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Journal of Pediatric Gastroenterology & Nutrition:
doi: 10.1097/MPG.0b013e318251443d
Invited Commentaries

Challenge of Measuring How Much Gluten Is Too Much

Kaukinen, Katri*; Lähdeaho, Marja-Leena

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*School of Medicine, University of Tampere, and the Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland

Pediatric Research Center, University of Tampere and Tampere University Hospital, Tampere, Finland.

Address correspondence and reprint requests to Katri Kaukinen, MD, PhD, University of Tampere, School of Medicine, FIN-33014, Tampere, Finland (e-mail:

Received 15 February, 2012

Accepted 17 February, 2012

The authors report no conflicts of interest.

See “Food Questionnaire for the Assessment of Gluten Intake by Children 1 to 4 Years Old” by Hopman et al on page 791.

The gluten-containing cereals wheat, rye, and barley are staple foods that are important sources of nutrients, dietary fiber, and other compounds with recognized benefits for health; however, in a subgroup of genetically predisposed individuals, the ingestion of these cereals causes an abnormal immune reaction called celiac disease. Because only few genetically susceptible individuals develop celiac disease, and even though virtually all people are exposed to gluten, it is concluded that the etiology of celiac disease is multifactorial, and in addition to genetic components, nutritional and other environmental factors are necessary in the disease pathogenesis (1).

The unique celiac disease epidemic among children younger than 2 years in Sweden in the 1980s showed that the timing of the introduction of gluten into the diet, as well as the pattern of breast-feeding, may influence the subsequent development of celiac disease (2). It has been further hypothesized that it may be possible to induce tolerance to gluten and thereby reduce the risk of celiac disease by introducing small quantities of gluten to breast-fed infants (2,3). The infancy period seems to be important for the development of the immune system and the discrimination between tolerance and intolerance of specific nutritional antigens. The attractive hypothesis on the effects of gluten is being tested in several follow-up studies (NCT00617838, NCT00819819, NCT00639444 and Research has thus far focused on the infancy period; however, without doubt, nutritional and other environmental factors may contribute to the development of celiac disease throughout the life span (1). Long-term follow-ups of cohorts of infants from studies above have been initiated. It takes time to learn how gluten consumption influences the natural history of celiac disease. Because a gluten-free diet can be introduced for reasons other than celiac disease, it is important that daily gluten consumption is confirmed when the natural history of celiac disease is studied.

In this issue of JPGN, a new tool, FQ-gluten4, to measure daily gluten consumption in 1- to 4-year-old children is introduced (4). Despite minor inaccuracies, this food frequency questionnaire (FFQ) performed reasonably well when results were compared with the criterion standard 2-day food record (FR).

The self-administered FFQs are designed to collect dietary information from large numbers of individuals (5). Although it is difficult to calculate absolute nutrient intakes from FFQs, these questionnaires are useful for gathering information on groups and for looking at the habitual intake of various foods. Moreover, FFQs are more easily administered and less time consuming than the criterion standard FR; however, results often show a tendency to overreport healthy foods such as whole-meal bread and vegetables in FFQs compared with FRs. Because FFQs seem to be able to identify adequately low and high consumers, for cost and feasibility reasons, these questionnaires are favored over traditional FRs in large epidemiological studies even if they provide cruder information (5).

FQ-gluten4 is clearly needed in celiac disease research because it provides an opportunity to study relations between disease-inducing gluten intake and development of the disorder in large population series in different countries.

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1. Abadie V, Sollid LM, Barreiro LB, et al. Integration of genetic and immunological insights into a model of celiac disease pathogenesis. Annu Rev Immunol 2011; 29:493–525.

2. Olsson C, Hernell O, Hörnell A, et al. Difference in celiac disease risk between Swedish birth cohorts suggests an opportunity for primary prevention. Pediatrics 2008; 122:528–534.

3. Norris JM, Barriga K, Hoffenberg EJ, et al. Risk of celiac disease autoimmunity and timing of gluten introduction in the diet of infants at increased risk of disease. JAMA 2005; 293:2343–2351.

4. Hopman EGD, Pruijn R, Tabben EH, et al. Food questionnaire for the assessment of gluten intake by children 1 to 4 years old. J Pediatr Gastroenterol Nutr 2012;54:791–6.

5. Deschamps V, de Lauzon-Guillain B, Lafay L, et al. Reproducibility and relative validity of a food-frequency questionnaire among French adults and adolescents. Eur J Clin Nutr 2009; 63:282–291.

Copyright 2012 by ESPGHAN and NASPGHAN


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