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 good sources of riboflavin, vitamin C and vitamin E [42]. In addition, pseudo-cereals permit a wider variety of foods, broadening the choice for CD children when selecting foods. Under the economic point of view, these grains offer a less expensive alternative with respect to standard gluten-free choices; also, this aspect could help increase dietary compliance by reducing the economic burden of the diet [43]. The nutritional advantages of pseudo-cereals are listed in Table 3.

**Table 3.** Nutritional advantages of pseudo-cereals (amaranth, buckwheat and quinoa).


#### *4.5. Oats*

The inclusion of oats in the GFD has been, for many years, and still is a matter of debate, because it was thought that avenin (the storage protein found in oats) was also toxic to CD patients. Moreover, attention has been focused on the issue of the frequent cross-contamination of oats with gluten-containing grains. Studies have demonstrated that when consumed in moderation, oats free from cross-contamination are well tolerated by most children [44,45]. Under the nutritional point of view, oats represent a good source of iron, dietary fiber, thiamin and zinc and, in addition, have a good palatability [46]. A study conducted by Størsund *et al.* in CD children suggests that oats may improve the nutritional value of GFD and, in view of the good palatability, may also help increase compliance [47]. Recently, Lee *et al.* demonstrated that adding three servings of gluten-free alternative grains, including oats, positively impacts the nutrient profile (fiber, thiamin, riboflavin, niacin, folate and iron) of the grain portion of the gluten-free diet [48].

#### *4.6. Vitamins and Minerals*

Meat, fish, fruit and vegetables are an important natural source of vitamins, minerals and trace elements. In view of the possible micronutrient deficiencies associated with GFPs, an appropriate consumption of these foods should be advised in children with CD. In particular, fruit and vegetables are low in energy and rich in vitamins and minerals; moreover, they contain phytochemicals and antioxidant compounds that exert a protective effect against diseases associated with oxidative damage [49]. The intake of at least five portions of fruit and vegetables a day should be recommended in children with CD. Minerals (calcium, phosphorus, sodium, potassium, chloride and magnesium) and trace elements (iron, zinc and selenium) are also contained in a significant amount in pseudo-cereals, in which the content can be twice as high as in other cereals. For example, in teff, iron and calcium contents (11–33 mg/100 g and 100–150 mg/100 g, respectively) are higher than those of wheat, barley, sorghum and rice.

#### *4.7. Nutritional Follow-Up*

Continuous long-term follow-up is crucial to promote adherence to GFD and for early identification of nutritional deficiencies and/or metabolic imbalances. Ideally, a skilled dietitian with knowledge in CD and GFD should be an integral part of the healthcare team. A child's nutritional status should be accurately assessed at diagnosis and at each follow-up, which ideally should be performed at six months post commencement of GFD and then annually, post-diagnosis. The evaluation of nutritional status should start from a thorough and accurate dietary history and include the assessment of anthropometric parameters (weight, height and body mass index). Adherence to GFD should be assessed, and information on how to safely broaden food choices and interpret food labeling should be given. Early identification and correction of nutritional deficiencies should be regularly addressed. Table 4 summarizes the key points of nutritional follow-up in children with CD.


**Table 4.** Recommended timing for nutritional follow-up. BMI: body mass index.

**Figure 1.** Schematic representation of proposed approach to a nutritionally adequate and balanced gluten-free diet.

#### **5. Conclusions**

Gluten-free diet, the only available treatment for CD, if not carried out with attention, may paradoxically lead to nutritional imbalances, which should be avoided, particularly at the pediatric age, the phase of maximal growth and development. Increasing awareness on the possible nutritional deficiencies associated with GFD may help healthcare professionals and families tackle the issue by starting from early education on GFD and clear dietary advice on how to choose the most appropriate gluten-free foods. Figure 1 summarizes, by means of a schematic representation, a proposed approach towards a nutritionally adequate and balanced gluten-free diet. Further studies on the technological and nutritional properties of the alternative cereals as wheat replacements are needed to confirm their role in improving the intake of protein, iron, calcium and fiber and reducing nutritional deficiencies in children with CD. Their role in the economic burden of the diet and their effect on compliance should also be further investigated. Furthermore, a promising field for gluten-free diet is food biotechnologies. By means of this science, it would be worth considering genetically modifying the amino acid sequence of gluten storage proteins, in order to make them free of those domains high in prolines and glutamines, which are responsible for the toxicity.

#### **Conflicts of Interest**

The authors declare no conflict of interest.

#### **References**


*Am. J. Clin. Nutr*. **1987**, *45*, 946–951.


¥¥ ¿À¥ ¿ « ¿ ~ Â ¿ ª À¿ ¦ *et al*. Effect of gluten-free diet on the growth and nutritional status of children with coeliac disease. *Srp. Arh. Celok. Lek*. **2009**, *137*, 632–637.

Reprinted from *Nutrients*. Cite as: Kaukinen, K.; Collin, P.; Huhtala, H.; Mäki, M. Long-Term Consumption of Oats in Adult Celiac Disease Patients. *Nutrients* **2013**, *5*, 4380-4389.

*Article* 
