Celiac disease is an immune-mediated enteropathy in which ingestion of gluten leads to intestinal veillositarian atrophy in genetically predisposed individuals [1]. It affects about 1% of the population, making it one of the most common chronic gastrointestinal disorders [2].

The only treatment for celiac disease is strict, lifelong adherence to a gluten-free (GF) diet which is not only complex and expensive, but can also be restrictive in social situations such as restaurant meals, birthdays, wedding parties, etc. Cross-contamination with gluten is a major problem because wheat is ubiquitous in the Moroccan diet. Poorly treated celiac disease can lead to complications, including nutritional deficiencies such as anemia and osteoporosis, stunted growth, infertility, the development of other autoimmune diseases, and malignant tumors [3].

As the number of patients diagnosed with celiac disease increases, the challenges of a gluten-free diet will become more common. There is little information on barriers to diet adherence, particularly the effects of the patient's age or geographical location. Identifying factors that affect adherence would help develop strategies to improve a patient's ability to maintain a strict gluten-free diet. This will not only help to relieve symptoms, but will also reduce the risk of complications.

Purpose of the Work

The purpose of the present study is to evaluate the acceptability and adherence to a GF diet in Moroccan patients with celiac disease (as opposed to Moroccan eating habits where wheat retains an important place) and to identify the factors that may influence this adherence.

This is a prospective study conducted between September 2019 and February 2020, focusing on patients with celiac disease, diagnosed (disease retained on a bundle of clinical, serological and histological arguments) and followed in our structure.

60 files were selected, patients were contacted by phone. A questionnaire was completed by the doctor conducting the study: some of the patients were seen in consultation, the other part answered the questionnaire by phone.

Each patient was subjected to a questionnaire (in consultation or by telephone) in order to obtain information on the patient, his family environment (socio-economic level, education of patients and parents) and on the gluten-free diet adopted.

Presentation of the Study Population

The study was carried out in 60 patients with celiac disease, followed in our training including 46 women (76.7%) and 14 men (23.3%) with a Sex Ratio of 3/1 (Figure 1).

Figure 1: Distribution of Patients by Sex

The average age of our patients is 31 years with extremes ranging from (16-54 years).

With regard to the level of family education, it is noted that for 18% of our patients, the level of education is high (at least one person with a university education), for 62%, the level of education is medium (a member of the small family or the patient himself having a secondary or basic level), for 20%, the level of education is low (the highest level of education in the family does not exceed the primary level).

For the socio-economic level of patients, about 58% of patients belong to a medium level, 32% to a low level and 10% to a high level.

Adherence

58% of patients admitted to having difficulty accepting their disease mainly in the age group between 16 and 34 years.

Adherence to an RSG is estimated based on the frequency of consumption of gluten-free products and the improvement in symptoms. 35% of survey respondents having poor compliance with the RSG (consumption of products with gluten, presence of symptoms). Strict adherence to the RSG was associated with a favourable clinical response defined by a significant decrease in the frequency and intensity of clinical symptoms in 48% of cases. However, 17% of respondents reported minimal clinical response or lack of improvement despite a respected RSG.

Adherence by Level of Education

Adherence to the RSG increases with the increase in the level of education of celiac patients. Among the 48% of celiac patients who have a good adherence to the RSG we find that 13% belong to a high level of education and 29% to an average level (Figure 2).

Figure 2: Distribution of Patients by Level of Education and Adherence to the RSG

Adherence According to Socio-Economic Level

Good compliance with the RSG is also linked to the socio-professional level of celiac patients. There was good adherence among patients belonging to households of medium (39%) and high (7%) economic level. For those belonging to households of low economic level only (2%) of patients have good compliance (Figure 3).

Figure 3: Distribution of Patients by Socio-Professional Level and Adherence to the GFR

Effectiveness of the Gluten-Free Diet

48% of our patients say that the gluten-free diet has brought an improvement to their health situation by reducing the frequency and intensity of symptoms compared to 52% of cases without a clear improvement.

The lack of improvement in patients is due to the reason that 35% of them do not adhere to their diet. The remaining 17%, 16% do not really know the products allowed and prohibited for such a diet and a celiac patient suspected of complication of celiac disease (degeneration).

Difficulties in Applying the GSR

98% of patients report the presence of several difficulties that prevent the strict application of the diet. The high price of gluten-free products with 48%, the unavailability by 56% and the difficulty of preparing gluten-free foods with 32%. Non-diversity in 24%.

Problems Caused by the Regime

Out-of-home feeding and anorexia are the major problems caused by the application of RSG in the patients surveyed with 72% and 68% respectively.

About 40% of patients report that RSG causes loss of conviviality and more loneliness with non-compliance with parties and group and family events.

The only treatment for celiac disease until today is the eviction of gluten which is not only present in cereals but also in some cosmetics and medicines [4]. To better adhere to a gluten-free diet, The National Institutes of Health in 2005, was able to identify the 6 key elements to succeed in a gluten-free diet (RSG):

• ü consultation with a qualified dietician

• ü education on the disease

• ü adherence to the gluten-free diet for life

• ü identification and treatment of nutritional deficiencies

• ü membership of a support group

• ü continue the follow-up by a long-term multidisciplinary team

The effectiveness and monitoring of the gluten-free diet is assessed by clinical and biological improvement after one to three months of diet and by regression of histological abnormalities and negativation of specific antibodies after 12 months of diet [5].

The interest of the diet is to improve the symptoms, nutritional status and quality of life of the patient, thus preventing complications such as undernutrition, osteoporosis and degeneration.

This diet can cause several problems including the deterioration of the patient's social life due to dietary restrictions [6-7] Depressive behaviors can also be seen, due to the chronic nature of the disease [6], accentuated if there are associated autoimmune pathologies [8].

Adherence to the diet is essentially impaired in adolescents by non-acceptance of the disease, the factors that influence this adherence are: age at the time of diagnosis [9], the level of instruction of the patient and his small family, and the socio-economic level (expensive gluten-free products) [10-11].

In our series the main problems encountered daily by Moroccan celiac patients are essentially:

• ü the non-availability and diversity of gluten-free products

• ü the high cost of these products;

• ü the poor quality of gluten-free products marketed on the market

• Ü the lack of specialized bodies to inform patients and their families about the details of their illness and the appropriate dietetics (prohibited foods and inexpensive recipes for authorized foods)

Celiac disease is a global health problem for which no treatment exists other than the eviction of gluten. The principle of treatment is theoretically simple, the follow-up of this diet for life is in practice difficult, and its difficulties stem mainly from the high price of gluten-free products, the non-availability and poor quality of products. This makes it difficult to observe the gluten-free diet in the diet of celiac patients, especially for the Moroccan population.

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