A Mixed-Methods Study of Knowledge, Attitudes, and Practices Related to Gluten- Free Diets in India

A Mixed-Methods Study of Knowledge, Attitudes, and Practices Related to Gluten- Free Diets in India | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article A Mixed-Methods Study of Knowledge, Attitudes, and Practices Related to Gluten- Free Diets in India Panchali Moitra, Bushra Salim Qureshi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9052215/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Recent evidence suggests a growing popularity of gluten-free diets (GFDs) beyond clinically indicated contexts in low middle income countries. However, a comprehensive investigation of public perceptions, motivations, and professional challenges related to both medically and non-medically indicated GFD adoption remains limited. Therefore, we conducted a mixed method study to explore the perspectives of dietetic professionals and assess the knowledge, attitudes, and practices (KAP) related to gluten and GFDs among adults aged 18–45 years in India. The clinical and nutritional considerations for GFD were examined through in-depth interviews (n = 9) and an online survey was conducted among adults (n = 285) to assess their KAP. Thematic analyses revealed fragmented public understanding, symptom-led self-diagnosis, influence of “anti-inflammatory” narratives, concerns regarding nutritional adequacy of GFDs, and the need to leverage traditional food systems. Data highlighted limited knowledge regarding gluten (50.9%), and GFDs (38.6%). Reasons for GFD adoption included perceived health benefits (19.8%), weight loss (26.4%) and no reasons (32.1%). Consumption of naturally gluten-free staples such as rice (58.9%), lentils (55.8%) and millets (30.9%) was higher than that of oats (7.7%), barley/ quinoa (2.8%), and speciality flours (2.1%). The study provides timely insights into the drivers of the GFD trend within India’s rapidly evolving urban nutrition landscape. Health sciences/Diseases Health sciences/Health care Health sciences/Medical research Gluten Gluten- free diet Celiac disease Gluten related diseases Health knowledge attitudes and practices dietitians health education India INTRODUCTION Gluten, a protein present in commonly consumed cereals like wheat, barley, and rye, has gained significant clinical and public health attention due to its association with conditions such as celiac disease, wheat allergy, and non-celiac gluten sensitivity (NCGS)(1–3). While celiac disease affects approximately 1% of the global population(4), the prevalence of NCGS is estimated to range between 2 to 14% depending on the region, definition, diagnostic method and the population studied (5). In recent years, gluten-free diets (GFDs) have gained considerable popularity beyond clinically indicated contexts, with many individuals adopting them for perceived benefits such as weight management, improved gastrointestinal health, and enhanced energy levels (6–8). However, most of the existing evidence originates from the United States, Europe, and Australia (9–12), limiting its generalizability to socio-culturally and nutritionally diverse settings such as India where dietary practices are known to be shaped by cultural, regional, and socioeconomic factors and wheat and other gluten-containing staples constitute an important component of habitual diets (13,14). In India, the epidemiology of gluten-related disorders (GRDs) is evolving, with emerging evidence indicating increased recognition of gluten sensitivity (15) concurrent with the rapid expansion of the market for gluten-free products (GFPs)(India Gluten Free Product Market - Revenue, Size & Growth, 2026.; India Gluten-Free Products Market Size & Outlook, 2033, 2025.). Recent market research analyses indicate that the gluten-free foods and beverages sector in India is already valued in the several hundred million USD range and is projected to grow substantially over the coming decade (India Gluten Free Product Market - Revenue, Size & Growth, 2025.; India Gluten-Free Products Market Size, Share Trends By 2035, 2026). As diagnostic infrastructure improves and awareness of GRDs and associated gastrointestinal disorders increase, the number of individuals diagnosed with celiac disease or NCGS is likely to further escalate, particularly in the wheat-consuming regions of northern India. Market trends also reflect the emergence of a “wellness-driven” consumer segment that increasingly adopts gluten-free alternatives as part of broader health and lifestyle choices rather than for clinically diagnosed conditions (18). This shift—from GFPs as a medical necessity to their positioning as mainstream lifestyle choices—is considered to be influenced by urbanization, global health and fitness trends, rising disposable incomes, expanding retail and e-commerce platforms, and a growing population of health-conscious consumers. Furthermore, this GFP market momentum is being reinforced by government initiatives promoting traditional, naturally gluten-free grains such as millets as modern and accessible staples (19), alongside private-sector innovation