**4. Dietary Advices for a Nutritionally Adequate and Balanced Diet in Children with Celiac Disease**

#### *4.1. Education and Compliance*

The first step towards a balanced diet starts from early education on CD and GFD, possibly provided by a skilled dietitian and/or by a physician with expert knowledge in CD. The diet is complicated and can be overwhelming if not presented using a thorough and proactive approach. Early education is fundamental to promote adherence to GFD. In fact, studies focusing on compliance to GFD indicate that adherence is compromised by a number of factors, including a lack of education and continued support by a physician and dietitian [33,34]. In a study conducted by Charalampopoulos *et al.* on determinants of the adherence of GFD in children with CD, baseline education was one of the main determinant factors influencing compliance, suggesting the importance for frequent reinforcement and an accurate explanation of dietary recommendations [34].

#### *4.2. Dietary Intake*

In CD children on GFD, the recommended distribution of daily calorie intake for a healthy and balanced diet does not differ from that recommended to the general population. According to the dietary reference intake values (DRI), the total daily dietary calories should be ideally obtained as 55% from complex and simple carbohydrates, 15% from dietary protein and 25%–30% or less from lipids. The intake of unsaturated fat (monounsaturated and polyunsaturated) should be preferred. Monounsaturated and polyunsaturated fatty acids should provide more than 15% and 10% of total calories, respectively. They are found in foods, such as vegetable oils, nuts, seeds and fish high in lipid content, such as salmon, trout and herring. Thus, it is important to inform and recommend children with CD on the ideal distribution of the daily calorie intake.

#### *4.3. Gluten-Free Foods*

It is advisable to prefer consumption of naturally GF foods, since it has been shown that they are more balanced and complete under both the macro- and micro-nutrient point of view. In fact, these foods are considered to have a higher nutritional value in terms of energy provision, lipid composition and vitamin content as opposed to the commercially purified GF products. Within the range of naturally GF foods, it is preferable to consume those rich in iron and folic acid, such as leafy vegetables, legumes, fish and meat. During explanation of naturally GF foods to patients, it is a good approach for healthcare professionals to bear in mind the local food habits and recipes of each country. This may provide tailored dietary advice, improving acceptance and compliance to GFD. Furthermore, increasing awareness on the availability of the local naturally GF foods may help promote their consumption, resulting in a more balanced and economically advantageous diet. Indeed, these aspects should always be addressed during dietary counseling. With regards to the commercially purified GFPs, it is recommended to pay special attention to the labeling and chemical composition. In European countries, the currently accepted definition of GF is the one designed by Codex Alimentarius (the gluten-free certification organization, 2007) [35]. The term "gluten-free" refers only to foods containing less than 20 ppm of gluten. In addition, the claim "very low gluten" is used for foods, such as bread, produced using cereals that have been specially processed to remove most of the gluten and containing less than 30 mg daily. Furthermore, some GFPs are enriched/fortified with vitamins and/or minerals, thus the choice of these products is preferred, to prevent the deficiencies associated with GFD, mentioned above. Clear labeling of GFPs and education of CD patients on how to interpret them is fundamental to helping CD subjects make safer and more informed food choices.

#### *4.4. Pseudo-Cereals and Minor-Cereals*

Pseudo-cereals, such as amaranth, quinoa and buckwheat, and other minor cereals represent a healthy alternative to frequently used ingredients in gluten-free products. They are a good source of carbohydrates, protein, dietary fiber, vitamins and polyunsaturated fatty acids [36]. In fact, the fiber content in these grains ranges from seven to 10 g/100 g [37], which is higher compared to those of other plant foods and cereals and approximately the same as the content in wheat (fiber 9.5 g/100 g). Furthermore, they are a valid source of protein, as their content is superior to that of wheat in terms of the quantity and quality of proteins: in particular, lysine, arginine, histidine, methionine and cysteine can be found in high amounts [38,39]. Although the lipid content of pseudo-cereals is higher compared to other plant foods, they are characterized by a higher content of unsaturated fatty acids, 

