Coeliac disease (CD) is an autoimmune disorder where the consumption of gluten, a glycoprotein found in wheat, rye and barley, triggers intestinal villous atrophy and leads to intestinal damage. This destruction subsequently leads to the malabsorption of essential nutrients that may cause the clinical symptoms and complications of CD. The only treatment at this time for CD is lifelong adherence to the gluten-free (GF) diet(Reference Snyder, Butzner and DeFelice1,Reference Green and Cellier2) .
The GF diet has become highly popularised for its perceived health benefits and incidence of food intolerance. However, many children following the GF diet may be relying on processed and packaged GF foods which can increase the risk of unhealthy dietary patterns(Reference Miranda, Lasa and Bustamante3–Reference Mager, Liu and Marcon7). Most GF processed foods are higher in fat, added sugar and glycaemic index which results in significantly higher intakes of fat and sugar in the diets of children with CD on the GF diet(Reference Miranda, Lasa and Bustamante3,Reference Elliott4,Reference Kulai and Rashid6,Reference Jamieson, Weir and Gougeon8,Reference Wild, Robins and Burley9) . Common micronutrients of concern related to the Western GF diet are low folate and vitamin D intake(Reference Alzaben, Turner and Shirton5,Reference Mager, Liu and Marcon7,Reference Mager, Marcon and Brill10) . Low folate intake in children consuming the GF diet is likely due to the lack of a folate fortification policy related to GF grains and hence the low folate content of GF processed foods(Reference Kulai and Rashid6,Reference Mager, Liu and Marcon7,Reference Mager, Marcon and Brill10–Reference Cyrkot, Anders and Kamprath12) . This can make it challenging for children with CD to eat a nutritiously dense diet. This is of significant public health concern as children consuming the GF diet are at increased risk of developing micronutrient deficiencies which may contribute to deficits in growth and development. This is particularly relevant to females of childbearing potential where suboptimal micronutrient deficiencies (e.g. folate) can lead to increased risk for adverse maternal and infant outcomes(Reference McGarel, Pentieva and Strain13).
Currently, there are no evidence-based nutrition guidelines for the GF diet, and the available general nutrition guidelines in Canada do not address eating GF or the nutritional inadequacies of the GF diet. A GF food guide is essential to ensure that children who follow the GF diet and their families can make informed food choices to consume a nutritious diet. The study objective was to describe the methodological considerations in forming a GF food guide for Canadian children and youth (4–18 years) with CD.
Methods
Three different phases informed the content of the GF food guide for Canadian children (4–18 years) with CD on the GF diet: (1) a comprehensive evaluation of food intake and diet patterns to identify nutrients of concerns(Reference Mager, Liu and Marcon7), (2) pre-guide stakeholder (e.g. health care professionals, adults with CD, parents of children with CD) consultations to inform food guide content and (3) development of GF diet simulations taking into consideration cultural preferences and food traditions, diet patterns and diet quality(Reference Mager, Liu and Marcon7). This cross-sectional study was conducted according to the guidelines laid down in the Declaration of Helsinki, and all procedures involving research participants were approved by the University of Alberta Human Research Ethics Board–Health Panel (Pro00065489, Pro00033867). Written informed consent/assent was obtained from participants and/or their responsible caregivers.
Evaluation of food intake
A detailed examination of dietary intake from a multi-ethnic cohort of children with CD and commercially available GF foods in the marketplace was completed and previously reported(Reference Mager, Liu and Marcon7,Reference Cyrkot, Anders and Kamprath12) . This included an in-depth analysis of diet patterning using cluster analysis which illustrated that >80 % of children with CD consume a Western diet (high fat, moderate-high carbohydrate). Low folate intake was likely secondary to the lack of folate-dense foods in the diet (e.g. legumes) and the lower folate content of GF foods (e.g. grains) purchased by families of children with CD(Reference Mager, Liu and Marcon7,Reference Cyrkot, Anders and Kamprath12) .
