Assessing food insecurity and other barriers to adherence to a gluten-free diet among coeliac disease individuals in Pakistan

Purpose: Food insecurity (FI) is a growing global challenge, especially for individuals with coeliac disease (CeD), who require strict adherence to gluten-free (GF) foods as the only therapeutic measure available. However, in Pakistan, where wheat is the staple food, there is limited evidence on the extent of FI and the challenges faced by CeD individuals in maintaining a GF diet. This study aimed to identify the GF-FI level and the key sociodemographic, economic, and behavioural factors associated with challenges in maintaining a GF diet among people with CeD in Pakistan. Methods: A cross-sectional online survey was conducted between June and September 2025 among 469 CeD adults aged 19-72 years in Pakistan. The difference between the FS and FI groups was analysed through χ2 and Mann-Whitney U testing. To identify the core perceived challenges of maintaining a GF diet, an explanatory factor analysis (EFA) was conducted on 19 Likert-scale statements. Results: The prevalence of FI was 58.8%, with 27.5% of participants experiencing low food security and 31.3% reporting very low food security. It is found that FI has a strong inverse relationship with household size, employment status, monthly income, education level, and mental health. The study also found that challenges perceived by CeD individuals in maintaining a GF diet are significantly related to cooking abilities, social circumstances, resources, and the availability of naturally GF foods. Conclusion: FI among CeD individuals in Pakistan is notably high and driven by economic, behavioural, and social barriers to GF diet adherence. Keywords: Coeliac disease, Food insecurity, Gluten-free diet, Dietary adherence.