aimed at diversifying convenient and health-oriented gluten-free offerings. Against this backdrop of dietary landscape in India, there is a need for comprehensive, context specific investigations so that public perceptions, motivations, and professional challenges related to both medically and non-medically indicated GFD adoption are better understood. Existing research on knowledge, attitudes, and practices (KAP) related to gluten and GFDs reveals significant gaps in knowledge and persistent misconceptions among the general public (20–22). For instance, cross sectional surveys conducted outside India have reported that a substantial proportion of consumers perceive gluten-free options as integral to healthy eating patterns, wellness routines, and digestive health management(6,12). Findings from several narrative reviews of consumer perceptions indicate challenges such as limited availability and variety of GFPs, higher prices compared to gluten containing counterparts, concerns regarding product quality and difficulties in interpreting food labels(3,23–25). A cross-sectional study assessing the GFD awareness among people with celiac diseases demonstrated inadequate knowledge regarding gluten-free alternatives to staple foods in patients and physicians(26). Healthcare professionals have also reported challenges in counselling patients due to limited understanding of gluten free food alternatives, divergent patient beliefs, dietary trends and influence of social media and self-diagnosis, and persistent confusion regarding the appropriate clinical indications for gluten restriction (7,12,27). These findings underscore the need for targeted professional training and structured public nutrition education efforts to improve dietary adherence and clinical counselling. However, to design these interventions, the existing knowledge and attitudes toward gluten and GFDs in the general population must be examined and the beliefs and counselling practices of nutrition and dietetic professionals related to gluten and GFDs must be explored. Despite the increasing adoption of GFDs, there are, to our knowledge, no studies that have assessed public awareness, underlying motivations for GFP preferences, and the clinical and nutritional considerations influencing consumer purchasing and consumption behaviours in India. Therefore, this mixed method study was designed to explore the perspectives of practicing dietetic professionals and concurrently assess the KAP related to gluten and GFDs among adults aged 18–45 years in India. We hypothesized that a mixed-methods approach integrating quantitative consumer survey data with in-depth professional insights would offer a nuanced and contextually grounded understanding of both individual behaviors and expert interpretations. Such evidence would be critical for developing culturally relevant public health strategies, clinical guidance, and responsible market communication in India. METHODS Study Design This study employed a mixed-methods design using a convergent parallel approach, integrating qualitative and quantitative methods to comprehensively address the study objectives. The professional perspectives on awareness, attitudes, and practices related to gluten and GFDs were explored using a series of in-depth interviews (IDIs) with practicing registered dietitians and a cross-sectional survey was conducted among adults aged 18–45 years residing in India to assess their KAP related to gluten and GFDs. Both qualitative and quantitative investigations were performed concurrently, analysed independently, and subsequently interpreted together to allow triangulation and complementarity of findings. Study Setting and Sampling In-depth Interviews with experts The interviews were conducted face to face using video-conferencing platforms between January and April 2025 in India. To seek participation for the IDIs, invitations were circulated through professional networks, and interested individuals meeting the inclusion criteria were contacted by the research team to discuss the study protocol in detail and seek informed consent for participation. Eligibility criteria included: (i) being a registered dietitian, currently practising in India, (ii) having a minimum of five years of clinical experience in a tertiary-care hospital setting and iii) prior experience of counselling patients with gastrointestinal or related clinical conditions including celiac disease, wheat allergy, irritable bowel syndrome (IBS) and NCGS. Of 12 experts who were contacted, eleven met the eligibility criteria, and nine provided informed consent and completed the interviews. Cross sectional survey among adults The cross-sectional study was administered online among adults aged 18–45 years residing in India using a secure web-based platform. The age group of 18–45 years was intentionally selected as this population is most likely to be exposed to and influenced by dietary trends such as gluten-free diets, actively seek nutrition-related information and make independent food purchasing and consumption decisions (Dunn et al., 2014 ). Participants were invited through social