Pre-guide consultations with external stakeholders
Pre-guide stakeholder consultations were conducted via Internet surveys with health care professionals (e.g. Registered Dietitians) and community end users (e.g. adults with CD, parents of children with CD) across Canada. Surveys were launched using RedCap® software through various health professional organisations (e.g. Canadian Association of Gastroenterology, College of Dietitians of Alberta) and through local chapters of the Canadian Celiac Association (e.g. Edmonton, Calgary) (online Supplementary Table S1)(Reference Harris, Taylor and Minor14,Reference Harris, Taylor and Thielke15) . Survey content addressed demographic information (e.g. province, urban/rural, type of health care professional, length of CD diagnosis) and perceptions regarding GF food guide content (e.g. relevant nutrition and food literacy topics, and guide layout). Thematic analysis and descriptive statistics were used to analyse open- and close-ended questions.
Diet simulations of nutritionally adequate gluten-free diets for children 4–18 years
Diet simulations were designed so that when evaluated, the nutrient content met relative dietary reference intake values for macronutrient and micronutrient intake for age–sex(16). Simulations were made to represent a 24-h dietary intake pattern for children (females and males) between 4 and 18 years to ensure that age-appropriate estimated average requirements (EAR) or adequate intakes were met. This methodology was modelled after Health Canada’s methodological approach for the preparation of the 2007 and the 2019 Canada’s Food Guide (CFG)(Reference Katamay, Esslinger and Vigneault17,18) . Simulations were created from an in-depth analysis of diet patterns of children with CD in Canada(Reference Alzaben, Turner and Shirton5,Reference Mager, Liu and Marcon7,Reference Mager, Marcon and Brill10) . This included a comprehensive evaluation of GF foods available in Canadian grocery stores(Reference Elliott4,Reference Kulai and Rashid6,Reference Jamieson, Weir and Gougeon8,Reference Cyrkot, Anders and Kamprath12) . Simulations were altered to meet the macronutrient and micronutrient recommendations for diet patterns across age–sex using Food Processor Nutrition Analysis Software (SQL 11.0.124, ESHA Research) and the Canadian Nutrient File(Reference Deeks, Verreault and Cheung19) (Fig. 1). The average nutrient content of GF bread and GF breakfast cereal was calculated using food labels based on the top twelve brands for GF breads and the top twenty brands for GF cereals available to consumer in Canada as identified in phase one(Reference Mager, Liu and Marcon7,Reference Cyrkot, Anders and Kamprath12) (online Supplementary Table S2A). While the simulations evaluated the content of all macronutrients and micronutrients, an enhanced focus was placed on the intake of fat, added sugar, fibre, vitamin B12, vitamin D, folate, Ca, Fe, Na and Zn. The gluten content of all diet simulations was assessed using the Osborne method with a cut-off value of <10 mg/d to indicate a safe gluten threshold(Reference Mager, Liu and Marcon7,Reference Mager, Marcon and Brill10,Reference Assor, Davies-Shaw and Marcon20) . Cuisines representing various cultures were chosen based on the ethnic diversity of the Canadian population and to reflect the global prevalence of CD(Reference Singh, Arora and Strand21). Diet simulations (>40 %) reflected a plant-predominant diet with fruits, vegetables, grains and plant-based proteins (e.g. legumes, tofu, nuts and seeds)(22). To encompass different food selections among the selected cuisines and diet patterns, numerous food substitution lists were developed prior to the diet simulations to ensure that representation of different ethnicities and diet patterns was incorporated into the guide (online Supplementary Table S2A–J)(Reference Mager, Liu and Marcon7,Reference Mager, Marcon and Brill10) . Substitutions and alterations to food items and food guide servings were made until diets were nutritionally adequate and fell within macronutrient and micronutrient, and energy ranges for age–sex (online Supplementary Table S3A–B)(16).
