pediatrics
August 2018, VOLUME142 /ISSUE 2

The Nutritional Quality of Gluten-Free Products for Children

  1. Charlene Elliott, PhD
  1. Department of Communication, Media, and Film, University of Calgary, Calgary, Alberta, Canada
  1. Dr Elliott conceptualized and designed the study, executed the data collection, researched and wrote the manuscript, approved the final manuscript as submitted, and agrees to be accountable for all aspects of the work.

Abstract

OBJECTIVES: To examine the nutritional quality of gluten-free (GF) products specifically marketed for children.

METHODS: All child-targeted food products were purchased from 2 major supermarket chains in Calgary, Alberta, Canada. Using the Pan American Health Organization Nutrient Profile Model, the nutritional quality of products with a GF claim was compared with those without such a claim. A secondary analysis further compared the nutrient profile of child-targeted GF products to their product “equivalents.”

RESULTS: Overall, child-targeted GF products had lower levels of sodium, total fat, and saturated fat but also had less protein and a similar percentage of calories from sugar compared with child-targeted products without a GF claim. According to the Pan American Health Organization criteria, both GF products and "regular" products designed for children can be classified as having poor nutritional quality (88% vs 97%; P < .001). When analyzed in light of their product equivalents without a GF claim, both had similarly high levels of sugar (79% vs 81%; P < .001).

CONCLUSIONS: GF supermarket foods that are targeted at children are not nutritionally superior to regular child-targeted foods and may be of greater potential concern because of their sugar content. The health halo often attributed to the GF label is not warranted, and parents who substitute GF products for their product equivalents (assuming GF products to be healthier) are mistaken. Parents of children with gluten intolerance and/or sensitivity, along with parents who purchase GF products for other health reasons, need to carefully assess product labels when making purchases.

  • Abbreviations:
    CD
    celiac disease
    GF
    gluten-free
    PAHO
    Pan American Health Organization
  • What’s Known on This Subject:

    Gluten-free (GF) products tend to have a health halo for consumers, although they are not nutritionally superior to regular foods. Children on GF diets may struggle to get adequate nutrition; they also consume more sugars (related to processed food intake).

    What This Study Adds:

    In this first study of child-targeted GF foods, the findings reveal that GF-labeled products are not nutritionally superior to other children’s foods nor to their gluten-containing equivalents. Approximately 80% of child-targeted GF products have high sugar levels.

    Celiac disease (CD) is an inherited immune reaction that is triggered by gluten, a protein found in wheat, rye, barley, and other grains. Among the most prevalent chronic diseases, CD is estimated to affect 1% of the world’s population.14 Given CD’s genetic basis, children are equally affected. Approximately 1% of children have CD,5 making it “one of the most common chronic disorders” in young people.6

    Treating CD requires a strict dietary regimen that is free of gluten. However, interest in gluten-free (GF) products from consumers without CD has burgeoned over the past decade. GF has been labeled “the fastest growing food intolerance category”2 and has been lauded for its “market potential.”2 Sales of GF foods globally are projected to reach $4.89 billion (US dollars) by 2021, expanding from $2.84 billion in 2014.7 In the United States, the world’s largest GF market, sales are projected to exceed $2 billion in 2020, an increase of almost $400 million since 2015.8 Reasons for this growth are not only due to purchases by those with CD or those with a gluten sensitivity but are also propelled by changes in consumer attitudes toward health. Mainstream consumers are experimenting with their diets for health-related reasons, and “free-from” foods (such as GF foods) are part of that trend.9 The Washington state–based Hartman Group’s Health and Wellness 2017 report reveals that consumer motivations for purchasing GF products include, among other things, the desire to “try something new” (35%), the belief that GF foods are “healthier” (30%), the desire to lose weight (23%), experimenting with a new eating plan (19%), and the belief that GF foods taste better (14%). Only 6% of the consumers surveyed said that they purchased GF products because they are allergic to gluten.9

    The dynamic growth of the GF market has been accompanied by an increased scrutiny of the nutritional quality and composition of GF products.1012 However, the nutritional quality of GF products specifically marketed for children has not been examined in a published study. Given that some parents opt for GF products because they believe that they will be healthier for their children13 and that the trade press has identified GF children’s food as a “big area for growth,”13 an analysis of these products is warranted. In this study, a novel contribution in 2 additional respects is provided: (1) the nutritional quality of GF children’s food products is compared with “regular” child-targeted foods found in the supermarket, and (2) the nutritional quality of a selection of GF children’s food products is compared with that of their product “equivalents” without a GF claim (eg, GF macaroni and cheese versus regular macaroni and cheese).

