Food insecurity and other barriers to adherence to a gluten-free diet in individuals with celiac disease and non-celiac gluten sensitivity in the Netherlands: a mixed-methods study

ObjectivesTo determine the prevalence of food insecurity among individuals with celiac disease (CeD) and non-celiac gluten sensitivity (NCGS) in the Netherlands and explore its association with diet quality and other barriers to adherence to a gluten-free diet. DesignMixed-method design comprising a survey and semi-structured interviews. SettingAn online survey was distributed through social media accounts and the newsletter of the Dutch Association for Celiac Disease. Community-dwelling patients were surveyed and interviewed between June and November 2023. Participants and outcome measuresIn total 548 adults with CeD and NCGS in the Netherlands who adhered to a gluten-free diet completed the survey including questions related to demographics, household food security, financial stress and dietary quality. Regression analyses were conducted to assess associations between food insecurity and diet quality, and between food insecurity and perceived difficulty of gluten-free eating and cooking. Additionally, semi-structured interviews with 8 food insecure adults with CeD were conducted. ResultsThe prevalence of food insecurity was 23.2%, with 10.4% reporting very low food security. Very low insecurity was associated with poorer diet quality ({beta}=-5.5; 95%CI=-9.2,-1.9; p=0.003). Food insecurity was associated with heightened perceived barriers across multiple themes, including skills, social circumstances, resources and gluten-free products, with odds ratios ranging between 1.9-4.7 for crude models (very low food security vs food security). The qualitative analysis provided a deeper understanding of these challenges, including employed strategies to manage costs and insights into the mental burden associated with adhering to a gluten-free diet. ConclusionThese findings indicate that food insecurity is prevalent among Dutch people with CeD and NCGS, with potential impact on dietary quality and adherence to a gluten-free diet. It further provided insight into perceived barriers to adhering to a gluten-free diet among this target population. These challenges should be taken into account by clinicians and policy makers. STRENGTHS AND LIMITATIONSO_LIThe study provides previously unexplored insights in food insecurity among people with CeD and NCGS in the Netherlands. C_LIO_LIBy employing a mixed-methods study design, the quantitative findings gained added depth as they were enriched by the personal experiences elucidated in the qualitative analysis. These provided a richer understanding of the challenges individuals face, including employed strategies to manage costs and insights into the mental burden associated with adhering to a GF diet. C_LIO_LIAn inherent limitation of the study is its cross-sectional design, which prevents drawing causal conclusions regarding factors associated with food insecurity. C_LIO_LIThe study relied on self-reported data through anonymous surveys, which introduces the possibility of recall bias and social desirability bias C_LIO_LIIn the context of this study, food insecurity might be limited to gluten-free food insecurity in otherwise food secure households. C_LI