The development of a composition database of gluten-free products

Nutritional Composition of Breakfast in Children and Adolescents with and without Celiac Disease in Spain-Role of Gluten-Free Commercial Products

Eating a nutritionally balanced breakfast can be a challenge when following a gluten-free diet (GFD). We assessed the ingredients and nutrient composition of 364 gluten-free breakfast products (GFPs) and 348 gluten-containing counterparts (GCCs), and we analysed the nutritional quality of breakfast in a group of Spanish children and adolescents with celiac disease (CD) (n = 70), as compared to controls (n = 67). Food intakes were estimated using three 24 h dietary records. The composition of GFPs and GCCs was retrieved from the package labels of commercially available products. Most participants (98.5%) ate breakfast daily, and only one person in each group skipped breakfast once. The breakfast contribution of the total daily energy was 19% in participants with CD and 20% in controls. CD patients managed a balanced breakfast in terms of energy (54% from carbohydrates; 12% from proteins; 34% from lipids) and key food groups (cereals, dairy, fruits), but their intake of fruits needs improvement. Compared to controls, breakfast in the CD group provided less protein and saturated fat, a similar amount of carbohydrates and fibre, and more salt. Fibre is frequently added to GFPs, but these contain less protein because of the flours used in formulation. Gluten-free bread contains more fat and is more saturated than is GCC. Sugars, sweets, and confectionery contribute more to energy and nutrient intakes in participants with CD, while grain products do so in controls. Overall, breakfast on a GFD can be adequate, but can be improved by GFPs reformulation and a lower consumption of processed foods.

Gluten-Free Products: Do We Need to Update Our Knowledge?

The gluten-free (GF) food market has been growing exponentially in recent years. However, GF products could contribute to imbalanced diets. The main objective of the present work was to perform a temporal nutritional comparison of GF foods over the last nine years. At the same time, the nutritional compositions of 104 GF products currently marketed in Spain were assessed and compared with their gluten-containing counterparts. Diets including GF products and the equivalent diets with homologous products with gluten were compared as well, the subjects being 25 adult celiac patients. A comparison of GF products (GFPs) in 2013 and 2022 showed nutritional differences in the groups of cookies, breakfast cereals, doughs/puff pastries/pizzas, and breads. The pasta group stands out from the rest due to an important decrease in energy, protein, simple carbohydrates, saturated lipids, dietary fiber, and salt. Comparing GF and gluten-containing homologous products in 2022, the major differences were found in protein and salt. Accordingly, GFPs lead to a diet lower in protein and higher in carbohydrates. Despite improvements in the formulation of GF products in recent years, their macronutrient profile maintains marked variation, and they cannot be considered nutritionally equivalent to their gluten-containing counterparts.

The Update of the Italian Food Composition Database of Gluten-Free Products and Its Application in Food-Based Dietary Guidelines Menus

Complete food composition databases (FCDBs) on gluten-free (GF) foods are needed to assess the nutrient intakes of celiac disease patients. The aim of the present work was to update the previously developed version of the Italian GF-FCDB and to apply it to a theoretical GF diet. The updated GF-FCDB includes the composition of 108 GF cereal-based foods, as sold, in terms of energy and macro- and micro-nutrients, imputed using food label information combined with the standard recipe approach. Three scenarios (i.e., refined, mixed, and wholegrain cereals) of the weekly guideline menu for the general Italian population were analyzed for energy and nutrient content in a theoretical dietary assessment using traditional gluten-containing (GC) foods and the corresponding GF substitutes. All GF menus were higher than the corresponding GC menus in polyunsaturated fatty acids, linoleic acid, and vitamin E. Zinc was lower in GF than in GC menus only in the wholegrain-cereal scenario. Thanks to the application of the updated GF-FCDB including a comprehensive list of micronutrients, we observed that it is possible for celiac disease patients to meet nutrient requirements by simply substituting GC with GF cereal-based products following recommendations for the general population.

Development of a Canadian Food Composition Database of Gluten-Free Products

Country-specific food composition data are needed for gluten-free (GF) food products to assess nutritional adequacy and diet quality. This research aimed to develop a comprehensive GF food composition database for key GF foods consumed in Canada. Average nutrient data from 167 products were estimated from Nutrition Fact Panel labels and the commercial ingredient list, using an iterative and systematic approach. The database reports mean values for energy and 29 nutrients per 100 g for 33 GF commercial grain-based foods. Nutrient values were evaluated with Health Canada’s nutrient content claims per standard reference serving. On average, GF products were, at minimum, a source of thiamin (73%), riboflavin (70%), niacin (58%), iron (58%), fibre (55%), magnesium (48%), folate (36%), zinc (19%), and calcium (15%). Most GF products were low in saturated fat (85%) and cholesterol (64%) but only 15% were low in total fat and 6% were free of sugar. Micronutrient enrichment and the use of nutrient-dense whole grain flours, legume flours, oil seed husks, and functional fibre ingredients varied within and between categories and brands but appeared to contribute to nutrient content. This database provides a new tool to enhance GF diet assessment in individuals or populations in Canada.

