Food Insecurity and Gastrointestinal Symptom Burden in Adults with Celiac Disease: A Cross-Sectional Study

Background/Objectives: Food insecurity (FI) is associated with adverse physical and mental health outcomes and poses unique challenges for individuals with celiac disease (CD), who must adhere to a lifelong, strict gluten-free diet (GFD) as their sole treatment. Gluten-free foods are often more expensive and less accessible, potentially exacerbating dietary burden and symptom severity. This study aimed to examine associations between food insecurity and gastrointestinal symptoms, dietary burden, disordered eating symptoms, and mental health outcomes in adults with CD. Methods: Participants were 397 adults with CD who completed a routine pre-visit screener at a tertiary celiac disease clinic in the southeastern United States. Food insecurity was assessed using the Hunger Vital Signs. Measures included gastrointestinal symptoms (GSRS), impact of following a gluten-free diet (IGFDQ), avoidant/restrictive eating (NIAS), eating disorder psychopathology (EDE-Q7), anxiety (GAD-2), and depression (PHQ-2). Group comparisons between food-secure and participants screening positive for food insecurity (high-risk of FI) were conducted using independent t-tests or Mann-Whitney U tests as appropriate. Missing data were handled using multiple imputations. Results: A total of 15.6% of participants were at high risk of FI. Compared to food-secure individuals, participants at high-risk of FI reported significantly greater gastrointestinal symptom severity, including bloating, constipation, diarrhea, and overall symptom burden. Participants at high risk of FI also reported significantly greater perceived burden of adhering to a gluten-free diet. Additionally, higher levels of avoidant/restrictive eating symptoms and shape/weight overvaluation were observed among high-risk FI individuals, though group differences in anxiety and depression symptoms were not statistically significant. Conclusions: FI is associated with greater gastrointestinal symptom burden and increased difficulty adhering to a gluten-free diet among adults with celiac disease. These findings highlight risk of FI as a clinically relevant barrier to effective disease management and underscore the importance of routine screening and targeted support for high-risk FI individuals with CD.