    Methods

    Following previous studies in which “fun foods” aimed at children were analyzed,14,15 all child-targeted food products were purchased from 2 major supermarket chains in Calgary, Alberta, from February 2017 to March 2017. Canada has 2 major national retail grocery and food distributors (Loblaw Companies Ltd and Sobeys Inc), and a large supermarket that represents each of these national grocery distributors was visited for data collection. Stores were visited multiple times during the data collection phase to ensure that no products were missed.

    In the study, children’s food was examined, not candy or junk food, so confectionary products (such as candies and chocolate bars), potato chips, cheese-flavored snacks, sugary sodas, etc were excluded from the sample. Instead, the intent was to examine the regular foods that have been repackaged to attract children. Products were identified as child targeted if they met 1 of the following criteria14,15:

    • the product or brand name contains the word “kids” or “child” or is marketed as specifically designed for children (eg, EnviroKidz, Chapman’s Kids, CLIF Kid);

    • links with children’s television programs, merchandise, or movies (ie, character licensing);

    • promoted for lunchboxes (including Lunchables);

    • contains child-friendly graphics (ie, cartoons or bubble font) or activities (games, puzzles, or crafts);

    • contains the word “fun,” “play,” or “kid(s)” on the package;

    • contains premium offers for children (ie, a free gift inside the package, a free download, merchandise with a code, etc); and

    • presents unusual or child-oriented shapes, unusual colors, or playful product names or tastes (eg, Flavor Blasted Xplosive Pizza–flavored crackers and Princess Potion–flavored ice cream).

    Duplicate products were excluded from the analysis. Products were photographed, and a research assistant coded them for variables, including the brand, product name, food category, food type, and presence of a specific GF claim. Nutrition information was recorded for all products.

    By using the Pan American Health Organization (PAHO) Nutrient Profile Model,16 nutritional content was compared between child-targeted products that contained a specific GF claim and those without a such claim. Products had different portion sizes; therefore, all portions and nutritional values per serving were adjusted to represent a 100 g serving. Overall poor nutrition was calculated by using the following PAHO criteria16: excessive sodium (ratio between sodium and energy ≥1), excessive free sugars (amount of energy from free sugar [g × 4 kcal] ≥10% of total energy), containing other sweeteners, excessive total fat (amount of energy from total fat [g × 9 kcal] ≥30% of total energy), and/or excessive total saturated fat (amount of energy from total saturated fat [g × 9 kcal] ≥10% of total energy). In keeping with PAHO recommendations, the PAHO criteria was only applied to processed and ultraprocessed foods within the sample. Note that the definition of “free sugars” comes from the World Health Organization and refers to monosaccharides (such as glucose and fructose) and disaccharides (such as table sugar) added to foods and drinks by the manufacturer, cook, or consumer and sugars naturally present in honey, syrups, fruit juices, and fruit juice concentrates. Free sugars were estimated as the total sugar content of products in which added sugars were listed in the first 3 ingredients (free sugars were calculated as 0 g for products with no added sugars).

    A secondary analysis was undertaken in which the nutrient profiles of the products with a GF claim were compared with those of their product equivalents. For example, EnviroKidz Apple Cinnamon–flavored oatmeal (with a GF claim) has a product equivalent (without a GF claim) in Quaker Apples and Cinnamon–flavored oatmeal. This also holds true for EnviroKidz Brown Sugar Maple Oatmeal (GF claim) and Quaker Maple and Brown Sugar Oatmeal (no GF claim). Similarly, the Nudge GF macaroni and cheese (white cheddar) has a product equivalent without a GF claim in the Kraft macaroni and cheese dinner (white cheddar). Along these lines, product equivalents to the products with a GF claim were purchased on a separate grocery trip (October 2017) so that nutritional comparisons between GF products and their counterparts without a specific GF claim could be made. A comparison by food category was also performed.

    Statistical analyses were performed in SAS 9.4 (SAS Institute, Inc, Cary, NC). t tests and χ2 tests were used to compare average nutrition content with and without gluten for the overall data set (variables were tested for skewness before reporting means). For the secondary analysis of matched products, paired t tests were used to compare nutrition content. In all analyses, a 5% significance level (P < .05) was considered.