Gluten-free foods: a 'health halo' too far for oral health?

Background Over the past decade, the rise of consumers following a gluten-free diet has increased greatly. The majority of people following a gluten-free diet have not been diagnosed with coeliac disease or gluten or wheat intolerance but believe it to be a health benefit.Aim To assess the differences between gluten-free and gluten-containing products with regards to the implications this might have on oral (and wider) health.Method In total, 50 purposively selected products (25 gluten-free and gluten-containing pairs) available to UK consumers, classified using the UK National Diet and Nutrition Survey food categories, were analysed using content analysis of food packaging. The European Union front-of-pack labelling system revealed the nutritional composition of each product, focusing on carbohydrates, sugars and energy. Cost and use of emotive language to market products was also assessed.Results A nutritional comparison of the 25 product pairings found that, on average, all gluten-free products contained more calories, total carbohydrates and total sugar. The majority of the gluten-free products were classified as 'confectionary' or 'baked goods,' emphasising that products primarily consisted of foods high in sugar. The average sugar per 100 g for each category of food ranged from 2.5-37.0 g/100 g (gluten-free) compared to 2.1-30 g/100 g (gluten-containing). All gluten-free products were considerably more expensive when compared with the conventional version; the average price difference ranged from £0.08 to £4.40.Conclusion This study emphasises the 'health halo' phenomena, where foods for special diets are regarded by consumers as healthy when in fact they are not. This results partly from the products being mainly high-sugar 'treats', which are not a core of the UK Eatwell Guide food-based dietary guidelines. As many people consuming gluten-free products in the UK do not need them from a medical perspective, this could have implications for oral and wider health. It is important that members of the dental team are aware of the possible implications of a gluten-free diet where it is not medically indicated, coupled with reliance on convenience foods.

Calcium and Iron Content of Cereal-Based Gluten-Free Products

The impact of a gluten-free (GF) diet on the intake of calcium and iron is broadly unknown, as the micronutrient content of GF cereal-based products has scarcely been measured. The study aimed to measure the calcium and iron content of GF cereal-based products from the UK. Seventy-three GF products were analysed. A laboratory analysis of calcium and iron from GF food samples was performed by spectrophotometric and flame emission photometry, respectively. The values for wheat-based products were from a nutrient database. The calcium in GF white loaf samples varied greatly from 54 to 140 mg/100 g, with a lower average calcium content compared with wheat-based values (99 ± 29 mg/100 g n = 13 versus 177 mg/100 g; p < 0.01). Only 27% of the white loaves and rolls were fortified with calcium; this contrasts with 100% of white wheat-based loaves. The calcium in GF flour mixes ranged from 54 to 414 mg/100 g, with 66% fortified. GF white pasta had more calcium compared with wheat-based pasta (76 ± 27 mg/100 g n = 7 versus 24 mg/100 g; p = 0.002). The iron in GF bread loaves and pasta samples was similar to wheat-based comparators, whereas lower iron levels were observed in GF wraps (0.8 ± 0.2 n = 11 versus 1.6 mg/100 g). GF bread had a significantly higher fibre content, and the majority of GF bread had a lower protein content, compared with wheat-based bread products. These calcium and iron values provide a valuable addition towards enabling more accurate nutrient intake analysis for adults and children with coeliac disease.

Gluten-free bakery products: Ingredients and processes

There is an increasing demand for gluten-free products around the world because certain groups of people, which have increased in the last decades, need to eliminate gluten from their diet. A growing number of people consider gluten-free products to be healthier. However, making gluten-free products such as bread is a technological challenge due to the important role of the gluten network in their development. However, other products, such as cakes and cookies usually made with wheat flour, can easily be made with gluten-free starches or flours since gluten does not play an essential role in their production. To replace wheat flour in these elaborations it is necessary to resort to gluten-free starches and/or flours and to gluten substitutes. Additionally, it can be convenient to incorporate other ingredients such as proteins, fibers, sugars or oils, as well as to modify their quantities in wheat flour formulations. Regarding gluten-free flours, it will also be necessary to know the parameters that influence their functionality in order to obtain regular products. These problems have originated a lower availability of gluten-free products which have a worse texture and are less tasty and more expensive than their homologues with gluten. These problems have been partially solved thanks to research on these types of products, their ingredients and their production methods. In recent years, studies about the nutritional improvement of these products have increased. This chapter delves into the main ingredients used in the production of gluten-free products, the processes for making gluten-free breads, cakes and cookies, and the nutritional quality of these products.