Fig. 1. The diet simulation process used to inform the content of the gluten-free food guide. EAR, estimated average requirement; AI, adequate intake; AMDR, acceptable macronutrient distribution range. Dietary data on children with coeliac disease was used to develop the diet simulations(Reference Mager, Liu and Marcon7). Diets were adjusted using Food Processor Nutrition Analysis Software (SQL 11·0·124, ESHA Research), the Canadian Nutrient File and manufacturer information to reflect diet patterns, cultural preferences and food traditions of the Canadian population and were based on the global prevalence of coeliac disease among the Canadian population(Reference Deeks, Verreault and Cheung19,Reference Singh, Arora and Strand21) . To meet Health Canada(16) and the Alberta Nutrition Guidelines for Children and Youth(25) recommendations, nutrient-dense foods were added or the serving sizes of nutrient-dense foods were adjusted to meet the EAR/AI. Proportions of food items and food group servings were adjusted until macronutrients and energy content fell within ranges. Diet quality of these nutritionally adequate diets was assessed by the Mediterranean Diet Quality Index in children and adolescence(Reference Serra-Majem, Ribas and Ngo23) and the Canadian Healthy Eating Index(Reference Woodruff and Hanning24).
The nutritional adequacy of the diet simulations was assessed by diet quality index scores (Mediterranean Diet Quality Index in children and adolescence and the Canadian Healthy Eating Index)(Reference Serra-Majem, Ribas and Ngo23,Reference Woodruff and Hanning24) . Mediterranean Diet Quality Index in children and adolescence ranged from 0 to 12 with >8 indicating an ‘optimal Mediterranean diet’, 4–7 ‘needs improvement’ and ≤3 indicating ‘low diet quality’(Reference Serra-Majem, Ribas and Ngo23). The Canadian Healthy Eating Index was subcategorised based on adequacy (maximum score of 50), moderation (maximum score of 40) and variety (maximum score of 10). An overall score of ≥80 signified ‘optimal/excellent diet quality’, 51–80 indicated ‘needs improvement’ and ≤50 signified ‘poor diet quality’(Reference Woodruff and Hanning24). Food guide servings were calculated from the diet simulations according to the 2007 CFG and Alberta Nutrition Guidelines for Children and Youth(25,26) .
Results
Stakeholder consultations: pre-guide formation
Health care professionals (n 151) and community end users (n 383) from all provinces and territories across Canada completed the Internet surveys. Health care respondents included Registered Dietitians (80 %, n 121), Pediatric Gastroenterologist and Pediatricians (11 %, n 16), Family Physicians (3 %, n 4), Registered Nurses (3 %, n 4), Social Workers (3 %, n 5) and others (<1 %, n 1). Health care professionals (17 %, n 22 of 127) reported seeing over five cases of CD per month, and 37 % (n 56) reported working with the paediatric CD population for more than 10 years. Most community participants were between 31–40 years (>35 %) and 41–50 years (>25 %). Over 65 % of community end users (n 256) reported having CD, and 42 % (n 160) reported having at least one child or grandchild diagnosed with CD.
Feedback from the health care professionals and members of the community for guide content was related to micronutrient concerns (Fe (65 % professionals v. 72 % community, P > 0·05), vitamin D (60 % professionals v. 69 % community, P = 0·048), folate (50 % professionals v. 36 % community, P = 0·003), added sugars (63 % professionals v. 48 % community, P = 0·002) and fat (23 % professionals v. 30 % community, P > 0·05)) in GF foods. Community end users also focused on Ca (55 %) and fibre (62 %) as important topics (Fig. 2(a) and (b)). Food literacy topics related to reading food labels (77 % professionals v. 60 % community, P < 0·001), GF processed foods (68 % professionals v. 43 % community, P < 0·001), eating out at restaurants (64 % professionals v. 62 % community, P > 0·05) and grocery shopping (66 % professionals v. 41 % community, P < 0·001) were identified by both groups as important guide content. Health care professionals and community members felt that addressing cultural preferences and food traditions were also needed (47 % professionals v. 21 % community, P < 0·001). Guide content related to CD (81 %) and lactose intolerance (25 %) was reported as important by community end users but addressing a wheat allergy was important to both groups (33 % professionals v. 26 % community, P > 0·05) (Fig. 2(c) and (d)). Over 80 % of health care professionals requested that the GF food guide be available in both electronic and hardcopy formats, while 80 % of community end users preferred electronic formats only.