    Results

    A total of 374 child-targeted products were purchased, and ∼18% of the sample (66 products) had a specific GF claim. Overall, products with a GF claim had lower levels of protein, sodium, total fat, and saturated fat compared with products without a GF claim. Free sugar levels were similar for child-targeted GF products versus child-targeted regular products (Table 1); and there was no difference in sugar accounting for the percentage of calories (P = .954). In fact, 80% of child-targeted GF products have high sugar levels (Table 1). When analyzed in light of the PAHO criteria, 88% of GF child-targeted products were classified as having poor nutritional quality compared with 97% of the child-targeted regular products (those without a specific GF claim; 88% vs 97%; P < .001; Table 1).

    TABLE 1

    Average Nutritional Values for Child-Targeted Products With a GF Claim Versus Child-Targeted Products With No Claim

    This comparison was repeated for child-targeted GF products against their product equivalents that did not have a specific GF claim. Although 66 of 374 child-targeted products had a specific GF claim, only 43 GF products in the data set were matched with comparable products because the pairing was precise. As mentioned, EnviroKidz GF instant oatmeal (Apple Cinnamon) was paired with Quaker instant oatmeal (Apples and Cinnamon; without a GF claim). However, GF products such as Chapman’s Kids Princess Potion–flavored ice cream (Pink Marshmallow, Blue Cake, and Vanilla Ice Cream With Colorful Sprinkles), Ouhlala Buddy Fruits (Banana Passion and Mango) applesauce pouches, General Mills Chex (Chocolate), and SimplyProtein Kids Bars did not have clear product equivalents without a GF claim; therefore, no match was included in the data set. For these 43 GF products and their equivalents, the caloric content, fat, and protein levels were similar per 100 g. However, GF products had higher levels of free sugars and lower levels of sodium when compared with their matched products (Table 2). Compared to the matched products, GF-labeled products were similar in terms of the percentage of products that contained high sugar levels (79% vs 81%; P < .001). A higher proportion of the GF products had high levels of fat and trans fat (Table 3). Overall, the nutritional quality of both GF-labeled products and their matched products was poor, according to the PAHO criteria (88% vs 93%; P < .001; Table 3). When viewed in terms of average calories and nutrients in 100 g of products in each food category (Table 4), child-targeted GF cookies or biscuits have fewer calories, and fruit snacks or applesauce have higher levels of sugar than their equivalents. When the entire data set of child-targeted foods is analyzed in terms of average calories and nutrients in 100 g of the products per category (products with a GF claim versus products without a GF claim), the GF products show a slightly better nutritional profile compared with the regular child-targeted foods. By category, GF cookies or biscuits have fewer calories and less fat; GF fruit snacks or applesauce have less sugar; GF granola bars have less sugar, sodium, and saturated fat; and GF ice cream has fewer calories, less sugar, and less sodium. This said, GF pastas and soups have higher levels of saturated fat than the regular products (Table 5). Note, however, that the sample sizes are small within the categories.

    TABLE 2

    Average Nutrition Levels for Child-Targeted GF Products Versus Product Equivalent With No Claim (per 100 g)

    TABLE 3

    Difference in Proportion of Nutrition Categories for Child-Targeted GF Products Versus Product Equivalent With No Claim

    TABLE 4

    Child-Targeted Products With a GF Claim Versus Product Equivalents With No Claim: Average Calories and Nutrients Comparison in 100 g Serving of Products in Each Food Category (Matched Data, N = 43)

    TABLE 5

    Child-Targeted Products With a GF Claim Versus Child-Targeted Products With No Claim: Average Calories and Nutrients Comparison in 100 g Serving of Products in Each Food Category (Full Data, N = 374)

    No significant difference exists between serving size or servings per package for GF products versus their no claim product equivalents, with the exception of slightly smaller serving sizes for fruit snacks or applesauce with a GF claim (P = .002; Table 6).

    TABLE 6

    Child-Targeted Products With a GF Claim Versus Child-Targeted Products With No Claim: Serving Sizes of Products (Matched Data, N = 43)

    Discussion

    Despite the health halo associated with GF products,17 this study reveals that child-targeted GF foods are not nutritionally superior to the children’s food products without a specific GF claim in the supermarket. Similarly, the nutritional quality of children’s GF products is comparable with that of their product equivalents without a GF claim. These findings align with previous studies in which the authors reported that GF products do not fare better nutritionally than their paired gluten-containing equivalents.10 Previous studies also reveal that GF products typically have a similar caloric value18 and lower average protein levels3,10,19; some authors report significantly inferior levels of dietary fiber.3 Although not statistically significant, lower protein levels in GF products were also reported in this study.

