Growth and Nutrition in Children with Celiac Disease on a Gluten-Free Diet

Celiac.com 11/07/2025 - This study from a large hospital in Turkey asked a practical question that many families and clinicians face every day: when children with celiac disease follow a strict gluten-free diet, do they eat enough of the right nutrients to grow as well as their healthy peers? The researchers compared growth and food intake in children with celiac disease who had excellent diet adherence with healthy children of the same age and sex. They looked not only at total energy and major nutrients such as protein, fat, carbohydrate, and fiber, but also at vitamins and minerals and the share of daily energy that came from commercial gluten-free products.

What the Researchers Wanted to Learn

The team focused on three goals. First, they assessed whether children with celiac disease who strictly avoided gluten met recommended intakes for energy, protein, fat, carbohydrate, fiber, vitamins, and minerals. Second, they examined whether boys and girls showed different patterns of nutrient intake. Third, they evaluated whether commercial gluten-free foods made helpful or unhelpful contributions to daily energy and major nutrients.

Who Took Part and How the Study Worked

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The research included fifty-one children with celiac disease and fifty-four healthy peers between two and eighteen years of age. All children with celiac disease had followed a gluten-free diet for at least one year, had normal blood tests that signal good dietary adherence, and attended regular visits with a dietitian. Families recorded everything the child ate and drank over three days, including two weekdays and one weekend day. A trained dietitian measured body weight and height and calculated body mass index. The team then compared diet quality and growth between the two groups.

Growth Findings

Children with celiac disease were, on average, shorter for their age and had a lower body mass index for their age than healthy children. When the groups were split by sex, boys with celiac disease had lower body weight, lower body mass index, and lower height for age than healthy boys, and girls with celiac disease had lower body mass index for age than healthy girls. These differences suggest that even with excellent gluten-free diet adherence, overall growth may lag without careful attention to total energy and nutrient density.

Energy and Major Nutrients

Children with celiac disease consumed less total energy, less protein, less fat, and less fiber than healthy peers. Average carbohydrate intake was also lower in absolute grams, but carbohydrate made up a slightly larger share of total energy in the celiac group, indicating a diet that was relatively more carbohydrate-heavy and relatively lighter in protein and fat. Despite eating less fat overall, the celiac group derived a similar percentage of total energy from fat as the control group, which points to generally high fat shares in both groups.

Types of Fat and Cholesterol

The proportions of energy coming from saturated fat, monounsaturated fat, and polyunsaturated fat did not differ meaningfully between groups. Cholesterol intake was lower in children with celiac disease than in controls. Taken together, these results suggest that fat quality patterns in both groups mirrored common modern eating habits rather than being driven only by gluten avoidance.

Protein and Fiber

Protein stood out as a weak point. Children with celiac disease ate less protein per day, a smaller share of energy from protein, and often failed to reach recommended intakes. Fiber intake was low in both groups and especially low in the celiac group. The authors note several likely reasons: commercial gluten-free products are often made from refined starches, contain less fiber and less protein than their wheat-based counterparts, and may crowd out naturally fiber-rich foods such as legumes, pseudocereals, fruits, vegetables, nuts, and seeds.

Vitamins and Minerals

Many vitamin and mineral intakes were lower in the celiac group. Both boys and girls with celiac disease had lower intake of thiamine and riboflavin, and lower intake of calcium, magnesium, phosphorus, and selenium. Girls with celiac disease also consumed less vitamin A, vitamin B six, vitamin C, niacin, folate, potassium, iron, and zinc than healthy girls. These gaps match what is known about many shelf products that are gluten-free: they tend to be lower in several B vitamins and in key minerals unless they are fortified.

Nutrient Adequacy Scores

To judge overall diet quality, the researchers calculated a nutrient adequacy ratio for individual nutrients and a mean adequacy ratio across nutrients. Children with celiac disease had lower adequacy for protein, thiamine, calcium, magnesium, iron, zinc, and fiber, and girls also had lower adequacy for vitamin A and folate. Importantly, even the healthy control group did not reach the ideal mean adequacy ratio, which means diet quality has room to improve in many children, not just those with celiac disease.

Role of Commercial Gluten-Free Products

On average, commercial gluten-free foods provided about one fifth of daily energy for boys and just under one fifth for girls with celiac disease. A large share of this energy came from carbohydrate, while contributions to fiber and protein were modest. This confirms that many gluten-free packaged products are energy-dense but not nutrient-dense, underscoring the need to balance them with naturally gluten-free whole foods.

What the Findings Mean

The results show that strict gluten avoidance alone does not guarantee an adequate diet for growth and long-term health. Even with excellent adherence, many children with celiac disease fall short on total energy, protein, fiber, B vitamins, calcium, magnesium, iron, zinc, and other minerals. Because the healthy peers also missed some targets, the study points to a broader need for better nutrition education, but the shortfalls were more pronounced in the celiac group.

Strengths and Limits

Strengths include careful diet recording over multiple days, direct measurements by a trained dietitian, and a comparison with healthy peers matched by age and sex. The study took place at a single center and relied on product labels and national databases for some nutrient values, which may underestimate or overestimate certain vitamins and minerals. Larger studies across multiple regions would help confirm how generalizable these results are.

Practical Takeaways for Families and Clinicians

• Pair gluten avoidance with nutrition goals: adequate energy, sufficient protein at each meal, and a daily plan for fiber.
• Favor naturally gluten-free whole foods such as legumes, lentils, chickpeas, quinoa, buckwheat, brown rice, nuts, seeds, fruits, and vegetables.
• Choose dairy or calcium-fortified alternatives, lean meat, eggs, fish, tofu, and legumes to boost calcium, iron, zinc, and protein.
• Read labels on gluten-free packaged foods and select options that are higher in fiber, higher in protein, and fortified with B vitamins and folate.
• Schedule regular visits with a knowledgeable dietitian to personalize meal plans and monitor growth, blood tests, and symptoms.

Why This Matters for People with Celiac Disease

For families living with celiac disease, this study delivers a clear message: a gluten-free label is not the same as a balanced diet. Children who strictly avoid gluten can still fall behind on key nutrients and show slower gains in height and body mass index for their age. The encouraging news is that targeted nutrition counseling, smarter use of fortified products, and a shift toward naturally gluten-free whole foods can close these gaps. Doing so supports steady growth, stronger bones, better energy, and a healthier future while maintaining the gut healing that a gluten-free diet provides.

Read more at: www.frontiersin.org