media platforms using a digital flyer that provided detailed information about the study objectives, eligibility criteria, voluntary nature of participation, and the contact information of researchers for queries. Eligibility screening was conducted through an initial section of the online questionnaire, where respondents self-reported age and confirmed residence in India. The sample size was determined using standard sample size estimation methods for proportion-based surveys. Assuming a conservative prevalence of 50% for adequate knowledge (as prior prevalence estimates of GFDs were limited in India), a 95% confidence interval and 80% statistical power, the sample size was calculated to be approximately 196 participants using Cochran’s formula for cross-sectional studies (29). To account for an anticipated 20% non-response or incomplete response rate, the target sample size was inflated to 235 participants to ensure adequate power to describe key knowledge, attitude, and practice indicators, and robustness against potential non-response bias. In our study, a total of 285 participants completed the online survey and were included in the final statistical analysis and data interpretation. Data Collection Procedures The interviews were conducted by the Principal Investigator, proficient in qualitative research data collection, and supported by a research assistant having postgraduate degree in clinical nutrition, using a semi-structured interview guide. The questions and probes were developed a priori by the research team based on the study objectives and a review of relevant literature to explore expert perspectives on patterns of GFD adoption, emerging trends, and clinical and counselling challenges encountered in routine practice(20,24,30). The guide comprised open-ended questions related to participants’ professional experience in counselling individuals with gastrointestinal disorders, including celiac disease, NCGS, and irritable bowel syndrome. Participants were asked to reflect on public awareness, motivations, and perceptions regarding gluten and GFDs, as well as temporal trends observed in both clinical practice and broader community contexts. Additional domains included counselling practices related to gluten restriction, dietary substitutions recommended, perceptions of the nutritional adequacy of GFPs, and clinical considerations such as diagnostic approaches for celiac disease or gluten sensitivity and nutrients commonly monitored in patients following GFDs. The views on the growing popularity of GFDs, and the role of social media were also discussed. All interviews were conducted in English, audio-recorded with participants’ permission, and lasted approximately 30–45 minutes. The discussions were kept informal, allowing for clarification and follow-up questions where appropriate to enable an in-depth exploration of participants’ perspectives. The semi structured interview guide is provided as Supplementary File 1. To assess KAP related to gluten and GFDs among general population, a self-reported, structured questionnaire was developed in English and administered electronically using Google Forms to facilitate broad geographic reach and ease of response. The survey included questions related to sociodemographic characteristics and KAP regarding gluten and GFDs. The knowledge regarding gluten and gluten-containing foods, common symptoms and underlying mechanisms of gluten consumption-related disorders, and potential effects of following a GFD on health were assessed in a multiple-choice or multiple select question option format. Each correct response was scored 1 and incorrect and/or don’t know options were marked as 0. The attitude section comprised of ten statements, rated on a five-point Likert scale ranging from “strongly disagree” to “strongly agree. Items assessed perceptions of the nutritional quality of gluten-free foods, beliefs regarding the role of GFDs in weight management and gut health, views on who should adopt a GFD, and opinions regarding GFDs as a lifestyle or preventive approach to better health. Additional items explored perceived social influences and reliable sources of nutrition information, benefits and risks of self-adoption of GFDs, and confidence in personal nutrition knowledge. To evaluate purchasing and consumption practices, participants were asked to report their frequency of intake of gluten-free food items over the preceding month. An 18-item qualitative food frequency questionnaire (FFQ) including most commonly consumed gluten-free foods in India was administered. The list of selected food items was developed based on previous literature (13,31), and our insights drawn from in-depth interviews. Consumption frequency was recorded using a five-point scale ranging from ‘everyday’ to ‘never or rarely (less than once a month)’. Also, purchasing behaviors, reasons for selecting gluten-free foods, and food label–reading practices were assessed. The questionnaire draft was piloted among 18 adults, aged 18–45 years to check for clarity, comprehensibility, content relevance, and the time required for completion. Based on