Systematic review: tolerable amount of gluten for people with coeliac disease.

BACKGROUND: The threshold amount of gluten in 'gluten-free' products that can be tolerated by people with coeliac disease is unclear.

AIM: To investigate the threshold amount of gluten and the threshold concentration of gluten in food products that can be tolerated by people with coeliac disease.

DESIGN: Systematic review of studies published between 1966 and May 2007.

METHODS: The data sources used were MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL, and reference lists of retrieved articles. We included studies that evaluated the amount of dietary gluten or the concentrations of gluten in food products that can be tolerated by people with coeliac disease whatever their design, method or language of publication.

RESULTS: Thirteen studies (three randomized controlled, one cohort, two crossover, and seven cross-sectional) met the inclusion criteria. The daily amount of tolerable gluten varied widely between studies. Whilst some patients tolerated an average of 34-36 mg of gluten per day, other patients who consumed about 10 mg of gluten per day developed mucosal abnormalities. The effect of the consumption of 'gluten-free' products with different degrees of gluten contamination was also inconsistent.

CONCLUSIONS: The amount of tolerable gluten varies among people with coeliac disease. Although there is no evidence to suggest a single definitive threshold, a daily gluten intake of <10 mg is unlikely to cause significant histological abnormalities.