Fig. 2. (a)–(d) Important gluten-free food guide topics identified during pre-guide stakeholder consultations related to (a) and (b) nutrition topics and (c) and (d) food literacy topics. Online surveys were completed by stakeholders which included health care professionals (Registered Dietitians n 121, Gastroenterologists/Pediatricians n 16, Family Physicians n 4, Registered Nurses n 4, Social Workers n 5, and others n 1) and community end users (n 383, e.g. adults with coeliac disease, parents of children with coeliac disease). Participants had the option to select ≥1 sub-topic from each of the two major topics if they felt that multiple sub-topics were important.
Diet simulations
There was a total of 1260 diet simulations created for the GF food guide to ensure that the guide met the nutritional needs of children (age 4–18 years) diagnosed with CD. Each age–sex category had a total of 210 diets created across all diet patterns. Diet simulations were created for Western (n 150), First Nations, Inuit and Métis (n 102), East Indian (n 150), Somalian (n 150), Chinese (n 150), Brazilian (n 150) and Iranian (n 102) cuisines, as well as lactose-free (n 102), lacto-ovo (n 102) and vegan (n 102) diets.
Gluten, macronutrient and micronutrient content of the diet simulations
The median (interquartile range) gluten content of all diet simulations was 4·3 mg/d (2·6–5·5). Macronutrient distributions across all diet simulations and all ages (20·9 (sd 2·2) % protein, 28·1 (sd 2) % fat, 52 (sd 3) % carbohydrate) were not significantly different between simulated diet patterns (P > 0·05). Except for the micronutrient vitamin D, diet simulations met 100 % EAR and 80–100 % of recommended dietary allowance (RDA) for all micronutrients based on age–sex (Table 1). Only 23 % of the diet simulations met the EAR (10μg) for vitamin D, and only 5 % met the RDA (15μg). To achieve the EAR for vitamin D, the diet simulations included an average of 2·5 servings of fortified fluid milk (or 3 servings of a fortified unsweetened plant-based beverage) and 1 serving of fish. When fish was not included in a diet simulation, 3·5 servings of fortified fluid milk (or 4 servings of a fortified unsweetened plant-based beverage) and 2 eggs or 1 serving of fortified yogurt was used instead. When a vitamin D supplement (10μg) was included in a simulation, only 2–2·5 servings of fortified fluid milk or an unsweetened plant-based beverage was needed to meet the RDA. The diet simulations were able to provide enough folate across all ages–sexes without supplementation (100 % EAR were met). Higher folate-containing food items (e.g. legumes, spinach, oranges) were added to the diets to meet the EAR.
Table 1. Macronutrient and micronutrient summary from the diet simulations based on age–sex*
AI, adequate intake; EAR, estimated average requirement; RDA, recommended dietary allowance; DFE, dietary folate equivalent; UL, tolerable upper intake level.
* %EAR/RDA/AI/UL for select nutrients were determined by dividing the absolute nutrient intake by the EAR/RDA/AI/UL based on age–sex and then multiplying by 100.
† Reference ranges for nutrient intake were based on guidelines from Health Canada(16) and the FAO of the UN(47).
‡ Energy (kcals) range for female/male age ≤6 years = 1200–1500, age 7–13 years = 1500–1800, ≥14 years = 2000–2300.
§ Acceptable macronutrient distribution range: carbohydrate, 45–65 %; protein, 10–30 %; fat, 25–35 %(16). All diet simulations (100 %, n 1260) based on age–sex met carbohydrate and protein recommendations. 94 % (n 1187) met fat recommendations with the remainder having fat intakes in the range of 23–25 % of total energy intake.
|| Sat Fat, saturated fat; recommended <10 %(47).
