{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T05:18:10Z","timestamp":1787894290487,"version":"build-2784847793"},"reference-count":78,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T00:00:00Z","timestamp":1787875200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Nutr."],"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To assess the impact of combining Mediterranean diet (MD)\u2013based 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      A randomized controlled trial was conducted in 59 celiac children and adolescents (aged 5\u201318 years), allocated into two groups. The intervention group (IG,\n                      <jats:italic>n<\/jats:italic>\n                      = 35) received standard therapeutic education plus MD\u2013based nutritional education, psychological support sessions, and cooking workshops. The control group (CG,\n                      <jats:italic>n<\/jats:italic>\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 (\u0394MD).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      At day 90, IG exhibited higher MD adherence (\n                      <jats:italic>p<\/jats:italic>\n                      &amp;lt; 0.001), better GFD adherence (\n                      <jats:italic>p<\/jats:italic>\n                      = 0.002), and improved lipid quality (\n                      <jats:italic>p<\/jats:italic>\n                      &amp;lt; 0.05), compared with CG. Moreover, increased intakes of fiber (\n                      <jats:italic>p<\/jats:italic>\n                      = 0.010) and calcium (\n                      <jats:italic>p<\/jats:italic>\n                      &amp;lt; 0.001) were noted. Reduced sedentary time (\n                      <jats:italic>p<\/jats:italic>\n                      = 0.005), and higher CDDUX \u201cGFD domain\u201d scores (\n                      <jats:italic>p<\/jats:italic>\n                      = 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 (\n                      <jats:italic>p<\/jats:italic>\n                      &amp;lt; 0.001). Additionally, CDDUX (\n                      <jats:italic>p<\/jats:italic>\n                      &amp;lt; 0.001), and KIDSCREEN-10 (\n                      <jats:italic>p<\/jats:italic>\n                      &amp;lt; 0.001) scores were improved compared with baseline. The linear mixed model revealed a significant group \u00d7 time interaction (\u03b2 = \u22124.42,\n                      <jats:italic>p<\/jats:italic>\n                      &amp;lt; 0.001), indicating that the change in MD adherence over time differed significantly between groups. In multivariate analysis, belonging to the IG (\u03b2 = 4.52,\n                      <jats:italic>p<\/jats:italic>\n                      &amp;lt; 0.001) and having difficulty in gluten-free bread preparation (\u03b2 = 1.65,\n                      <jats:italic>p<\/jats:italic>\n                      = 0.008) were independently associated with improvement in \u0394MD.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Integrating MD\u2013based nutritional education into reinforced therapeutic education represents a promising strategy for the long-term management of CeD in children and adolescents.<\/jats:p>\n                  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