitus’. Studies were selected with at least 100 individuals with type 1 diabetes being screened for coeliac disease where the coeliac diagnosis was later confirmed through small intestinal biopsy. Data synthesis used random-effects inverse variance-weighted models, and meta-regression was used to examine heterogeneity in subgroups.

RESULTS: A pooled analysis, based on 26,605 patients with type 1 diabetes, found a prevalence of biopsy-confirmed celiac disease of 6.0% (95% CI = 5.0-6.9%). More than one in twenty patients with type 1 diabetes have biopsy-verified celiac disease. “This prevalence is high enough to motivate screening for celiac disease among patients with type 1 diabetes.”⁶

“Silent celiac disease is over-represented in children with type 1 diabetes and their siblings.” This study investigating untreated coeliac disease in children with type 1 diabetes and their siblings autoantibodies against tissue transglutaminase (anti-tTG) to detect found that silent celiac disease has a high incidence in children with type 1 diabetes and their siblings.

Anti-tTG was measured in prospectively collected sera from 169 children at the onset of diabetes, 88 of their siblings and 96 matched control children. Celiac disease was confirmed with a small intestinal biopsy.

RESULTS: Celiac disease was diagnosed in five children before diabetes onset. A further 12 children were diagnosed after diabetes onset, without any gastrointestinal symptoms, and 11 of these had anti-tTG at the onset of diabetes, with the remaining child showing seroconversion within 6 months. Hence, all the children with both diseases had anti-tTG at or before diabetes diagnosis, and the prevalence of coeliac disease was 10.1%. Moreover, 6.8% of the siblings and 3.1% of the control children had elevated levels of anti-tTG. None of the siblings reported any coeliac-related symptoms, despite being positive for anti-tTG, and celiac disease has so far been biopsy confirmed in 4.5%.³

“Clinical benefit of a gluten-free diet in type 1 diabetic children with screening detected celiac disease.” This study investigating the effect of Gluten Free Diet on growth and diabetic control of children with type 1 DM and Celiac Disease demonstrated identification and dietary treatment of Celiac Disease in children with DM improved growth and influenced diabetic control. Evaluation of the outcome of treatment of Celiac Disease in diabetics should include assessments of gluten intake.¹⁴

“Anthropometry, metabolic control, and thyroid autoimmunity in type 1 diabetes with celiac disease: a multicenter survey.” This study investigating the influence of Celiac Disease on growth and metabolic control in a nationwide cohort of German children and adolescents with type 1 DM demonstrated females were significantly more predisposed to have Type 1 DM and Celiac Disease. Celiac Disease patients were characterized by earlier onset of diabetes and decreased growth and weight than diabetic patients without Celiac Disease. Evidence for thyroid disease was more commonly observed in the Type 1 DM with Celiac Disease group (6.3% vs 2.3%) and HbA1c values were lower.⁸

“Effect of gluten-free diet and adherence on growth and diabetic control in diabetics with coeliac disease.” This study investigating the prevalence of Celiac Disease in a diabetic population of children by measuring IgA anti-transglutaminase antibodies in parallel with classical markers (IgA and IgG antigliadin and IgA antiendomysium) and measuring the temporal relationship between type 1 diabetes onset and Celiac Disease, demonstrated an excellent correlation between IgA-antiEMA and IgA-anti-tTG antibodies and that Celiac Disease is most often present before the onset of diabetes. Anti-tTG antibodies should alert pediatricians to the atypical forms of Celiac Disease which are the most common forms in type 1 DM. Celiac Disease-positive patients had earlier onset of diabetes and decreased growth and weight gain.⁴

“Early infant feeding and risk of developing type 1 diabetes-associated autoantibodies.” This study investigating breastfeeding, food supplementation, or age at introduction of gluten-containing foods in newborns of parents with type 1 DM demonstrated that reduced total or exclusive breastfeeding did not significantly increase the risk of developing islet autoantibodies. Giving gluten-containing foods before age 3 months, however, was associated with significantly increased islet autoantibody risk.¹⁵