¶ MUFA, monounsaturated fatty acids; recommended 10-14 %(47).
** PUFA, polyunsaturated fatty acids; recommended >3 %(47).
Assessment of diet quality and food group intake of the diet simulations
Mediterranean Diet Quality Index in children and adolescence and the Canadian Healthy Eating Index scores were indicative of optimal/excellent diet quality in 100 % and 93·5 % of the diet simulations, respectively. Fig. 3(a)–(c) outlines the daily number of servings based on each food group that children with CD need to eat to meet their macronutrient and micronutrient needs. This led to the formation of a plate model where >50 % represents fruits and vegetables (FV), <25 % GF grains and 25 % protein foods with a stronger emphasis on plant-based protein sources and those higher in vitamin D (e.g. fish) (online Supplementary Table S4). Fluid milk and/or unsweetened plant-based alternatives that are fortified with Ca and vitamin D are included as the primary beverages of choice with a particular focus to increase vitamin D intake.
Fig. 3. (a)–(c) Recommended number of food group servings for children with coeliac disease (a) ages 4–8 years, (b) ages 9–13 years and (c) ages 14–18 years. Servings are based on nutritionally adequate gluten-free diet simulations. The black horizontal bar indicates recommended servings based on the four food groups according to the 2007 Canada’s Food Guide and the Alberta Nutrition Guidelines for Children and Youth(25,26) .
Discussion
The development of a GF food guide was in response to end-stakeholder users (e.g. health care professionals, parents of children with CD) identifying a need for universally available nutrition guidelines on the GF diet(Reference Mager, Liu and Marcon7,Reference Mager, Marcon and Brill10) . Most families and their children with CD understand the need to follow a GF diet, but many do not have in-depth knowledge related to the nutritional limitations(Reference Isaac, Wu and Mager27). Almost 80 % of Canadian adults report seeing a dietitian at least once at time of CD diagnosis, but longitudinal follow-up has been reported at 15 % with some clinics only conducting dietitian-led follow-up if requested(Reference Isaac, Wu and Mager27,Reference Zarkadas, Cranney and Case28) . This is potentially due to limited resources (e.g. dietitian), extended clinic wait times or those with CD reverting to the Internet for quicker access despite the possibility for inaccurate information. For this reason, accessible and evidence-based GF nutrition guidelines are warranted for children with CD. A GF food guide will help educate families and their children on the complexities of nutrient intake, label reading and manoeuvring complex food environments (e.g. school, social gatherings, travel). The methods used to inform the development of the GF food guide were based on standard methodological approaches used to develop the 2007 and 2019 CFG, and the Alberta Nutrition Guidelines for Children and Youth(Reference Katamay, Esslinger and Vigneault17,18,22,25) . The study objective was to describe the methodological considerations in forming a GF food guide for Canadian children and youth (4–18 years) with CD.
The GF pre-guide consultations yielded similar themes compared with the 2019 CFG regarding fat and added sugar, but micronutrient intake (e.g. folate) was a unique theme for the GF food guide due to the nature of the GF diet(29). The GF diet can be nutritious, but many individuals inadvertently consume more fat and added sugar from GF processed products(Reference Alzaben, Turner and Shirton5,Reference Mager, Liu and Marcon7,Reference Mager, Marcon and Brill10) . This is likely due to GF processed grains where fat and sugar have been added to replace the loss of taste and texture when gluten is removed(Reference Miranda, Lasa and Bustamante3,Reference Kulai and Rashid6) . This is concerning as a higher intake has been associated with obesity and chronic disease(22). As a result, the development of the diet simulations was critical to ensure that diet patterns for age–sex were nutritionally adequate for children by primarily focusing on the consumption of whole foods and reducing the intake of ultraprocessed GF foods. This will ensure that the GF food guide can meet the nutritional needs of children with CD while providing evidence-based information to follow a healthy eating patterns while on the GF diet.
