ESPE Yearbook of Paediatric Endocrinology

To read the full abstract: JAMA Pediatr 2019; 173:953–960.

Dietary proteins, such as gluten, have been suggested to serve as triggers of the autoimmune process that leads to type 1 diabetes (T1DM). These authors studied the potential associations of cereal, gluten, and dietary fiber intake with the development of islet autoimmunity (IA) and T1DM.

The prospective birth cohort Finnish Type 1 Diabetes Prediction and Prevention Study initially recruited children with known genetic susceptibility to T1D from 1996 to 2004 from two university hospitals in Finland and followed up every 3–12 months up to 6 years for dietary intake (cereals, gluten, and dietary fiber from repeated 3-day diaries), islet autoantibodies (IA), and manifestation of T1DM. 6081 infants (78% of those invited) participated. Dietary data were available for 5714 (94.0%) and dietary and IA (defined as repeated positivity for islet cell antibodies and at least one of three autoantibodies analyzed, or the presence of T1D) for 5545 (91.2%), of whom 3762 (68%) had IA data up to age 6 years. Data on incident T1DM were available on all children from the Finnish Pediatric Diabetes Register, updated in 2015.

During the 6-year follow-up, 246/5545 (4.4%) children developed IA and 90/ 5714 (1.6%) developed T1DM. For IA, the intakes of oats (hazard ratio [HR] per +1 g/MJ: 1.08; 95% CI, 1.03–1.13), wheat (HR, 1.09; 95% CI, 1.03–1.15), rye (HR, 1.13; 95% CI, 1.03–1.23), gluten-containing cereals (HR, 1.07; 95% CI, 1.03–1.11), gluten without avenin from oats (HR, 2.23; 95% CI, 1.40–3.57), gluten with avenin (HR, 2.06; 95% CI, 1.45–2.92), and dietary fiber (HR, 1.41; 95% CI, 1.10–1.81) were all associated with higher risks. Also for T1DM, the intakes of oats (HR, 1.10; 95% CI, 1.00–1.21) and rye (HR, 1.20; 95% CI, 1.03–1.41) was associated with higher risks. After multiple testing correction, the associations with IA remained statistically significant.

Higher intakes of oats, gluten-containing cereals, gluten, and dietary fiber were associated with an increased risk of IA. This confirms the notion that, beneath substantial genetic components (that do not change over short time periods), environmental factors (that can change quickly) particularly dietary factors are likely to explain the increases in childhood T1DM seen in many countries. Cereals are the most important carbohydrate source in most populations. There is a known link between IA and e.g. the dietary intake of gluten. However, many studies report that gluten free diets do not prevent T1DM in children with high genetic susceptibility (1). In the current highly selected high risk population from Finland, energy adjusted intakes of oats and rye were associated with study development of both IA and T1DM in this. The findings might not be extrapolated to lower risk populations or different HLA risk cohorts, but they do serve as a model for disease development. Whole grain cereals with high fibre content are usually a good dietary choice in the general population but might not be so in those at high risk for T1DM.

Reference:

1. Aronsson CA, Lee H-S, HårdafSegerstad EM, Uusitalo U, YangJ,Koletzko S, Liu E, Kurppa K, Bingley PJ, Toppari J, Ziegler AG, She J-X, Hagopian WA, Rewers M, Akolkar B, Krischer JP, Virtanen SM, Norris JM, Agardh D, for the TEDDY Study Group. Association of gluten intake during the first 5 years of life with incidence of celiac disease autoimmunity and celiac disease among children at increased risk. JAMA 2019;322(6):514–523. doi:10.1001/jama.2019. 10329