A comparison of the nutritional profile and price of gluten-free products and their gluten-containing counterparts available in the Spanish market

Introduction

Background: to date, gluten-free (GF) diet is the only treatment available for individuals with celiac disease. Both individual and collective food intake assessments are a challenge because a food composition database of GF products (GFPs) is lacking. Objectives: to describe the process of developing a food composition database of GFPs, and to compare the nutritional profile and price of some GFPs and non-GFPs. Methods: initially, a total of 216 brands of GFPs marketed in Spain were recorded. Nutritional information was collected from nutritional labels and product fact sheets that had been provided by food companies or collected first-hand by researchers. Then, the nutritional profile and price of the cereal and cereal byproducts foodstuff groups, including 19 types of products, were compared. Statistical analyses were performed using the SPSS statistical program (22.0 edition; SPSS, Chicago, IL, USA). Results: a total of 2,247 GFPs from 126 different foodstuff brands were included in the food composition database of GFPs (CELIAC-BASE). We classified these products into 14 foodstuff groups. The protein content of the GFPs studied was significantly lower, and the price was higher, than that of their non-GFP counterparts. Some, but not all, GFPs had a higher content of fat and sugar, and a lower content of dietary fiber as compared to their non-GFP counterparts. Some GFPs were up to 6 times more expensive than the corresponding non-GFPs. Conclusions: CELIAC-BASE is a pioneering tool for dietitians. Many GFPs have poor nutritional profiles and should be consumed only occasionally in a balanced GF diet.

Nutritional facts regarding commercially available gluten-free bread worldwide: Recent advances and future challenges

Recently, there has been an increase in demand for gluten-free (GF) products due to the growing number of gluten-intolerant and healthy individuals choosing to follow a gluten-free diet. Gluten-free bread (GFB) is a staple food product; therefore, many recent studies have reported the nutritional properties of GFB. However, an overview of the current ingredients and nutritional labeling of GFB worldwide has not yet been provided. This review aimed to gather the latest information regarding the most used ingredients in GFB formulations and the nutritional quality of these products from different countries, based on studies published in the last decade (2010-2020). Our analysis showed that GFB had a lower protein and a higher fat content than gluten-containing bread, and the dietary fiber content was highly variable between countries. Some studies have revealed a high glycaemic index in most products, which is associated with the extensive use of rice flour and starch as the main ingredients in GFB formulation. Label information presented significant differences from the data obtained through the chemical analysis of fiber and other nutritional components. Micronutrient fortification is not common in the GFB. The nutritional quality of commercial GFB is a crucial issue that needs to be addressed.

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

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).

Influence of nutrition education in paediatric coeliac disease: impact of the role of the registered dietitian: a prospective, single-arm intervention study

BACKGROUND

The diagnosis of coeliac disease (CD) involves a change in the diet of the individual, which may influence their quality of life and nutritional status. The present study aimed to determine whether nutrition education by a registered dietitian is able to improve eating habits and body composition in children with CD.

METHODS

Dietary, physical activity and body composition changes were analysed, comparing baseline assessments with those 1 year after receiving education on healthy eating. At both time points, a 3-day dietary survey, a food frequency consumption questionnaire, an adherence to the Mediterranean diet test (Kidmed), duration of activity and an electrical bioimpedance study were conducted. Student's paired t-test and the McNemar test were also employed.

RESULTS

Seventy-two subjects (42 girls) with an mean (range) age of 10 (2-16) years were included. Before the intervention, an unbalanced diet was observed, rich in protein and fat, and deficient in complex carbohydrates. Only 14% consumed an adequate Mediterranean diet. After nutrition intervention, a significant increase in the consumption of plant-based foods and a concomitant decrease in meat, dairy and processed food intake (P < 0.001) were observed. Moreover, 92% of the patients (P < 0.001) managed to consume an adequate Mediterranean diet. Similarly, an increase was observed in the duration of physical activity undertaken [mean (SD) 1.02 (1.79) h, P < 0.001] and improvements in body composition were recorded, with a 17% decrease in fat mass percentage (P < 0.001).