The GF diet simulations address the concerns of fat and sugar intake and improve diet quality after modelling the GF diet using the Dietary Approach to Stop Hypertension and the Mediterranean-style diet(22). These diet patterns have been associated with lower cardiovascular risk factors and disease risk, respectively(22). The simulations also focused on a plant-predominant diet (e.g. fruits, vegetables, legumes, nuts and seeds) which was highlighted in the 2019 CFG. It placed a larger focus on the regular intake of plant-based foods with less emphasis on animal-based(22). Limited amounts of animal-based foods (meat, poultry, fish) in conjunction with a plant-predominant diet can contribute to a healthy diet and lower chronic disease risk factors such as blood pressure(Reference Gibbs, Gaskin and Ji30).
The incorporation of more plant-based foods (i.e. legumes, FV) into the diet simulations helped achieve the EAR for folate. Unlike the 2019 CFG where folate is not a nutrient of concern due to wheat fortification, suboptimal intake in children on the GF diet has been observed without a mandated fortification of GF grains(Reference Mager, Liu and Marcon7,Reference Mager, Marcon and Brill10–Reference Cyrkot, Anders and Kamprath12) . Fortunately, the diet simulations identified that by following a plant-predominant diet pattern, folate requirements can be met across all ages–sexes without supplementation (100 % EAR met). This was achieved by incorporating higher folate-containing foods (e.g. pulses, spinach, oranges) into the simulations. This finding is extremely encouraging and means that the GF food guide can help educate families who are following the GF diet to better meet their nutrient requirements. Nevertheless, advocacy for nutrient fortification (e.g. folate) of GF foods, particularly GF grains, continues to remain a priority so that the burden of meeting nutritional requirements does not fall solely on the child with CD and their family. This is especially needed when dietary intake is highly impacted by food/taste preferences, food traditions, multiple food allergies and intolerances, and/or from a food insecurity perspective where recommendations may impact the practicality of guide recommendations.
The diet simulations met the EAR for all micronutrients (e.g. Ca) except for vitamin D whereby diet alone was challenging to meet due to the limited food supply of vitamin D-rich sources. In order to meet the EAR for vitamin D, numerous servings per day of fortified fluid milk or unsweetened plant-based alternatives in addition to fish, eggs or fortified yogurt would need to be consumed by children. This intake is likely not practical on a routine basis due to food/taste preferences and the higher cost of vitamin D-rich sources (e.g. fish) which could be impacted by food insecurity. Despite recently proposed updates to vitamin D fortification in Canada, it is still currently challenging to meet vitamin D needs(31). This is worrisome as the risk of vitamin D deficiency is of concern especially in Canada with the northern latitude(Reference Munasinghe, Willows and Yuan32,Reference Munasinghe, Willows and Yuan33) . No known information is available on Health Canada’s website identifying whether daily vitamin D intake can be achieved by following the 2019 CFG recommendations(34). Though, a recent study analysing the 2019 CFG suspects that most Canadians will not meet their vitamin D needs due to the plate’s de-emphasis of milk products and/or fortified plant-based alternatives(34,Reference Barr35) . Moreover, the 2019 CFG emphasises water as the beverage of choice with little focus on Ca and vitamin D-fortified fluid milk or plant-based alternatives(34). Without a doubt, water is important for adequate hydration but choosing fortified fluid milk or unsweetened plant-based alternatives in its place provides the added benefit of vitamin D for bone health(Reference Munasinghe, Willows and Yuan32). Previous reports on the 2007 CFG also indicate that meeting vitamin D (≥10μg) by diet alone is not routinely achievable without drastically increasing dietary intake or a routine vitamin D supplement(Reference Katamay, Esslinger and Vigneault17). Therefore, parents of children with CD should seek dietary advice from a physician or dietitian on vitamin D supplementation until fortification policies are re-evaluated. Until then, the GF food guide will encourage purchasing and consuming fortified Ca and vitamin D fluid milk or unsweetened plant-based alternatives in addition to other rich vitamin D sources (e.g. fish, fortified yogurt, eggs) whenever possible to increase nutrient intake. It is worth noting that those who primarily follow a vegetarian or vegan diet may also benefit from choosing vitamin B12-fortified foods to optimise intake given that most naturally rich sources are found in animal-based foods(36).
