Sticking to the gluten-free diet is the only effective treatment for celiac disease. But new research shows two largely overlooked factors can seriously derail that effort: financial hardship and a troubled relationship with food.
The study, published in Scientific Reports, enrolled 172 adults with celiac disease and measured how food insecurity and disordered eating attitudes affected their ability to follow the diet. Adults with severe food insecurity were 95% less likely to follow the gluten-free diet well. Their symptoms were markedly worse and their quality of life notably lower — as were those of participants with disordered eating patterns.
What This Means for You
Celiac community conversations typically center on label-reading, restaurant safety, and cross-contact risk. Those are real and important. What this study adds is a reminder that those conversations assume a level of financial stability and psychological ease that not every celiac patient has.
For families with tight food budgets, the gluten-free premium is not a minor inconvenience — it’s a barrier to treatment. Certified gluten-free products routinely cost two to three times more than conventional equivalents. When patients cannot afford safe food, they may substitute cheaper options that contain gluten, or eat less overall to manage costs. Either path leads to more exposure, worse symptoms, and poorer long-term health.
The disordered eating finding deserves its own attention. Celiac disease demands constant food vigilance — scrutinizing every label, questioning every ingredient, navigating every social meal. For some patients, that necessary vigilance tips into something more psychologically costly: extreme restriction beyond what the diet actually requires, intense anxiety around eating, or erratic patterns that actively interfere with consistent gluten-free adherence. We have previously covered how body image and emotional awareness affect adults with celiac disease, and the pattern this study documents — disordered eating attitudes tracking with worse adherence and health outcomes — fits that broader picture.
As a celiac parent, I think about both of these pressures. The cost of keeping my son safe adds up relentlessly. And as he gets older, I worry about the psychological weight of managing a lifelong dietary restriction. What I want from his medical team is awareness of both — not just a reminder to avoid gluten.
Key Takeaways
- Adults with severe food insecurity were 95% less likely to follow the gluten-free diet well.
- Disordered eating attitudes reduced adherence odds by roughly 50–65%, depending on how adherence was measured.
- Both factors were tied to worse symptoms and lower quality of life — independently of each other.
- Clinicians rarely screen for food insecurity or eating attitudes during celiac care; this study argues they should.
- BMI was not significantly linked to either factor, suggesting weight alone does not reveal how well a patient is managing their disease.
The Science
Want to understand how this actually works? We’ll walk you through the technical details below and define every term. No medical degree required.
The Study Design
Researchers at Shiraz University of Medical Sciences enrolled 172 adults with celiac disease from the Fars Province Celiac Disease Registry in Iran. This was a cross-sectional study — meaning researchers gathered data at a single point in time and looked for statistical associations between variables. That design can identify correlations but cannot establish that one factor directly causes another. It is possible, for example, that sicker patients face greater financial strain rather than financial strain causing worse outcomes. Even with that caveat, the strength of the associations here is hard to dismiss.
Measuring Food Insecurity
The team assessed food insecurity using the Household Food Insecurity Access Scale (HFIAS) — a validated questionnaire that captures whether people experience uncertainty about their food supply, reduce the quality of what they eat, or skip meals because they lack resources. Participants were classified across a spectrum from food-secure to severely food-insecure.
Measuring Eating Attitudes
For eating attitudes, researchers used the Eating Attitudes Test-26 (EAT-26), a widely used screening instrument. It flags attitudes and behaviors associated with disordered eating — things like excessive dietary restraint, fear of eating, and preoccupation with food and body weight. Scoring above the threshold indicates potentially disordered attitudes; it does not diagnose a clinical eating disorder.
That distinction matters in the celiac context. The medical requirement to scrutinize food constantly can create or amplify food-related anxiety. Researchers have noted overlap with orthorexia (an obsessive focus on eating only foods perceived as “pure” or “correct”) and ARFID (avoidant/restrictive food intake disorder — extreme food avoidance not driven by body image concerns). As covered previously, ARFID appears at elevated rates in both adult and pediatric celiac patients. The EAT-26 captures a related but distinct set of disordered patterns.
Measuring Gluten-Free Diet Adherence
Two validated instruments measured how well participants followed the gluten-free diet:
- The Celiac Disease Adherence Test (CDAT) — a questionnaire measuring dietary compliance behaviors and attitudes toward the diet.
- The Biagi tool — a separate validated instrument assessing adherence through dietary habit and symptom questions.
Using two independent measures strengthens the findings. When both instruments point in the same direction, the pattern is more credible than a result from a single tool.
The Numbers
The results are difficult to dismiss. Compared to food-secure participants, those with severe food insecurity had:
- An odds ratio (OR) of 0.05 on the CDAT — meaning 95% lower odds of good adherence.
- An OR of 0.14 on the Biagi tool — 86% lower odds of good adherence.
- A symptom severity score (measured on a Visual Analog Scale, where higher scores mean worse symptoms) that was 22.48 points higher on average (P < 0.001).
- A quality of life score (measured via the Celiac Disease Quality of Life questionnaire) that was 22.91 points lower on average (P < 0.001).
Participants with disordered eating attitudes showed:
- An OR of 0.46 on the CDAT (54% lower odds of good adherence).
- An OR of 0.36 on the Biagi tool (64% lower odds).
- Symptom severity scores 17.20 points higher on average (P < 0.001).
- Quality of life scores 11.49 points lower on average (P = 0.001).
One notable null result: BMI (body mass index, a ratio of weight to height used as a rough measure of nutritional status) was not significantly associated with either food insecurity or disordered eating attitudes. That challenges the assumption that a patient’s weight reveals how well they are managing their disease.
What Clinicians Should Take From This
The authors conclude that screening for food insecurity and disordered eating attitudes should become standard practice in celiac clinical care. Currently, most gastroenterology and dietetics appointments focus on whether patients know how to follow the diet — not on whether they can afford to, or whether their psychological relationship with food is working against them.
This finding parallels what a cross-sectional study on gluten-free diet adherence factors in Palestinian celiac patients found: economic and social variables shape adherence as powerfully as clinical knowledge does. Addressing only the medical side of celiac disease leaves a significant part of the problem untreated.
For patients who struggle with adherence despite understanding the diet — and for clinicians puzzled by that struggle — this research points toward two questions that often go unasked: Can this person afford safe food? And is their relationship with eating helping them or hurting them?
Related Coverage
- Factors Associated with Adherence to the Gluten-Free Diet Among Celiac Patients in Palestine
- Avoidant/Restrictive Food Intake Disorder Is Common in Adult and Pediatric Patients with Celiac Disease and Non-Celiac Gluten Sensitivity
- Body Image Perception and Emotional Awareness in Adults with Celiac Disease
References
- Khoshrang A, Foshati S, Niknam R, et al. The relationship of eating attitudes and food insecurity with health outcomes in adults with celiac disease. Scientific Reports. 2026 Jul 11. doi: 10.1038/s41598-026-60143-3. PubMed