CONCLUSIONS

Nutrition intervention focused on healthy eating is effective with respect to improving the nutritional status and diet quality in CD patients.

Gluten Deprivation: What Nutritional Changes Are Found During the First Year in Newly Diagnosed Coeliac Children?

Aim: A gluten-free diet (GFD) can expose children to excessive calories and fat intake. The study is intended to verify whether and how food intake, laboratory parameters, and growth are modified by a year of GFD. Methods: In 79 CD (coeliac disease) children (mean age 7.9 ± 3.8 years, 52 females, 27 males) diagnosed over 24 months, 24-h food diaries, food-frequency patterns, anthropometric and laboratory parameters (mainly blood sugar, insulin, lipid profile, and homocysteine) were prospectively collected before and during the first year of GFD. Nutrient intakes were compared over time and with recommendations. They were also used as regressors to explain the levels and changes of metabolic and growth variables. p-values < 0.05 were considered statistically significant. Results: Average macronutrient intake did not change during the year. Caloric intake remained below 90% (p ≤ 0.0001) and protein intake above 200% (p ≤ 0.0001) of recommendations. Lipid intake was stable at 34% of overall energy intake. Unsaturated fats increased (less omega-6 and more omega-3 with a ratio improvement from 13.3 ± 5.5 to 8.8 ± 3.1) and so did fibers, while folate decreased. The children who experienced a containment in their caloric intake during the year, presented a slower catch-up growth. Some differences were found across gender and age groups. In particular, adolescents consumed less calories, and females more omega-3. Fiber and simple sugar intakes emerged as implicated in lipid profile shift: fibers negatively with triglycerides (TG) (p = 0.033), simple sugars negatively with high-density lipoprotein (HDL) (p = 0.056) and positively with TG (p = 0.004). Waist-to-height ratio was positively associated with homocysteine (p = 0.018) and Homeostasis Model Assessment (p = 0.001), negatively with fibers (p = 0.004). Conclusion: In the short run, GFD is nutritionally very similar to any diet with gluten, with some improvements in unsaturated fats and fiber intake. Along with simple sugars containment, this may offer CD patients the opportunity for a fresh start. Caloric intakes may shift and should be monitored, especially in adolescents.

Impact of FODMAP Content Restrictions on the Quality of Diet for Patients with Celiac Disease on a Gluten-Free Diet

Restrictive diets as gluten-free (GFD) or reduced in Fermentable, Oligosaccharides, Disaccharides, Monosaccharides, and Polyols (FODMAP) are used to improve gastrointestinal (GI) symptoms in sensitive individuals. Aiming at comparing the nutritional quality and effects of a regular GFD regimen (R-GFD) and a low-FODMAP GFD (LF-GFD), in 46 celiac patients with persistent GI symptoms we conducted a randomized, double-blind intervention-controlled study. Patients received a personalized diet, either a strict GFD (n = 21) or a LF-GFD (n = 25) for 21 days. A validated food-frequency questionnaire before intervention and a 7-day weighed-food record after the intervention assessed the diets. Patients were 41.1 ± 10.1 years (mean ± SD), 94% women, with mean BMI 21.8 ± 2.9 kg/m². On day 21, patients on R-GFD still showed poor nutritional adequacy compared to dietary recommendations, with decreased energy intake, even though an improvement in carbohydrates and folates was observed (all p < 0.025). In both groups, intake of iron, calcium, vitamin D, sodium and folates did not meet daily recommendations. As expected, consumption of legumes and grains was lower and that of fruits was higher in the LF-GFD group than in the R-GFD one (all p < 0.05). The nutritional quality of both diets was not different. When restrictive diets are useful to improve the persistent GI symptoms, careful nutritional surveillance and counseling is mandatory.

Micronutrient Analysis of Gluten-Free Products: Their Low Content Is Not Involved in Gluten-Free Diet Imbalance in a Cohort of Celiac Children and Adolescent

Data about the nutritional composition of gluten-free products (GFP) are still limited. Most studies are based on ingredient and nutrition information described on the food label. However, analytical determination is considered the gold standard for compositional analysis of food. Micronutrient analytical content differences were observed in a selection of GF breads, flakes and pasta, when compared with their respective gluten-containing counterparts. In general terms, lower iron, piridoxin, riboflavin, thiamin, niacin, folate, manganese and vitamin B5 can be underlined. Variations in biotin and vitamin E content differed among groups. In order to clarify the potential contribution of the GFP to the gluten-free diet's (GFD) micronutrient shortages, analytical data were used to evaluate GFD in a cohort of celiac children and adolescent. Participants did not reach recommendations for vitamin A, vitamin E, folic acid, vitamin D, biotin, iodine, and copper. It does not seem that the lower micronutrient content of the analyzed GFP groups contributed to the micronutrient deficits detected in GFD in this cohort, whose diet was not balanced. Nevertheless, GFP fortification for folate and biotin is proposed to prevent the deficiencies observed in GFD, at least in the case of pediatric celiac disease.