The methodology behind the GF food guide was used to justify the rationale for the proportion of fruits, vegetables, grains and protein foods on the GF plate. Compared with the 2019 CFG plate model(34), the GF plate will put more emphasis on the consumption of FV (>50 % of the plate) with reduced servings of GF grains (<25 % of plate). Protein foods will represent 25 % of the plate with a focus on plant-based (e.g. legumes, tofu, nuts and seeds) and vitamin D-rich sources (e.g. fish). Fortified fluid milk and/or unsweetened plant-based alternatives will be included as the primary beverage of choice. The total number of servings per d of GF grains is recommended to be lower than the Alberta Nutrition Guidelines for Children and Youth and the 2007 CFG(25,26) . This was implemented due to the higher fat and sugar content of many GF processed grain products(Reference Miranda, Lasa and Bustamante3,Reference Elliott4,Reference Kulai and Rashid6,Reference Jamieson, Weir and Gougeon8,Reference Wild, Robins and Burley9) . By reducing the proportion of grains, it also allowed for more emphasis on FV intake to enhance micronutrient (e.g. folate) and fibre intake.
The layout of the GF food guide is in the form of a plate to mirror the 2019 CFG plate model(34). In 2018, it was noted that twelve countries officially use the plate model as their primary food guide format, while the majority of other countries continue to use the pyramid(Reference Truman37). The plate model has been preferred by both adults and children in parts of the world like Australia(Reference Talati, Pettigrew and Moore38). The key features that have been noted include visual ease, organised design, ability to clearly show food group proportions, the ease of interpretation and being conducive to children’s learning(Reference Talati, Pettigrew and Moore38). The 2019 CFG uses photos of real food items which have also been identified as a preferred aesthetic feature compared with cartoon depictions(34,Reference Talati, Pettigrew and Moore38) . Real photos will be incorporated into the GF food guide while considering the unique nutritional attributes of GF foods and the selection of age-appropriate foods.
Post-guide stakeholder consultations to evaluate food guide content and strategies for food guide dissemination and uptake are in progress. End-stakeholder consultations will include health care professionals, community end users and professional organisations such as the Canadian Celiac Association, Health Canada, Canadian Association of Gastroenterology and/or the Canadian Nutrition Society. This will ensure that guideline content has been scientifically peer-reviewed. This will also ensure that guideline uptake can occur and will be devoid of potential sources of bias. Nutrition champions and an informed process to critically evaluate nutrition guideline content are important in all phases of guidelines development(Reference Downs, Farmer and Quintanilha39–Reference Quintanilha, Downs and Lieffers43). This method was used in the development of the recently released CFG(18,Reference Dai, Kroeger and Lawrence41) .
The intake of FV has notoriously been low in children, and it is important to acknowledge that this could impact guide uptake(Reference Chu, Farmer and Fung44,Reference Garriguet45) . To address this barrier, visually appeasing supplementary educational materials (e.g. handouts, videos with recipes) will be developed to help educate parents and their children on how to incorporate more FV into their meals and snacks. This may include additional tips on increasing FV accessibility within the home, parental role modelling, allowing children to taste foods multiple times, or focusing on developing food skills to promote greater FV intake(Reference Chu, Farmer and Fung44). Eating FV on a budget will also be addressed as guide uptake may be affected by the feasibility of purchasing FV on a regular basis.
