Limited health literacy (HL), depression and anxiety are common in dialyzed patients and affect health outcomes and self-management. We explored whether depression and anxiety mediate the association of HL with diet non-adherence (DN-A) in dialyzed patients. We performed a cross-sectional study in 20 dialysis clinics in Slovakia (n = 452; mean age: 63.6 years; males: 60.7%). Hierarchical cluster analysis was performed to create three HL groups. Logistic regression adjusted for age, gender and education was used to explore whether depression and anxiety mediate the association of HL with DN-A. Patients in the moderate HL group were more likely to be non-adherent to diet (OR (Odds Ratio)/95% CI: 2.19/1.21-3.99) than patients in the high HL group. Patients in the low HL and moderate HL group more likely reported depression or anxiety. Patients reporting depression (OR/95% CI: 1.94/1.26-2.98) or anxiety (OR/95% CI: 1.81/1.22-2.69) were more likely to be non-adherent with diet. Adjustment for depression reduced the association between moderate HL and DN-A by 19.5%. Adjustment for anxiety reduced the association between moderate HL and DN-A by 11.8%. Anxiety and depression partly mediated the association of HL with DN-A. More attention should be paid to treating patients' psychological distress to ensure adequate adherence with recommended diet.

2nd Department of Internal Medicine P J Safarik University Trieda SNP 1 040 01 Kosice Slovakia

Department of Community and Occupational Medicine University Medical Center Groningen University of Groningen Antonius Deusinglaan 1 9713 AV Groningen The Netherlands

Department of Health Psychology and Research Methodology Faculty of Medicine P J Safarik University Trieda SNP 1 040 01 Kosice Slovakia

FMC Dialysis Services Slovakia Trieda SNP 1 040 01 Kosice Slovakia

Graduate School Kosice Institute for Society and Health Faculty of Medicine P J Safarik University in Kosice Trieda SNP 1 040 01 Kosice Slovakia

Institute of Mathematics Faculty of Science P J Safarik University Jesenna 5 040 01 Kosice Slovakia

Olomouc University Social Health Institute Palacky University Univerzitni 22 771 11 Olomouc Czech Republic

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Low Health Literacy Is Associated with Poorer Physical and Mental Health-Related Quality of Life in Dialysed Patients

Health Literacy and Change in Health-Related Quality of Life in Dialysed Patients