Gluten-Free Diet: Gaps and Needs for a Healthier Diet

The gluten-free diet (GFD) is currently the only effective treatment in remitting the symptoms of coeliac disease (CD), a chronic systemic autoimmune disorder caused by a permanent intolerance to gluten proteins in genetically susceptible individuals. The diet entails the substitution of gluten-containing products with gluten-free-rendered products. However, over recent decades the nutritional profile of gluten-free (GF) food products has been increasingly questioned within the scientific community. The aim of this paper is to review the nutritional profile of gluten-free-rendered products currently available on the market, and discuss the possible relationship thereof with the nutritional status of coeliac patients on a GFD. Key inadequacies of currently available GF products are low protein content and a high fat and salt content. More adequate levels of dietary fiber and sugar than in the past have been reported. Population studies confirmed the above mentioned inadequacies. Further efforts are required to conceive adoptable interventions for product development and reformulation in order to achieve compliance with nutritional recommendations.

Gluten-free diet in non-celiac patients: beliefs, truths, advantages and disadvantages

A gluten-free diet is the safest treatment for the treatment of patient with celiac disease (CD) and other gluten-related disorders. However, in the last years, gluten-free diet is one of the most popular diet followed by the general population and by patients affected from others clinical conditions, such as non-celiac gluten sensitivity (NCGS), irritable bowel syndrome (IBS), autism, neurological, psychiatric and rheumatologic diseases and for improving sports practice. This review highlights some questions about the appropriateness of following this trend answering to some questions such as how safe are the current gluten-free products, what are the benefits and side effects of gluten-free diet and what are clinical conditions that might benefit from gluten avoidance.

Nutritional composition of gluten-free food versus regular food sold in the Italian market

BACKGROUND

Some concerns have been raised about the nutritional composition of gluten-free (GF) food.

AIM

To compare the nutritional composition of GF food with regular foods.

METHODS

This study examined in total 235 GF products and 349 regular products purchased in Italy, from seven categories: biscuits, rusks, snacks, bread, pasta, bread substitutes and wheat flour. The following nutritional facts, have been considered: energy, proteins, total and saturated fats, carbohydrates, simple sugars, fibers and salt. The mean nutrient composition for products of the two groups was compared by independent samples t-test.

RESULTS

The protein content of GF food is lower in all the categories (P < 0.001). s. Total energy was lower for GF bread (P < 0.001) and higher for GF pasta (P = 0.05). GF biscuits and pasta had higher saturated fats content (P < 0.001 and P = 0.003). No difference was seen for total fat. Sugar content was lower for GF pasta (P < 0.001). Fiber content was lower in GF biscuits, bread substitutes (P < 0.001) and pasta (P = 0.02), higher in bread (P = 0.03). Salt content was higher in GF pasta (P < 0.001) and rusks (P = 0.04), lower in biscuits (P < 0.001).

CONCLUSIONS

There are some differences in the nutritional composition of GF food and regular food. These differences should be taken into account when planning a balanced GF diet.

Bread Enrichment with Oilseeds. A Review

The use of oilseeds in bakery products has gained popularity in recent years, both for their organoleptic and nutritional characteristics. The aim of this work is to provide an overview of the studies centered on the use of oilseeds (flaxseed, chia, sunflower, pumpkin, sesame and poppyseed) in breads and other bakery products. This review highlights the effect of oilseeds on the mechanical and physical properties of bread according to the enrichment level, origin and way of addition (whole, crushed, oil or mucilage). In general, the incorporation of oilseeds improves the nutritional profile of bakery products with and without gluten, and provides several health benefits. Mucilages of oilseeds can also act as a fat replacer thanks to their properties. The incorporation of oilseeds modifies the rheology of the doughs, the volume of the products and their texture, affecting their organoleptic characteristics and their acceptability. Nevertheless, these changes will depend on the type of seed used, as well as on the method of addition.