The GF food guide will include various cuisines that reflect cultural preferences and food traditions. This will ensure that the guide is tailored and applicable to meet the needs of culturally diverse populations. This is important as evidence indicates that adherence to nutritional guidelines may be a concern for youth of multi-ethnic backgrounds(Reference Kolahdooz, Nader and Daemi46). This will also complement the 2019 CFG which focuses heavily on cultural preferences and food traditions(22).
To develop comprehensive GF nutrition guidelines, the supplementary educational materials (e.g. handouts and videos) will further address healthy eating habits and food environments (home/community). Encouraging the development of food literacy (e.g. grocery shopping, label reading, food preparation) will promote informed food choices and the consumption of nutritious meals(22). This is needed for children with CD as they enter adulthood due to the complexities of buying and eating safe and healthy GF foods.
The content of the GF food guide was derived by using important methodological approaches which include pre-guide consultations and the evaluation of diet patterns and nutrient intake through diet simulations(48–56). A GF food guide is needed to adequately educate families and their children with CD due to the complexities of the GF diet. Evidence-based and easily accessible resources will provide educational opportunities to help children and their families make informed foods choices to consume a nutritious GF diet. Important nutrients of concern for children with CD on the GF diet are fat, added sugar, folate and vitamin D. This methodological and nutritional analysis highlights the need for policy makers to support the development of dietary guidelines for specialised therapeutic diets and to advocate for nutrient fortification of GF foods particularly when diets represent the main treatment strategy to treat a highly prevalent chronic disease.
Acknowledgements
The authors would like to acknowledge Shelley Case RD, Amanda Liu MSc and Kristin Harms BSc for their assistance with feedback and diet simulation development. The authors would also like to gratefully acknowledge the contribution of the Canadian Celiac Association: Edmonton and Calgary Chapters, and the health care professionals and community end users who provided feedback in the stakeholder consultations.
This work was supported by the Canadian Celiac Association: Edmonton and Calgary Chapters; Alberta Health Services - Maternal Newborn Child and Youth Strategic Clinical Network; Alberta Health Services - the Diabetes, Obesity and Nutrition Strategic Clinical Network; the Canadian Celiac Association: JA Campbell Award 2019 to D. R. M.; and the Vitamin Fund provided by the University of Alberta. Funders had no role in the design, analysis or writing of this article.
D. R. M.: lead role and responsible for all study aspects including design/inception, supervision of data collection, methodology, data analysis, intellectual and scientific interpretation, co-wrote manuscript and approved final manuscript prior to submission. S. C.: contributed to guide conceptualisation, data curation, formal analysis, methodology, resources, software, validation, co-wrote manuscript and approved final manuscript prior to submission. C. L.: contributed to guide conceptualisation, data curation, formal analysis, methodology, project administration, resources, software, validation, co-wrote manuscript and approved final manuscript prior to submission. H. B.: contributed to guide conceptualisation, data curation, investigation, validation, writing-review/editing and approved final manuscript prior to submission. J. D.: contributed to guide conceptualisation, data curation, investigation, validation, writing-review/editing and approved final manuscript prior to submission. H. M.: contributed to guide conceptualisation, data curation, investigation, validation, writing-review/editing and approved final manuscript prior to submission. C. B-H.: contributed to guide conceptualisation, data curation, investigation, validation, writing-review/editing and approved final manuscript prior to submission. R. N.: contributed to guide conceptualisation, data curation, investigation, validation, writing-review/editing and approved final manuscript prior to submission. E. A.: contributed to guide conceptualisation, data curation, investigation, validation, writing-review/editing and approved final manuscript prior to submission. M. M.: contributed to guide conceptualisation, data curation, investigation, validation, writing-review/editing and approved final manuscript prior to submission. J. M. T.: contributed to guide conceptualisation, data curation, investigation, validation, writing-review/editing and approved final manuscript prior to submission.
The authors declare that there are no conflicts of interest.
Supplementary material
For supplementary material referred to in this article, please visit https://doi.org/10.1017/S0007114521000994
