Quantity of dietary gluten during infancy as a risk factor for coeliac disease has mainly been investigated by means of international ecological studies. Thus, several countries have been compared with respect to estimated gluten intake in healthy infants and the incidence of the disease.41-43 A higher intake of wheat gluten was reported for infants in Sweden and Italy, compared to Finland, Denmark and Estonia. Further, the first mentioned countries reported a higher occurrence ofcoeliac disease than the latter. A report from the Netherlands contradicted this; in spite of a comparatively high intake of dietary gluten the incidence of symptomatic coeliac disease was low.44 However, a recent screening study revealed that the disease is much more common than previously recognised.10 Thus, it seems that the Netherlands can also be included among those countries in which a comparison using an ecological approach supports the importance of a larger quantity of dietary gluten as a risk factor for coeliac disease.
The Swedish case-referent study by Falth-Magnusson etal found that the cases were introduced to gluten-containing food by bottle more often than the referents, which presumably contributed a larger amount of gluten.35 Further, the findings in our case-referent study also support larger amounts of gluten as a risk factor for the disease, irrespective of type of food, i.e. gluten-containing follow-on formula or other foods (to be published).
Moreover, clinical experimental design has also been used as an approach to this question by giving individuals a certain amount of dietary gluten and following the possible effect on the small intestinal mucosa. This has been done in adult volunteers, patients with dermatitis herpetiformis,45 and in children with diagnosed coeliac disease and treated with a gluten free diet.46 All these studies reported a dose-related effect on the small intestinal mucosa.
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