Future Doctors in Palestine Fall Short on Celiac Disease and Gluten-Free Nutrition Knowledge

Celiac disease is one of the most common chronic autoimmune conditions in the world, yet the physicians of tomorrow may be startlingly unprepared to manage it. A new cross-sectional study conducted in the West Bank, Palestine, and published in BMC Medical Education, has found that fewer than three in ten medical students and internship doctors possess adequate general knowledge of celiac disease, and fewer than one in five demonstrate adequate knowledge of the nutritional deficiencies and diet-quality issues that define long-term care for these patients. The findings, drawn from 479 future physicians across Palestinian medical schools, expose a training gap that the study’s authors argue must be closed before a new generation of doctors enters clinics and wards.

The research team, led by Tala Imad Ikhzamia of the Faculty of Medicine at Arab American University of Palestine and corresponding author Hamza Karmi of Al-Quds University, set out to measure a dimension of medical training that is often overlooked: not whether trainees can recognize celiac disease in a textbook, but whether they can guide patients through the lifelong dietary management that is the only available treatment. Celiac disease is triggered by gluten, a family of proteins found in wheat, barley, and rye, and its management requires strict adherence to a gluten-free diet, ongoing nutritional monitoring, assessment of diet quality, and collaboration with dietitians. A doctor who cannot advise on these elements leaves a patient with only half a treatment plan.

The study employed a cross-sectional survey design targeting medical students and internship doctors throughout the West Bank. The investigators adapted a questionnaire covering general celiac disease knowledge, knowledge of nutritional deficiencies associated with the condition, attitudes toward vitamin D monitoring and dietitian involvement, and perceived barriers that patients face in adhering to a gluten-free diet. To keep the analysis clean, the main analyses included only participants who had heard of celiac disease and who had no personal or family diagnosis of the condition, removing the confounding effect of lived experience with the disease. The researchers set explicit thresholds for competence: adequate general celiac disease knowledge was defined as a score of at least 17 out of 27, while adequate nutritional-deficiency knowledge required at least 13 out of 21.

The headline numbers are sobering. Among the 479 participants, comprising 253 medical students and 226 internship doctors, only 138 individuals, or 28.8 percent, achieved adequate general celiac disease knowledge. Performance on the nutritional side was even weaker: just 84 participants, or 17.5 percent, reached the threshold for adequate nutritional-deficiency knowledge. This means that more than four out of five future physicians surveyed could not reliably answer questions about the micronutrient shortfalls, vitamin deficiencies, and dietary quality concerns that dominate the day-to-day health of people living with celiac disease.

Diagnostic knowledge fared somewhat better but still revealed significant gaps. Only 231 participants, or 48.2 percent, correctly identified upper gastrointestinal endoscopy with small-intestinal biopsy as the confirmatory examination for celiac disease. This test, in which a flexible endoscope is used to obtain tissue samples from the duodenum to look for villous atrophy and other characteristic changes, remains the diagnostic gold standard, and the fact that roughly half of the trainees could not name it raises questions about how the condition is being taught in the region’s medical curricula.

Perhaps the most striking deficiencies emerged around the composition of gluten-free products themselves, a topic that sits at the heart of dietary counseling. Only 156 participants, or 32.6 percent, recognized that processed gluten-free foods may contain more saturated fat than their gluten-containing counterparts. And only 96 participants, or 20.0 percent, correctly rejected the statement that gluten-free products contain more dietary fiber. In reality, many commercially processed gluten-free items are formulated with refined starches and gums to mimic the texture of wheat-based products, which can reduce fiber content and increase fat. A clinician unaware of these nutritional trade-offs may inadvertently reassure patients that a gluten-free label guarantees a healthier diet, when the opposite can be true.

