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

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.