Adherence to a Gluten-Free Diet is associated with receiving gluten-free foods on prescription and understanding food labelling
Muhammad H, Reeves S, Ishaq S et al. Nutrients 2017, 9, 705; doi:10.3390/nu9070705
The only treatment for coeliac disease (CD) is a strict lifelong gluten-free diet (GFD). Adherence to the diet can be challenging and reported rates vary from 36% to 96%. Adherence is associated with a range of different factors including availability and cost of manufactured gluten-free (GF) versions of wheat-based products. The current trend for restriction of GF prescriptions, along with higher costs and limited availability in supermarkets, could lead to long-term health risks for people with CD, through dietary non-adherence.
The only treatment for coeliac disease (CD) is a strict lifelong gluten-free diet (GFD). Adherence to the diet can be challenging and reported rates vary from 36% to 96%. Adherence is associated with a range of different factors including availability and cost of manufactured gluten-free (GF) versions of wheat-based products. The current trend for restriction of GF prescriptions, along with higher costs and limited availability in supermarkets, could lead to long-term health risks for people with CD, through dietary non-adherence.
This cross-sectional study explored if practical factors have an impact on adherence to a GFD in adult Caucasians and South Asians with CD in England. 972 patients were identified from a hospital database with histologically-confirmed CD and supporting coeliac serology, over a ten year period. Information was collected on diagnosis, dietary habits, symptoms, interaction with clinicians (physicians and dietitians) and the practicalities of following a GFD. The validated Coeliac Dietary Adherence Test (CDAT) was used to determine dietary adherence. 375 adults with CD (39%) completed the questionnaire with respondents being significantly younger than those who did not. A significantly lower proportion of South Asians returned the questionnaire compared with Caucasians (337 Caucasians and 38 South Asians). Whilst 62% of respondents self-reported never knowingly ingesting gluten, only 52% were found to adhere to a GFD when assessed by CDAT score. Similar CDAT scores were seen for those diagnosed in childhood and those diagnosed as adults. Of the 139 patients who reported ingesting gluten at least once a month, only 84 reported symptoms after gluten ingestion.
A lack of understanding of food labels was significantly associated with poorer dietary adherence with 73% of those reporting a lack of understanding classed as not adhering to a GFD compared with 45% who understood labels. Over half of South Asian respondents reported difficulty in this area compared with just 4% of Caucasians. A significantly higher proportion of patients adhered to a GFD when receiving GF foods on prescription compared with those not receiving a GF prescription. Of those respondents not receiving GF foods on prescription, 62% were classified as not adhering to diet compared with 42% of those receiving a prescription. Only 53% of respondents had joined the patient charity. Those who were members had a significantly lower CDAT score than non-members. There were a number of reasons for not joining with the most common being that they did not feel it was important (48%). There was no real difference in membership of Coeliac UK between Caucasians and South Asians. Interestingly, CDAT scores were similar between South Asians who were members and those who were not. In addition South Asian respondents reported a greater dislike of GF foods which is of interest because within the total cohort, there was a higher CDAT score in those reporting a dislike of these foods, although similar CDAT scores were observed in South Asians who like and disliked GF foods.
A direct logistic regression model was built to explore what practicalities influence patients not adhering to a GFD and it contained four independent variables (based on patient responses): i) ‘My GP does not prescribe GF products’; ii) I don’t understand labelling on foods’; iii) GF foods have an unpleasant taste’ and iv) ‘whether they were a member of Coeliac UK’. The full model was significant and explained 7-10% variance in gluten ingestion. Additional factors that may be associated with adherence including psychological traits were not assessed and this helps to explain why only 7-10% of variance was accounted for.
The authors recommend retaining an adequate provision of GF foods on prescription, improving access to suitably priced GF foods, membership of a coeliac society and regular dietetic consultations to support patients in adherence to a GFD.
A lack of understanding of food labels was significantly associated with poorer dietary adherence with 73% of those reporting a lack of understanding classed as not adhering to a GFD compared with 45% who understood labels. Over half of South Asian respondents reported difficulty in this area compared with just 4% of Caucasians. A significantly higher proportion of patients adhered to a GFD when receiving GF foods on prescription compared with those not receiving a GF prescription. Of those respondents not receiving GF foods on prescription, 62% were classified as not adhering to diet compared with 42% of those receiving a prescription. Only 53% of respondents had joined the patient charity. Those who were members had a significantly lower CDAT score than non-members. There were a number of reasons for not joining with the most common being that they did not feel it was important (48%). There was no real difference in membership of Coeliac UK between Caucasians and South Asians. Interestingly, CDAT scores were similar between South Asians who were members and those who were not. In addition South Asian respondents reported a greater dislike of GF foods which is of interest because within the total cohort, there was a higher CDAT score in those reporting a dislike of these foods, although similar CDAT scores were observed in South Asians who like and disliked GF foods.
A direct logistic regression model was built to explore what practicalities influence patients not adhering to a GFD and it contained four independent variables (based on patient responses): i) ‘My GP does not prescribe GF products’; ii) I don’t understand labelling on foods’; iii) GF foods have an unpleasant taste’ and iv) ‘whether they were a member of Coeliac UK’. The full model was significant and explained 7-10% variance in gluten ingestion. Additional factors that may be associated with adherence including psychological traits were not assessed and this helps to explain why only 7-10% of variance was accounted for.
The authors recommend retaining an adequate provision of GF foods on prescription, improving access to suitably priced GF foods, membership of a coeliac society and regular dietetic consultations to support patients in adherence to a GFD.
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