A Retrospective Study on Dietary FODMAP Intake in Celiac Patients Following a Gluten-Free Diet

Our aim was to evaluate the intake of foods containing fermentable oligo/di/mono-saccharides and polyols (FODMAP) as a possible factor that induces gastrointestinal symptoms in treated celiac disease (CD) patients. We collected seven-day weighed food records for 104 CD patients and 91 healthy volunteers. All evaluated food items were from sources with high and low content of FODMAP, which were divided into cereals and sweets, sweeteners and soft drinks, fruits, dried fruits, and vegetables. Nutrient intake was calculated using the food database of the European Institute of Oncology. The symptoms reported were assessed by a Rome IV Irritable bowel syndrome (IBS) diagnostic questionnaire and by specific questions for the evaluation of functional gastrointestinal disorders (FGIDs). The 12% of CD patients met IBS symptoms criteria as opposed to 6% of controls (p = 0.09) and 27% of patients reported FGIDs symptoms vs. 22% of healthy controls (p = 0.42). The intake by CD patients was significantly higher than healthy volunteers for: sweeteners and sugars with low content of FODMAP (p = 0.0007), fruits, dried fruits, and vegetables high in FODMAP (p = 0.003) and low in FODMAP (p = 0.04) when compared to controls. CD patients had a lower intake of cereals and sweets with a high content of FODMAP (p = 0.00001). Healthy volunteers consumed significantly higher alcoholic beverages and fats high in FODMAP (both p < 0.044). The mean daily intake of other food categories did not differ between both groups. Even though CD patients had a low intake of gluten-free cereals high in FODMAP, they still consumed a significant amount of fruits and vegetables high in FODMAP. The clinical effect of a concomitant gluten-free diet and low-FODMAP diet should be prospectively evaluated as a supportive therapy in CD patients.

The Handbook of Minerals on a Gluten-Free Diet

The importance of a gluten-free diet (GFD) in the treatment of celiac disease and other gluten-related disorders is undisputable. However, strict GFD often lead to nutritional imbalances and, therefore, to deficiencies. One of the most common deficiencies from a GFD are an insufficient amount of Ca, Fe, Mg, and Zn. This is mainly because the most of popular gluten-free (GF) raw materials are poor in minerals. Although the popularity of GFD is constantly growing, the data on minerals in GF products are still limited. More importantly, an access to the data is even more restricted. Therefore, the paper reviews the Ca, Fe, Mg, and Zn contents in hundreds of grain GF products available worldwide. The data for 444 products from categories of flours, mixes for cooking, bakery products, cereals, groats, rice, and pasta are obtained from research papers and nutritional databases. The calculation of the realization of mineral requirements from a portion of each product with its graphical classification as rich/average/poor source of each mineral is given. The review is a handbook of minerals for people on a GFD, dietitians, and food producers.

The Nutritional Quality of Gluten-Free Products for Children

OBJECTIVES

To examine the nutritional quality of gluten-free (GF) products specifically marketed for children.

METHODS

All child-targeted food products were purchased from 2 major supermarket chains in Calgary, Alberta, Canada. Using the Pan American Health Organization Nutrient Profile Model, the nutritional quality of products with a GF claim was compared with those without such a claim. A secondary analysis further compared the nutrient profile of child-targeted GF products to their product "equivalents."

RESULTS

Overall, child-targeted GF products had lower levels of sodium, total fat, and saturated fat but also had less protein and a similar percentage of calories from sugar compared with child-targeted products without a GF claim. According to the Pan American Health Organization criteria, both GF products and "regular" products designed for children can be classified as having poor nutritional quality (88% vs 97%; P < .001). When analyzed in light of their product equivalents without a GF claim, both had similarly high levels of sugar (79% vs 81%; P < .001).

CONCLUSIONS

GF supermarket foods that are targeted at children are not nutritionally superior to regular child-targeted foods and may be of greater potential concern because of their sugar content. The health halo often attributed to the GF label is not warranted, and parents who substitute GF products for their product equivalents (assuming GF products to be healthier) are mistaken. Parents of children with gluten intolerance and/or sensitivity, along with parents who purchase GF products for other health reasons, need to carefully assess product labels when making purchases.

