Gluten-free guide lifts diet quality for children but lasting change needs support

A Canadian study reveals that while a new Gluten-Free Food Guide can help children with celiac disease eat healthier in the short term, maintaining those improvements requires continuous guidance and nutrition education.

Study: A Gluten Free Food Guide Used in Diet Education to Improve Diet Quality in Children with Newly Diagnosed Celiac Disease: A Pilot Randomized Control Trial. Image Credit: Galigrafiya / Shutterstock

In a recent article in the British Journal of Nutrition, researchers evaluated the effectiveness of a novel Gluten-Free Food Guide (GFFG) in reducing children’s consumption of ultra-processed foods (UPFs) and improving their dietary quality after a diagnosis of celiac disease.

They found that after three months of dietary counselling according to the GFFG, children had higher total, adequacy, and variety scores on the Healthy Eating Index–Canadian (HEI-C), along with greater dietary variety and higher intake of unsweetened milk and dairy than those in the control group, although these improvements were short-lived and not sustained at six months.

Nutritional Challenges in Pediatric Celiac Disease

Celiac disease affects up to 1% of the population. This chronic autoimmune condition requires a lifelong gluten-free diet. Many gluten-free commercial products are high in fat and sugar but low in micronutrients and fiber, making it difficult to maintain a nutritious diet.

Processed Gluten-Free Foods and Health Risks

Children with celiac disease often struggle with poor dietary quality. More than half of their energy comes from processed gluten-free foods, placing them at risk of metabolic conditions and nutrient deficiencies.

Barriers to Nutrition Literacy and Balanced Diets

Managing celiac disease effectively requires strong nutrition literacy among both parents and children. However, online information is often inconsistent and misleading, and limited access to registered dietitians can lead to an incomplete understanding of the condition. Nutrition education also tends to focus narrowly on gluten avoidance rather than overall nutritional balance.

Research Design: Evaluating the GFFG Intervention

Researchers evaluated whether counselling using the newly designed GFFG, which promotes a balanced, nutritious gluten-free diet, could improve dietary quality and reduce ultra-processed food intake in children newly diagnosed with celiac disease.

They conducted a randomized controlled trial (RCT) from 2021 to 2023 at two Canadian pediatric gastroenterology clinics. Forty children (ages 4–18) and their parents were randomly assigned to either a control group (standard dietary care) or an intervention group (standard care plus GFFG counselling). Standard care included virtual education by a registered dietitian on gluten avoidance, prevention of cross-contamination, and balanced eating according to the 2019 Canada’s Food Guide.

GFFG Counselling and Assessment Methods

The intervention group received an additional 45–60-minute virtual session using the evidence-based GFFG. The guide’s plate model recommends more than 50% fruits and vegetables, 25% protein, less than 25% gluten-free grains, and fortified unsweetened milk or plant-based beverages. Individualized feedback was provided based on each child’s three-day food record.

Dietary quality was assessed using the Healthy Eating Index–Canadian (HEI-C) total and adequacy scores, and processed food intake was measured via the NOVA classification system. Other outcomes included adherence to GFFG plate recommendations, Mediterranean diet score, inflammatory diet score, adherence to a gluten-free diet, and parent nutrition literacy. Data were collected at baseline, three months, and six months using repeated-measures ANOVA and chi-square tests.

Short-Term Gains and Long-Term Challenges

Out of 83 children screened, 36 child–parent pairs completed the six-month study. Baseline characteristics were similar between groups. Both groups showed improvement in gastrointestinal symptoms, ferritin levels, and serum anti-tissue transglutaminase levels.

Children receiving GFFG education showed significant increases in total HEI-C, adequacy, and variety scores at three months, as well as greater unsweetened milk intake; however, these benefits were not sustained at six months. The control group showed a short-term rise in processed (NOVA 3) foods, whereas this was not observed in the intervention group. Total diet quality and intake of ultra-processed foods did not differ significantly between groups over time.

Children under 10 generally had better diet quality, variety, and adherence to a gluten-free diet (97% vs 73%). Fiber and vitamin A intake were higher in the intervention group, though not statistically significant. Grain and dairy servings also rose between three and six months post-counselling. However, most children still failed to meet fruit and vegetable targets, and more than half of total energy continued to come from ultra-processed foods.

Adherence to the gluten-free diet remained high (>85%) in both groups. Parental nutrition literacy was strong but unchanged. The control group showed poorer adherence to the Mediterranean diet at six months, while the intervention group’s scores remained stable. No significant differences were found in dietary inflammation or quality of life.

Conclusions: Sustaining Diet Quality Beyond the Pilot

This pilot RCT found that a single GFFG-based counselling session improved short-term total diet quality, adequacy, dietary variety, unsweetened milk intake, and some nutrient intakes (fiber and vitamin A) in children newly diagnosed with celiac disease. However, these effects were not sustained over six months due to ongoing reliance on processed gluten-free foods, low intake of fruits and vegetables, and barriers such as food cost.

The study’s strengths include its randomized design and focus on newly diagnosed children. Limitations include a small and homogeneous sample, a short follow-up period, and reliance on self-reported data.

Overall, while GFFG counselling produced immediate benefits, lasting improvements likely require ongoing, dietitian-led education and support. Future interventions should include multiple sessions, address food affordability and access, and explore family motivation and environmental influences to enhance long-term impact.