Gluten-Free Diet: Nutritional Strategies to Improve Eating Habits in Children with Celiac Disease: A Prospective, Single-arm Intervention Study

Abstract

Background: Elimination of gluten-containing cereals and consumption of ultra-processed gluten-free foods might cause an unbalanced diet, deficient in fiber and rich in sugar and fat, circumstances that may predispose celiac children to chronic constipation.

Aim: to evaluate if counseling with a registered dietitian (RD) was capable of improving eating and bowel habits in a celiac pediatric population.

Methods: Dietetic, lipid profile and stool modifications were analyzed, comparing baseline assessments with those twelve months after receiving heathy eating and nutrition education sessions. At both time points, 3-day food records, a bowel habit record and a lipid panel were conducted. Calculated relative intake of macro- and micro-nutrients were compared with current recommendations by the European Food Safety Authority (EFSA). Student's paired t-test, McNemar test, Mandasky test and Pearson correlation tests were used.

Results: Seventy-two subjects (58.3% girls) with a mean (standard deviation (SD)) age of 10.2 (3.4) years were included. Baseline diets were imbalanced in macronutrient composition. Significant improvements were observed in their compliance with dietary reference values (DRVs), where 50% of the subjects met fat requirements after the education and 67% and 49% with those of carbohydrates and fiber, respectively (p < 0.001). Celiac children decreased red meat and ultra-processed foods consumption (p < 0.001) and increased fruits and vegetables intake (p < 0.001), leading to a reduction in saturated fat (p < 0.001) and sugar intake (p < 0.001). Furthermore, 92% of the patients achieved a normal bowel habit, including absence of hard stools in 80% of children constipated at baseline (p < 0.001).

Conclusions: RD-led nutrition education is able to improve eating patterns in children with celiac disease (CD).

Keywords: dietary therapy; dietitian; gluten-free diet; healthy eating; nutritional management.

Figure 1

Percentage of celiac disease (CD) pediatric patients’ compliance with the recommendations for fats, carbohydrates (expressed in percentage) and fiber (expressed in g/day) intake, from baseline (inclusion) to twelve months after nutrition education (follow-up).

Figure 2

Percentage of celiac children’s compliance with the recommendations for minerals intake, from baseline (inclusion) to twelve months after nutrition education (follow-up).

Figure 3

Percentage of celiac children’s compliance with the recommendations for vitamins intake, from baseline (inclusion) to twelve months after nutrition education (follow-up).

Figure 4

Comparison of the relative intake of animal-based whole foods: grams of poultry meat, red meat, white fish, oily fish, eggs, whole milk, semi-skimmed milk, skimmed milk, plain yogurt, low-fat yogurt, strong cheese, soft cheese per day consumed by 72 CD pediatric individuals at baseline (inclusion) and after nutrition intervention (follow-up).

Figure 5

Comparison of the relative consumption of ultra-processed products: grams of processed meat, sugary yogurt, sugared dairy desserts, processed cheese, pastries, biscuits, sweets, savory snacks, sugary cocoa powder, bottles juices, soft drinks and sauces per day consumed by 72 CD pediatric individuals at baseline (inclusion) and after nutrition intervention (follow-up).

Figure 6

Comparison of the relative consumption of plant-based foods: grams of fruit, vegetables, salad, legumes and nuts per day consumed by 72 CD pediatric individuals at baseline (inclusion) and after nutrition education (follow-up).

Figure 7

Comparison of the relative consumption of tubers and cereals: grams of potato, white rice, brown rice, white pasta, wheat bread and homemade dough per day consumed by 72 CD pediatric individuals at baseline (inclusion) and after nutrition intervention (follow-up).

Figure 8

Type of stool data of 72 CD pediatric individuals referred from the baseline (inclusion) and after six (follow-up) and twelve months after the intervention (final).