Old Fashioned vs. Ultra-Processed-Based Current Diets: Possible Implication in the Increased Susceptibility to Type 1 Diabetes and Celiac Disease in Childhood

Ultra-processed foods are ready-to-heat and ready-to-eat products created to replace traditional homemade meals and dishes due to convenience and accessibility. Because of their low-fiber and high-fat and sugar composition, these foodstuffs could induce a negative impact on health. They are partially responsible for obesity and chronic non-transmissible diseases; additionally, they could impact in the prevalence of autoimmune diseases such as type 1 diabetes and celiac disease. The rationale is that the nutritional composition of ultra-processed foodstuffs can induce gut dysbiosis, promoting a pro-inflammatory response and consequently, a “leaky gut”. These factors have been associated with increased risk of autoimmunity in genetically predisposed children. In addition, food emulsifiers, commonly used in ultra-processed products could modify the gut microbiota and intestinal permeability, which could increase the risk of autoimmunity. In contrast, unprocessed and minimally processed food-based diets have shown the capacity to promote gut microbiota eubiosis, anti-inflammatory response, and epithelial integrity, through bacterial butyrate production. Thus, to decrease the susceptibility to autoimmunity, genetically predisposed children should avoid ultra-processed food products and encourage the consumption of fresh and minimally processed foods.

Current and Forward-Looking Approaches to Technological and Nutritional Improvements of Gluten-Free Bread with Legume Flours: A Critical Review

The gluten-free market currently offers a range of products which can be safely consumed by patients affected by celiac disease. Nevertheless, challenges for optimal formulation remain on the way in terms of appreciable texture, flavor, and adequate nutritional characteristics. Within that framework, legumes have recently attracted attention among scientists as structure- and texture-forming agents, as source of nutrients and bioactive compounds, and as a low-glycemic-index ingredient. This work aims at providing an updated and comprehensive overview of the advantages and disadvantages in the use of legumes in gluten-free breadmaking. It also shows how legumes can contribute to tackling the main technological, nutritional, and organoleptic challenges. From this critical analysis, it emerged that viscoelastic properties of gluten-free bread batter can be enhanced by the use of carob germ, chickpea, lupin, and soybean. Gluten-free bread organoleptic acceptability can be improved by incorporating leguminous flours, such as carob, chickpea, lupin, and soybean. Moreover, a better nutritional quality of gluten-free bread can be obtained by the addition of chickpea and soybean. Gaps and needs in the use of legumes in gluten-free breadmaking emerged and were gathered together to have a sound basis for future studies. The technological and nutritional potential of sourdough should be more extensively exploited. Moreover, in vitro and in vivo studies should be prompted to understand the health benefits of bread formulated with legumes. A holistic approach, interfacing food science, nutrition, and health might help to have, on the market, products with improved sensory properties and nutritional profile.

Challenges in gluten-free diet in coeliac disease: Prague consensus

BACKGROUND

New treatments in coeliac disease are being vigorously pursued to either replace or facilitate the difficult-tofollow gluten-free diet.

DESIGN

The present review intends to summarise the challenges in gluten-free diet adherence during the transitional period, as reflected in the last Prague consensus, published in 2016.

RESULTS

The honourable panel members recommended that dietary adherence and the consequences of nonadherence represent key components for discussion in the transitional period setting.

CONCLUSIONS

There are numerous difficulties in adhering to gluten withdrawal, but the transition period from adolescence to young adulthood is considered a fragile and high-risk period for intentional and unintentional gluten intake.

Are Treated Celiac Patients at Risk for Mycotoxins? An Italian Case-Study

Urinary biomarkers of mycotoxin exposure were evaluated in a group of celiac patients (n = 55) and in a control group of healthy subjects (n = 50) following their habitual diet. Deoxynivalenol (DON), zearalenone (ZEN), and fumonisin B1 (FB1) were monitored in 105 urinary samples collected from the two groups. Dietary habits were also recorded through compilation of a seven-day weighed dietary diary. Biomarkers of mycotoxin exposure were detected in 21 celiac patients and in 15 control subjects, corresponding to about 34% of total participants. In particular, ZEN was the most detected mycotoxin among all the studied subjects with a total of 19 positive cases. Results did not show a statistically significant difference in mycotoxin exposure between the two groups, and the presence of specific mycotoxins was not related to the intake of any particular food category. Our findings suggest little urgency of specific regulation for gluten free products, although the prevalence of exposure observed in free-living diets of both celiac and healthy subjects underlines the need of a constant surveillance on mycotoxins occurrence at large.

Evaluation of a Modified Italian European Prospective Investigation into Cancer and Nutrition Food Frequency Questionnaire for Individuals with Celiac Disease

BACKGROUND

To date, it is unclear whether individuals with celiac disease following a gluten-free (GF) diet for several years have adequate intake of all recommended nutrients. Lack of a food frequency questionnaire (FFQ) for individuals with celiac disease could be partly responsible for this still-debated issue.

