The gluten-free guide improves the quality of children’s diets, but lasting change requires support

In a recent article in British Nutrition Journalresearchers assessed the effectiveness of the new Gluten-Free Food Guide (GFFG) in reducing children’s consumption of ultra-processed foods (UPF) and improving the quality of their diet after being diagnosed with celiac disease.

They found that after three months of GFFG dietary counseling, children had higher total, adequacy and variety scores on the Canadian Healthy Eating Index (HI-C), along with greater dietary diversity and greater consumption of unsweetened milk and dairy products than the control group, although these improvements were short-lived and did not last for six months.

Nutritional challenges in celiac disease in children

Celiac disease affects up to 1% of the population. This chronic autoimmune disease requires a lifelong gluten-free diet. Many commercial gluten-free 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 an inadequate diet. More than half of their energy comes from processed gluten-free foods, which puts them at risk of metabolic disorders and nutrient deficiencies.

Barriers to nutrition skills and a balanced diet

Effective treatment of celiac disease requires extensive nutritional knowledge among both parents and children. However, information available online is often inconsistent and misleading, and limited access to registered dietitians can lead to an incomplete understanding of the disease. Nutrition education also focuses on gluten avoidance rather than overall nutritional balance.

Research design: evaluation of the GFFG intervention

Researchers assessed whether counseling using a newly designed GFFG that promotes a balanced, nutritious gluten-free diet could improve diet quality and reduce the consumption of ultra-processed foods in children newly diagnosed with celiac disease.

They conducted a randomized, controlled trial (RCT) from 2021 to 2023 in two Canadian pediatric gastroenterology clinics. Forty children (aged 4–18 years) and their parents were randomly assigned to a control group (standard dietary care) or an intervention group (standard care plus GFFG counseling). Standard care included virtual education led by a registered dietitian on avoiding gluten, preventing cross-contamination and eating sustainably according to Canada’s 2019 Food Guide.

GFFG counseling 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% fruit and vegetables, 25% protein, less than 25% gluten-free grains, and fortified unsweetened milk or plant-based drinks. Individualized feedback was provided based on each child’s three-day menu.

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

Short-term gains and long-term challenges

Of the 83 children studied, 36 child-parent pairs completed the six-month study. Baseline characteristics were similar in both groups. Both groups showed improvement in gastrointestinal symptoms, ferritin levels, and serum tissue transglutaminase levels.

Overall, children receiving GFFG education showed significant growth HI-Cadequacy and variety after three months, as well as greater consumption of unsweetened milk; however, these benefits were not maintained after six months. The control group showed a short-term increase in processed food consumption (NOVA 3) food, which was not observed in the intervention group. Total diet quality and consumption of ultra-processed foods did not differ significantly between groups over time.

Children under 10 years of age generally had better gluten-free diet quality, variety and adherence (97% vs. 73%). Fiber and vitamin A intake were higher in the intervention group, although statistically insignificant. Portions of grains and dairy products also increased in the three to six months after the counseling ended. However, most children still did not meet their fruit and vegetable targets, and more than half of their total energy still came from ultra-processed foods.

In both groups, adherence to the gluten-free diet remained high (>85%). Parents’ knowledge of nutritional principles was high but unchanged. The control group showed poorer adherence to the Mediterranean diet after six months, while the intervention group’s results remained stable. No significant differences in diet were found inflammation or quality of life.

Conclusions: Maintaining diet quality beyond the pilot stage

This pilot RCT found that a single GFFG-based counseling session improved the short-term quality, adequacy, dietary diversity, intake of unsweetened milk, and certain nutrients (fiber and vitamin A) in children with newly diagnosed celiac disease. However, these effects did not last for six months due to continued reliance on processed gluten-free foods, low fruit and vegetable intake, and barriers such as the cost of food.

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

Overall, although GFFG counseling provided immediate benefits, lasting improvement likely requires ongoing education and support from a dietitian. Future interventions should include multiple sessions, address affordability and food access, and examine family motivation and environmental influences to increase long-term impact.