Diet quality in cystic fibrosis – associations with patient reported outcome measures and enablers and barriers to eating a healthy diet: A protocol paper for a mixed methods study

<ns3:p> Background People living with cystic fibrosis (PwCF) have increased energy requirements. However, in recent years concerns have emerged regarding the ‘cystic fibrosis (CF) diet’ in terms of reliance on energy-dense, nutrient poor foods, which tend to be higher in saturated fat, sugar, and salt. These foods lack essential nutrients and are aetiologically linked with diet-related chronic diseases. The aim is to explore habitual dietary intakes in PwCF and <ns3:italic>(i)</ns3:italic> assess adherence to CF dietary guidelines and population specific healthy eating guidelines; <ns3:italic>(ii)</ns3:italic> derive a diet quality score and the inflammatory potential for the average diet consumed by PwCF and assess associations with patient reported outcome measures; <ns3:italic>(iii)</ns3:italic> assess drivers for current consumption patterns and enablers and barriers to eating a healthy diet. Methods The aim is to recruit between 70-100 PwCF. A mixed methods study will be performed. Using three-day food diaries and food frequency questionnaires, aims <ns3:italic>(i)</ns3:italic> and <ns3:italic>(ii)</ns3:italic> will be addressed. The Diet Quality Index -International and Healthy Eating Index-2020 (HEI-2020) will derive diet quality scores. The Dietary Inflammatory Index (DII®) will ascertain inflammatory potential of the diet. Validated questionnaires will be used to report health related quality of life measures. Online focus groups and semi-structured interview with PwCF will address aim <ns3:italic>(iii)</ns3:italic> . Conclusions It is timely to revise dietary priorities and targets for CF. However, a greater understanding of what adults with CF currently consume and what they require in terms of nutrition and dietary guidance into the future is needed. In doing so, this research will help to clarify nutrition priorities and simplify the dietary aspects of CF treatment, thereby supporting adherence. </ns3:p>