Gluten-free diet adherence and associated practical, socioeconomic, and psychological factors among Tunisian adults with self-reported celiac disease: a cross-sectional study

Abstract

Background Maintaining a gluten-free diet (GFD) is essential in celiac disease, but North African adherence data are limited. We described adherence classifications and explored associated factors in a selected Tunisian online sample. Methods The survey was conducted from 25 June to 30 September 2021 through one celiac-association Facebook group. Ninety-one adults reporting celiac disease and more than one year on a GFD were included. Telephone contact confirmed participant reports but did not verify diagnostic records. The combined operational classification required Biagi ≥3 and Celiac Dietary Adherence Test (CDAT) < 13. Hospital Anxiety and Depression Scale (HADS) scores assessed symptoms. Revised analyses used retained aggregate summaries; participant-level records and the original translated questionnaire were unavailable. Results Participants had a mean age of 33 years; 84.6% were women and 75.8% had higher education. The combined criterion was met by 32/91 (35.2%; Wilson 95% CI 26.1–45.4), compared with 40/91 (44.0%) for Biagi alone and 35/91 (38.5%) for CDAT alone. Eleven classifications were discordant. Anxiety symptoms occurred in 6/32 (18.8%) meeting the combined criterion and 36/59 (61.0%) not meeting it. Other comparisons were exploratory, unadjusted and subject to sparse cells, multiple testing and overlap with CDAT content. An unresolved label-reading count discrepancy prevented that association analysis. Conclusion The 35.2% figure is a sample-specific estimate using an unvalidated combined rule and translations without documented local validation; it cannot be generalized to Tunisian adults with confirmed celiac disease or directly compared with single-instrument estimates. Anxiety symptoms showed an unadjusted association with the combined classification. Selection, measurement and archival uncertainty require prospective confirmation.

The authors' abstract, as published at the source. Frontiers in Nutrition, 2026 · DOI ↗