Factors associated with adherence to gluten-free diet among celiac patients in Palestine: a cross-sectional study

Abstract Celiac disease (CD) is an autoimmune disease. Since the only treatment is a lifelong strict gluten-free diet (GFD), good adherence is the cornerstone. No research has examined the degree of GFD adherence among CD patients in Palestine and how it impacts the disease activity and prognosis. Therefore, this study aims to determine the level of adherence to GFD among adult patients with (CD) in Palestine, and its association with disease activity, mental health, patients’ awareness, attitude, barriers, lifestyle, and sociodemographic variables. The study involved 137 patients with celiac disease using a cross-sectional design. Participants were recruited from private and governmental clinics, as well as community-based lists and associations. Disease activity was measured using the Celiac Symptom Index (CSI), mental health was measured using the General Health Questionnaire (GHQ-12), and knowledge, awareness, attitudes, and barriers were assessed using a structured questionnaire developed by the research team. Adherence level was measured through the participants’ practices section of the questionnaire. A multivariate logistic regression was performed. The mean age of participants was 37.7 ± 13.1 years, and the majority were female (71%). Overall, 36.5% of participants demonstrated high adherence, 61.3% moderate adherence, and 2.2% low adherence. Bivariate analysis showed that symptom burden (CSI), psychosocial distress (GHQ-12), subjective knowledge, attitudes, and barriers related to meal preparation and social situations were significantly associated with adherence ( P < 0.05). However, multivariate analysis identified a more positive attitude toward a gluten-free diet as the most consistent independent predictor of higher adherence, while the association with male sex was weaker and less stable across sensitivity analyses. A more positive attitude toward a gluten-free diet was the most consistent independent correlate of higher adherence, while the association with male sex was weaker and less stable across sensitivity analyses. These findings underscore the central role of attitudinal factors in shaping adherence and support the development of targeted, culturally sensitive interventions to optimize outcomes in patients with celiac disease.