“Family history and risk of type 1 diabetes mellitus.” This study investigating the association of type 1 diabetes in children and adolescents with positive family history demonstrated risk of type 1 diabetes was significantly associated with a positive family history for type 1 DM, Celiac Disease, allergic diseases, and Crohn’s disease.¹⁶

Sources:

1. Liu E, Eisenbarth GS. Type 1A diabetes mellitus-associated autoimmunity. Endocrinology and Metabolism Clinics of North America. Jun 2002;31(2):391-410, vii-viii. [↩]
2. La Villa G, Pantaleo P, Tarquini R, Cirami L, Perfetto F, Mancuso F, Laffi G. Multiple immune disorders in unrecognized celiac disease: a case report. World J Gastroenterol. 2003;9(6):1377-1380. [↩]
3. Hansson T, Dahlbom I, Tuvemo T, Frisk G. Silent coeliac disease is over-represented in children with type 1 diabetes and their siblings. Acta Paediatr. 2014 Oct 5. doi: 10.1111/apa.12823. [↩] [↩]
4. Saadah Ol, Zacharin M, O’Callaghan A, Olover MR, Catto-Smith AG. Effect of gluten-free diet and adherence on growth and diabetic control in diabetics with coeliac disease. Archives of Disease in Childhood. Sep 2004;89(9):871-6. [↩] [↩] [↩]
5. Ziegler AG, Schmid S, Huber D, Hummel M, Bonifacio E. Early infant feeding and risk of developing type 1 diabetes-associated autoantibodies. JAMA: The Journal of the American Medical Association. Oct 1, 2003;290(13):1721-8. [↩]
6. Elfström P, Sundström J, Ludvigsson JF. Systematic review with meta-analysis: associations between coeliac disease and type 1 diabetes. Aliment Pharmacol Ther. 2014 Nov;40(10):1123-32. doi: 10.1111/apt.12973. [↩] [↩]
7. Atkay AN, Lee PC, Kumar V, Parton E, Wyatt DT, Werlin SL. The prevalence and clinical characteristics of celiac disease in juvenile diabetes in Wisconsin. Journal of Pediatric Gastroenterology and Nutrition. Oct 2001; 33(4):462-5. [↩]
8. Kaspers S, Kordonouri O, Schober E, Grabert M, Hauffa BP, Holl RW. Anthropometry, metabolic control, and thyroid autoimmunity in type 1 diabetes with celiac disease: a multicenter survey. Journal of Pediatrics. Dec 2004;145(6):790-5. [↩] [↩]
9. Sipetic S, Vlajinac H, Kocev N, Marinkovic J, Radmanovic S, Denic L. Family history and risk of type 1 diabetes mellitus. Acta Diabetologica. Sep 2002;39(3):111-5. [↩]
10. Daniela Cihakova MD, PhD. Type 1 Diabetes Mellitus. http://autoimmune.pathology.jhmi.edu/diseases.cfm?systemID=3&DiseaseID=23. Retrieved 9/3/13. [↩]
11. Book LS. Diagnosing celiac disease in 2002: who, why, and how? Pediatrics. May 2002;109(5):952,3p. [↩]
12. Cummins AG, Thompson FM, Butler RN, et al. Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease. Clinical Science. Apr 2001;100(4):379-86. [↩]
13. Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [↩] [↩] [↩] [↩] [↩] [↩]
14. Hansen D, Brock-Jacobsen B, Lund E, et.al. Clinical benefit of a gluten-free diet in type 1 diabetic children with screening detected celiac disease. Diabetes Care. 2006; 29:2452-2456. [↩]
15. Ziegler AG, Schmid S, Huber D, Hummel M, Bonifacio E. Early infant feeding and risk of developing type 1 diabetes-associated autoantibodies. JAMA: The Journal of the American Medical Association. Oct 1, 2003;290(13):1721-8. [↩]
16. Sipetic S, Vlajinac H, Kocev N, Marinkovic J, Radmanovic S, Denic L. Family history and risk of type 1 diabetes mellitus. Acta Diabetologica. Sep 2002;39(3):111-5. [↩]