The researchers also ran statistical models to identify which factors predicted better knowledge. In an adjusted pooled model, female gender was associated with higher odds of adequate celiac disease knowledge, with an adjusted odds ratio of 2.48 and a 95 percent confidence interval of 1.56 to 3.93. Medical students had lower odds of adequate knowledge than internship doctors, with an adjusted odds ratio of 0.45 and a 95 percent confidence interval of 0.26 to 0.80, suggesting that clinical exposure during the internship year adds something that pre-clinical education does not. Notably, no factor was independently associated with adequate nutritional-deficiency knowledge, indicating that this deficit is pervasive across the trainee population rather than concentrated in any particular subgroup. The total celiac disease knowledge score and the total nutritional-deficiency knowledge score were moderately positively correlated, with a Spearman’s rho of 0.433, meaning that trainees who knew more about the disease generally also knew more about its nutritional consequences, but the correlation was far from perfect.

Beyond measuring knowledge, the study asked trainees what they believed prevented patients with celiac disease from sticking to a gluten-free diet. The most frequently cited barrier, identified by 74.5 percent of participants, was the high cost and limited availability of gluten-free products. This is a particularly salient concern in the Palestinian context, where specialty gluten-free items are imported, expensive, and often difficult to find outside major urban centers. The second most common barrier, cited by 68.7 percent, was a lack of knowledge about gluten-free foods, while 55.3 percent pointed to reliance on wheat-based foods, a reference to the centrality of bread and other wheat staples in Palestinian and broader Middle Eastern cuisine. These responses suggest that trainees are at least aware that effective counseling must be culturally and economically feasible, not merely nutritionally correct in the abstract.

The study received ethical approval from the Al-Quds University research committee under reference number 620/REC/2025, and all participants provided electronic informed consent before taking part, in line with the principles of the Declaration of Helsinki. The research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors, and the authors declared no competing interests. The article was published open access on 5 October 2026 under a Creative Commons Attribution 4.0 International License, making the full dataset of findings freely available to educators and policymakers worldwide.

The implications reach well beyond Palestine. Medical education globally has been criticized for devoting scant curricular time to clinical nutrition, and this study provides a quantified case study of what that neglect looks like at the trainee level. The authors conclude that medical curricula should integrate micronutrient monitoring, diet-quality assessment, dietitian referral, and culturally feasible counseling into celiac disease education. In practical terms, that means teaching future doctors not only how to diagnose celiac disease with serology and biopsy, but also how to screen for iron deficiency, vitamin D insufficiency, and B vitamin shortfalls; how to evaluate whether a patient’s gluten-free diet is nutritionally sound; when to bring a dietitian into the care team; and how to advise patients for whom imported gluten-free bread is neither affordable nor accessible. As gluten-free diets continue to attract public attention and as celiac disease prevalence holds steady or rises in many regions, the gap between what patients need and what newly minted physicians know is a problem that medical schools everywhere would do well to measure, and then fix.

Subject of Research: Assessment of celiac disease and gluten-free diet nutritional knowledge among Palestinian medical trainees

Article Title: Celiac disease and gluten-free diet-related nutritional knowledge among medical students and internship doctors in Palestine: a cross-sectional training-needs assessment

Article References: Ikhzamia, T. I., HajMohammed, I., Salahaldin, M. M., Hassan, A. R., Zahran, A. M., Adam, A., Alawneh, A., Abuzaina, M., Bali, I. N., Badawi, M., Al-Natsheh, A., Amleh, S., Salah, Y. Z., Abukhater, A. K., Abukeshek, A., Abusarhan, B. A. Y., & Karmi, H. (2026). Celiac disease and gluten-free diet-related nutritional knowledge among medical students and internship doctors in Palestine: a cross-sectional training-needs assessment. BMC Medical Education. https://doi.org/10.1186/s12909-026-10532-z

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10532-z

Keywords: celiac disease, gluten-free diet, medical education, medical students, internship doctors, nutrition, nutritional deficiencies, Palestine, cross-sectional study, dietitian referral, medical curriculum, training needs