Amount May Beat Timing: Gluten Intake and Risk of Childhood Celiac Disease.

In the current issue of Clinical Gastroenterology and Hepatology, Aronsson et al from The Environmental Determinants of Diabetes in the Young (TEDDY) study group explore the relationship between gluten intake and risk of celiac disease (CD) in genetically atrisk children. Although the data in this nested casecontrol study originated from Sweden where the rate of CD is highest, the TEDDY study group has its scientific center in Florida, and a novel by one of that state’s most famous authors may serve as an introduction to this article. In Ernest Hemingway’s book The Sun Also Rises, two of the main characters, Bill and Mike, discuss financial matters, and Bill asks: “How did you go bankrupt?”, and Mike answers, “Two ways. Gradually, then suddenly.” This article shows that even if you introduce gluten gradually into an infant’s diet, the child can still develop CD suddenly. Children with early diagnosed CD had a lower gluten consumption at 6 months of age than controls (albeit nonsignificant), but children with CD consumed larger amounts of gluten later at the age of 1–2 years than genetically predisposed children who did not subsequently develop the disease. Because of the abundant previous literature on infant feeding and other risk factors, what does this article add? It actually adds a lot. In recent years, prospective cohort studies and 2 randomized clinical trials have shown that age at gluten introduction and breastfeeding duration may be less important for the risk of developing CD (at least in childhood) than previously thought. However, no earlier study has used prospectively collected data to investigate the range of gluten quantity in early infant nutrition and risk of CD. Aronsson et al analyzed a subset of the prospective cohort TEDDY study, matching 146 Swedish children with CD with 436 controls. The authors found that for each additional gram of gluten consumed per day before tissue transglutaminase seroconversion, the risk of future CD increased by 28%. They also found that