An easy-to-use instrument to quantify the gluten consumption of young children up to 4 years of age was lacking. Therefore, we developed such an instrument: the FQ-gluten4. To our knowledge, we present here the first questionnaire to assess the gluten consumption by children 1 to 4 years old. We have validated this FQ-gluten4 by using an accepted method for food consumption studies as a reference: a 2-day FR.
Overall, results show that the FQ-gluten4 compared with the FR method gives similar results in detecting the mean amount of daily gluten consumption, but that the FQ-gluten4 detects a significantly lower amount of gluten intake in 1- to 2-year-old children and a significant lower percentage of gluten from porridge among 1- to 3-year olds.
A possible explanation for these differences is that we compared a 7-day method (FQ-gluten4) to a 2-day method (FR). For example, the youngest-age children had relatively high gluten consumption on the 2 days the FR was filled in caused by eating pancakes or pasta as their warm meal, whereas the FQ-gluten4 only reported that pasta or pancakes were eaten by the children once or twice per week. In averaging these amounts over 7 days, as the FQ-gluten4 does, it will lead to a lower gluten intake from pasta and pancakes. Furthermore, a higher number of slices of bread were consumed according to the FR compared with the number of slices of bread filled in the FQ-gluten4. This caused differences of 2000 to 6000 mg of gluten per day. The Bland-Altman limits of agreement with an SD of 2600 mg were −5118 to 5630 mg. This means that for individual cases, the difference is large, but considering that variances in consumption of basic food products such as bread in young childrens’ daily food intake are common (7), these differences can be acceptable. To illustrate this, a difference in the intake of 1 slice of bread or 1 pancake will lead to a difference in gluten consumption of about 2500 or 2800 mg of gluten, respectively. Had we asked the parents to fill in a 7-day FR, the higher gluten intake on the 2 days would have been averaged with the other 5 days to a lower mean and would probably be more consistent with the results of the FQ-gluten4. A 2-day FR, however, is an accepted method used in food consumption studies because it gives good enough information on the variety of the food products that these young children consume (7,8) and is of lesser burden on the parents than a 7-day FR. Seemingly, in cases in which the nutrient of interest is gluten and in the age category of 1 to 4 years, the 2-day FR is less suitable. For that reason, a 7-day method such as the FQ-gluten4 will be more representative than the 2-day FR specific for gluten intake, averaging it to a mean daily gluten intake but not overestimating the amount of gluten consumption.
Another possible explanation may be that this is the first test of validity. We did not pretest this FQ-gluten4 to rule out possible shortcomings.
For practical reasons, the inclusion period for the study was only 3 months. In that period, 75 parents of healthy young children agreed to participate. The total number of invited parents was not registered because the present study was aimed to validate an FQ on gluten intake against the widely used FR and not aimed to study the representativity of the study population. For that reason we did not register information on the social status or the age of the participating parents. We do not believe that representativity is an issue because the comparison between the FQ and FR is independent of the social status and of the representativity of the population. The number of participating children in the 3 age categories was rather small; however, groups were large enough to detect significant differences in the 1- to 2- and 2- to 3-year-old children.
The previously developed FQ-gluten for quantification of gluten intake by infants 0 to 12 months old (4) was based on the Dutch eating pattern, with specific Dutch brand names; it was suitable to be used only in the Dutch population. On the contrary, this FQ-gluten has been adapted in other countries to the eating patterns and food products used by their young children through obtaining information on the food products and brand names used from food consumption studies. Afterwards, the FQs were validated using a 2-day FR, and are now being used in a multinational study, the PreventCD study (www.preventcd.com) (3). The newly developed and validated FQ-gluten4 can be adapted by researchers in other countries following the same procedure. Where food consumption studies are not available, a possible way to obtain the necessary information is by using a FR for a basis inquiry among young children. From these results an FQ-gluten can be composed and validated.
Another application for the new FQ-gluten4 can be in quantifying the gluten intake in children suspected to have celiac disease, but with dubious specific celiac antibodies or with mild histological changes in small bowel biopsy samples, under which circumstances the diagnosis cannot be confirmed. One possible reason for these results may be a lower-than-normal gluten intake, for example, in children living in families with patients with celiac disease. Using this FQ-gluten4 for this purpose can give an indication of the average daily gluten intake by the child.
An advantage of a preprinted FQ above the use of a FR is that it can be easily computerized, is less burdensome for the patient or the parent, and may generate an outcome in a short time that can be helpful in consultation with his or her doctor.
In conclusion, the new, short, standardized, validated, and easy-to-use FQ-gluten4 may be a useful instrument to assess gluten intake in individual children 1 to 4 years old suspected of having CD to assess gluten consumption and, at the population level, for study purposes. The use of this standardized method by investigators in different countries will provide opportunities for better comparisons of the results of gluten consumption throughout the world.
We thank PreventCD for their request to develop the FQ-gluten4 and providing the opportunity to use the PROMISE computerized database.
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Keywords:Copyright 2012 by ESPGHAN and NASPGHAN
assessment; children; food questionnaire; gluten intake