The results of a large cross-sectional study published in Alimentary Pharmacology & Therapeutics showed that psychological distress and poor knowledge of the gluten-free diet were independent risk factors for inadequate adherence to the gluten-free diet among celiac disease patients.

At present, the only available treatment for celiac disease is maintaining a lifelong, gluten-free diet. Consuming even a small amount of gluten can trigger intestinal damage and severe symptoms in patients with celiac disease. Despite this, a sizeable percentage of those diagnosed with celiac disease report they do not regularly follow a strict, gluten-free diet.

To evaluate which patient factors may influence adherence to the gluten-free diet, the researchers surveyed 5,310 celiac disease patients in Australia and New Zealand. The internet-based survey consisted of questions relating to demographics, knowledge of celiac disease and the gluten-free diet, diagnosis and management, and membership to celiac disease-related groups. Validated measures, such as the Celiac Dietary Adherence Test, Celiac Disease Quality of Life, and the Kessler Psychological Distress Scale were also included in the survey.

The researchers found 61% of survey respondents had very good or excellent adherence to the gluten-free diet. Male gender, older age, more severe symptoms associated with gluten ingestion, better food knowledge scores, and lower levels of psychological distress were all found to independently predict gluten-free diet adherence.

Interestingly, patients with self-perceived poorer knowledge in reading food labels were able to correctly identify gluten-containing foods, but were less likely to correctly identify gluten-free foods. These patients were more likely to be non-adherent. This finding could suggest that, for some patients, a perception of fewer gluten-free options might reduce dietary adherence because they consider following a gluten-free diet to be more challenging and restrictive than those with better knowledge of gluten-free options.

As measured by the Kessler Psychological Distress Scale, 72% of patients met criteria for being well. The remaining patients met criteria for having a mild (14%), moderate (7%), or severe (7%) mental disorder. Higher levels of psychological distress increased the risk for poor dietary adherence.

These results are encouraging because psychological distress and knowledge of the gluten-free diet can be modified to improve health outcomes. Treating physicians should consider mental health assessment and treatment for patients with possible underlying mental health conditions and referral to a dietitian in the context of inadequate food knowledge.