Impact of Mediterranean diet-based nutritional intervention on gluten-free diet, nutritional status, and quality of life in a pediatric celiac population: a randomized controlled trial.

INTRODUCTION: Although strict adherence to gluten-free diet (GFD) is essential for celiac disease (CeD) management, it does not necessarily ensure optimal or nutritionally adequate diet and lifestyle. OBJECTIVE: To assess the impact of combining Mediterranean diet (MD)-based nutritional education, and psychological and culinary workshops on adherence to GFD, dietary quality, physical activity (PA), and quality of life (QoL) in children and adolescents with CeD. METHODS: A randomized controlled trial was conducted in 59 celiac children and adolescents (aged 5-18 years), allocated into two groups. The intervention group (IG, n = 35) received standard therapeutic education plus MD-based nutritional education, psychological support sessions, and cooking workshops. The control group (CG, n = 24) received only standard therapeutic education. Anthropometric measurements, biochemical parameters, MD (KIDMED index) and GFD (CDAT) adherence, PA, CeD-specific QoL (CDDUX), health-related (HR) QoL (KIDSCREEN-10), and nutritional intakes were assessed at baseline and at day 90. A linear mixed- model was used to assess the effect of group, time, and their interaction on MD adherence. A multivariate linear regression analysis was performed to identify independent predictors of change in MD adherence (ΔMD). RESULTS: At day 90, IG exhibited higher MD adherence (p < 0.001), better GFD adherence (p = 0.002), and improved lipid quality (p < 0.05), compared with CG. Moreover, increased intakes of fiber (p = 0.010) and calcium (p < 0.001) were noted. Reduced sedentary time (p = 0.005), and higher CDDUX "GFD domain" scores (p = 0.05) were observed. At day 90 in IG, significant improvements were observed for KIDMED index GFD adherence, as well as fiber, protein and calcium intakes (p < 0.001). Additionally, CDDUX (p < 0.001), and KIDSCREEN-10 (p < 0.001) scores were improved compared with baseline. The linear mixed model revealed a significant group × time interaction (β = -4.42, p < 0.001), indicating that the change in MD adherence over time differed significantly between groups. In multivariate analysis, belonging to the IG (β = 4.52, p < 0.001) and having difficulty in gluten-free bread preparation (β = 1.65, p = 0.008) were independently associated with improvement in ΔMD. CONCLUSION: Integrating MD-based nutritional education into reinforced therapeutic education represents a promising strategy for the long-term management of CeD in children and adolescents.