OBJECTIVE

The aim of the study is to evaluate the performance of a modified European Prospective Investigation into Cancer and Nutrition (EPIC) FFQ in estimating nutrient and food intake in a celiac population.

DESIGN

In a cross-sectional study, the dietary habits of individuals with celiac disease were reported using a modified Italian EPIC FFQ and were compared to a 7-day weighed food record as a reference method.

PARTICIPANTS/SETTING

A total of 200 individuals with histologically confirmed celiac disease were enrolled in the study between October 2012 and August 2014 at the Center for Prevention and Diagnosis of Celiac Disease (Milan, Italy).

MAIN OUTCOME MEASURES

Nutrient and food category intake were calculated by 7-day weighed food record using an Italian food database integrated with the nutrient composition of 60 GF foods and the modified EPIC FFQ, in which 24 foods were substituted with GF foods comparable for energy and carbohydrate content.

STATISTICAL ANALYSES PERFORMED

An evaluation of the modified FFQ compared to 7-day weighed food record in assessing the reported intake of nutrient and food groups was conducted using Spearman's correlation coefficients and weighted κ.

RESULTS

One hundred individuals completed the study. The Spearman's correlation coefficients of FFQ and 7-day weighed food record ranged from .13 to .73 for nutrients and from .23 to .75 for food groups. A moderate agreement, which was defined as a weighted κ value of .40 to .60, was obtained for 30% of the analyzed nutrients, and 40% of the nutrients showed values between .30 and .40. The weighted κ exceeded .40 for 60% of the 15 analyzed food groups.

CONCLUSIONS

The modified EPIC FFQ demonstrated moderate congruence with a weighed food record in ranking individuals by dietary intakes, particularly food groups.

Gluten-free food database: the nutritional quality and cost of packaged gluten-free foods

Notwithstanding a growth in popularity and consumption of gluten-free (GF) food products, there is a lack of substantiated analysis of the nutritional quality compared with their gluten-containing counterparts. To put GF foods into proper perspective both for those who need it (patients with celiac disease) and for those who do not, we provide contemporary data about cost and nutritional quality of GF food products. The objective of this study is to develop a food composition database for seven discretionary food categories of packaged GF products. Nutrient composition, nutritional information and cost of foods from 63 GF and 126 gluten-containing counterparts were systematically obtained from 12 different Austrian supermarkets. The nutrition composition (macro and micronutrients) was analyzed by using two nutrient composition databases in a stepwise approximation process. A total of 63 packaged GF foods were included in the analysis representing a broad spectrum of different GF categories (flour/bake mix, bread and bakery products, pasta and cereal-based food, cereals, cookies and cakes, snacks and convenience food). Our results show that the protein content of GF products is >2 fold lower across 57% of all food categories. In 65% of all GF foods, low sodium content was observed (defined as <120 mg/100 g). Across all GF products, 19% can be classified as source high in fiber (defined as >6g/100 g). On average, GF foods were substantially higher in cost, ranging from +205% (cereals) to +267% (bread and bakery products) compared to similar gluten-containing products. In conclusion, our results indicate that for GF foods no predominant health benefits are indicated; in fact, some critical nutrients must be considered when being on a GF diet. For individuals with celiac disease, the GF database provides a helpful tool to identify the food composition of their medical diet. For healthy consumers, replacing gluten-containing products with GF foods is aligned with substantial cost differences but GF foods do not provide additional health benefits from a nutritional perspective.

Nutritional aspects of gluten-free products

In recent years, gluten-free (GF) goods have become popular, fuelling a growing market, as they not only cater to individuals with medical needs but also to consumers who seek a GF diet. In their development, it is pivotal to pay attention to nutritional quality. This review aims to provide some insights on the nutritional quality of GF products, focusing on major concerns and the strategies to overcome them. In order to mimic the viscoelastic properties of gluten, a large number of flours and starches and other ingredients have been used. Therefore the different mixtures of these ingredients bring a wide difference in the nutritional composition of GF foods with respect to gluten-containing counterparts. Several GF foodstuffs contain more fat, including saturated, and salt but fewer minerals and vitamins than their equivalents with gluten. The increased fibre content and improved technological processes have positively affected the glycaemic responses from these goods. However, in order to improve their nutritional quality, wholemeal GF cereals and pseudocereals with high nutritive value should replace the low-nutritional GF flours and consequently the technological processes would be optimized. The improvement of the nutritional quality of GF products, and in turn that of the GF diet, should also be aimed at lowering the risk of later chronic degenerative disorders, especially for infants and young children.