    These findings have implications for children both with and without a gluten intolerance. Children with CD and gluten sensitivity may have difficulty getting adequate nutrition from the packaged foods available in the marketplace. Consuming a nutritionally adequate GF diet has been deemed a major challenge for children,20 particularly because of the higher glycemic index of processed GF food.20 More importantly, this research reveals that 88% of the packaged GF foods aimed at children can be classified as unhealthy because of their high levels of sugar, sodium, and/or fat, which means that the options for purchasing healthy packaged foods are limited. As for the parents who purchase GF products for their children because they believe such items are healthier than regular products, this study reveals that there is little nutritional advantage to doing so. Such findings echo those in other studies of child-targeted supermarket foods and reveal that products marketed as “better for you” for children are as much about marketing as they are about nutrition.14 This holds true for products aimed at even our youngest consumers, which have been found to fare poorly when it comes to sugar and sodium.21,22 In the case of GF foods, the situation is concerning insomuch as the amount of sugar is high in both child-targeted GF products and child-targeted regular products (Table 1). In the paired data set (Table 3), both the GF-labeled products and their gluten-containing counterparts had a large percentage of products with high sugar levels (79% vs 81%; P < .001).

    It is worth noting that the average serving sizes for products with a GF claim in the full data set (n = 374) are significantly smaller than those for regular products. However, although eating less might be considered a positive step in our “eat more” environment,23 smaller serving sizes do not compensate for products that are of poor nutritional quality in the first place. Given children’s lower daily caloric intake and the challenges associated with consuming a nutrient-rich GF diet for children with CD in particular,20 it is important that the products designed for children are held to a higher nutritional standard.

    Limitations of this study are that it does not purport to represent all child-targeted GF products available in the marketplace. Although the data set represents a significant portion of child-targeted GF foods and brands collected from the country’s 2 largest supermarket chains, including other supermarkets and retail outlets would broaden its scope. A second limitation pertains to the use of GF labeling in products that are naturally free of gluten; this is particularly salient to the category of fruit snacks or applesauce because neither applesauce nor fruit snacks contain gluten. In this case, the use of a GF claim on products that are inherently free of gluten might be understood as a marketing tool directed at consumers who view GF products as healthier than their regular counterparts. This is why the study used the terms “gluten free claim” and “no claim” rather than “gluten free” and “contains gluten” because some products without a GF claim may in fact be free of gluten. For those products that are naturally GF, the applesauce or fruit snack matches were the same brands; in this case, the sugar levels were higher for those with a GF label compared with those without a GF label (103.28 g vs 50.40 g; P < .001). Finally, in designing the study, the researchers elected not to collect child-targeted GF products from brand Web sites. The choice to go into the stores and purchase what parents actually have available to them is considered a strength rather than a limitation, however. Relying on Web sites could misrepresent the number of products available; for example, discontinued items are often still found on the Web, and products posted on Web sites do not always reflect the current promotions targeted at children (eg, soups that feature Star Wars characters and shapes, cereals with links to the movie Frozen, etc).

    Conclusions

    As the first study in which the nutritional quality of GF supermarket products targeted at children are examined, this research reveals that products with a GF claim are not nutritionally superior. This has implications for parents who seek healthy products for their children, especially in the case of children with CD (for whom gluten must be avoided), but also in the case of parents who mistakenly believe that GF products will confer health benefits. It is important to unsettle the assumption that GF food equals healthy,17 which has functioned as an excellent sales tool for the food industry but does little to support public health. Reminding parents and caregivers to read the nutrition facts table and to serve whole, unprocessed foods is 1 step in the right direction; so too is the development of a policy that allows consumers to easily assess the nutritional quality of packaged products (such as an easily understood, federally regulated front-of-pack symbol). This is particularly important in light of the finding that foods targeted at children in general (both GF and regular products) are of poor nutritional quality.

    Acknowledgment

    Thank you to Ms Danielle A. Southern, who performed the data analysis and reviewed the final article.

    Footnotes

      • Accepted May 11, 2018.
    • Address correspondence to Charlene Elliott, PhD, Department of Communication, Media, and Film, University of Calgary, SS236, 2500 University Dr NW, Calgary, AB T2N 1N4, Canada. E-mail: charlene.elliott{at}ucalgary.ca
    • FINANCIAL DISCLOSURE: The author has indicated she has no financial relationships relevant to this article to disclose.

    • FUNDING: Funded by the Canadian Institutes of Health Research Canada Research Chairs Program.

    • POTENTIAL CONFLICT OF INTEREST: The author has indicated she has no potential conflicts of interest to disclose.

    References