Rate, Risk Factors, and Outcomes of Nonadherence in Pediatric Patients With Celiac Disease: A Systematic Review

Adherence to a gluten-free diet in children with coeliac disease may vary between 45% and 90%.

“reinforcing at each visit the importance of dietary compliance which may vary between 45-90% (6-9).”

Compared with other methods to evaluate adherence, GIP testing disclosed the lowest adherence rate to the gluten-free diet (75%).

“Compared with other methods to evaluate adherence, GIP testing disclosed the lowest adherence rate to the GFD (75%), suggesting that this assay is more sensitive than others to detect cases occasionally exposed to inadvertent gluten ingestion (9).”

GIP testing is more sensitive than other methods to detect cases occasionally exposed to inadvertent gluten ingestion.

“suggesting that this assay is more sensitive than others to detect cases occasionally exposed to inadvertent gluten ingestion (9).”

A recent systematic review including 7850 children from 49 studies published up to 2019 showed a median adherence rate to the gluten-free diet of 78% (range 23% to 98%) in paediatric patients.

“A recent systematic review including 7850 children from 49 studies published up to 2019, showed a median adherence rate to GFD of 78% (23% to 98%) in paediatric patients (132)”

Age and age at diagnosis have been observed as an important factor for adherence to the gluten-free diet.

“Age and age at diagnosis have been observed as an important factor for adherence.”

Difficulties in investigating adherence to the gluten-free diet include the definition of strict adherence and the different methods to assess adherence, which are most frequently subjective.

“Some of the difficulties when investigating adherence to the GFD include, the definition of 'strict adherence' and the different methods to assess adherence to GFD, which are most frequently subjective (132).”

Adherence rates to the gluten-free diet were similar regardless of the method used: 87% for biopsies, 81% by self-reports, 77% for structured dietary reports, 76% for serology tests, and 75% for GIP.

“Adherence rates were similar regardless of the method used: 87% for biopsies, 81% by self-reports, 77% for structured dietary reports, 76% for serology tests and 75% for GIP.”

Adherence rate to the gluten-free diet varied with geographical area: Scandinavia 90%, Europe excluding Scandinavia 74%, and North America 79%.

“which varied with geographical area: Scandinavia 90%, Europe (excluding Scandinavia) 74% and North America 79%.”

There is no clear association between adherence to the gluten-free diet and factors such as gender, the presence of comorbidities other than anxiety and depression, the presence of coeliac disease-related symptoms at diagnosis, the presence of extradigestive symptomatology, family history of coeliac disease, or socioeconomic status.

“There is no clear association between adherence to the GFD and factors such as gender (132,137,141), the presence of comorbidities other than anxiety and depression (132,141), the presence of CD-related symptoms at diagnosis, the presence of extradigestive symptomatology, family history of CD or socioeconomic status (132).”

Several factors that have been identified to influence adherence, either personal or situational factors, are summarized in Figure 6.

“Several factors that have been identified to influence adherence, either personal or situational factors (environmental barriers that hinder adherence and resources that promote it), are summarized in Figure 6 (47,132,137,141,143,152-164).”

Adolescence is considered to be a critical period where adherence to the gluten-free diet is frequently poorer than in younger children.

“Specifically, adolescence is considered to be a critical period were adherence is frequently poorer than in younger children, although some authors did not find such association (132).”

Some authors did not find an association between adolescence and poorer adherence to the gluten-free diet.

“although some authors did not find such association (132).”

Systematic dietary interviews are time-consuming and have shown large variability.

“It is timeconsuming and has shown large variability (132), although efforts have been made to standardize the methodology (133).”

Adherence to the gluten-free diet can be assessed by systematic dietary interviews by a trained dietitian.

“Adherence to the GFD can be assessed by systematic dietary interviews by a trained dietitian.”