participant feedback, minor rephrasing was undertaken before administering the final version to study participants. Data Analysis The interview transcripts were reviewed initially by the investigators for familiarisation and then analysed using an inductive thematic analysis approach. Codes were assigned iteratively to describe actions, perceptions, beliefs, or experiences, and then reviewed and refined by comparing them across transcripts, merging the overlapping or redundant codes and grouping related codes into sub themes and overarching themes to capture recurrent pattern in the data. These emergent themes were further refined to ensure coherence, credibility and alignment with the study objectives. Representative quotations were identified to support each theme and are presented in the Results section. Data collected from the survey were analysed using Jamovi version 2.6.17 (The Jamovi Project, Australia)(32). Continuous variables were summarised as mean ± standard deviation and analysed using independent-samples t-tests. Categorical variables were expressed as frequencies and percentages and compared using chi-square tests. Gender differences in questions with multiple responses (such as reasons for preferring gluten-free foods or adoption of GFDs) were analysed using separate chi-square tests for each response option, with adjustment for multiple comparisons using the Bonferroni correction. Statistical significance was set at p 35 years old, and 33.3% had >10 years of professional experience (Table 1).INSERT TABLE 1 The results of the qualitative and quantitative data are provided separately in this section. Results of the thematic analysis of IDI data Thematic analysis of interview data identified six interrelated themes describing registered dietitians’ perspectives on public knowledge, attitudes, and practices related to gluten and GFDs in India. A summary of the main themes and illustrative quotes reflecting the dominant and recurrent insights are provided below: Theme 1: Limited and Fragmented Public Understanding of Gluten Dietitians reported that although most individuals were familiar with the term gluten , their understanding of its sources, physiological role, and clinical relevance was superficial. Gluten was commonly perceived as synonymous with roti , bread, or bakery items, with minimal recognition of its presence in a wider range of foods ( “Most patients know the word gluten, but very few can actually identify where it comes from or who really needs to avoid it.”). Participants noted that gluten was frequently perceived as an inherently “unhealthy” component of the diet rather than a protein relevant primarily to specific medical conditions. Theme 2: Symptom-Led Self-Diagnosis and Clinical Counselling Challenges A recurrent observation that emerged from the interviews was the increasing adoption of GFDs without medical indication or proper diagnosis ( “Quite often an individual would have initiated gluten avoidance for reasons unrelated to diagnosed celiac disease or gluten sensitivity.”) Reported motivations included perceived weight loss benefits, improved digestion, better skin health, and alignment with wellness trends. Participants expressed concern that such symptom-led self-diagnosis tends to complicate clinical evaluation, delays diagnosis of celiac disease or non-celiac gluten sensitivity, and poses challenges for effective counselling—particularly when individuals had already eliminated gluten from their diets. All experts agreed that GFDs should be prescribed cautiously and primarily for individuals with confirmed diagnoses such as celiac disease, NCGS, or wheat allergy. Several dietitians highlighted the need for interdisciplinary coordination with gastroenterologists for early flagging of symptoms and subsequent management strategies. Theme 3: Poor Recognition of Hidden Gluten and Cross-Contamination Risks Discussions with dietitians revealed that awareness of hidden gluten sources and cross-contamination risks remains limited in general public but also among dietitians who are not actively involved in gastrointestinal disorders or celiac disease management. Participants highlighted significant gaps in public understanding around non-food sources of gluten exposure, such as medications, nutritional supplements, and even personal care products like lip balms. “In several processed foods, gluten may appear as stabilizers, thickeners, flavourings, or additives (e.g., malt extract, modified food starch, soy sauce, and certain spice blends).” “The products labelled as “wheat-free” are often mistakenly assumed to be gluten-free, creating confusion between wheat exclusion and complete gluten elimination ”. “ Interpreting ingredient lists can be challenging, particularly when gluten-containing derivatives are listed under unfamiliar names ”. Additionally, cross-contamination risks during food preparation and storage were discussed as areas of concern. Shared toasters, cutting boards, cooking water (e.g., for pasta), bulk food bins, and deep fryers are not always identified as potential contamination points. This gap was considered particularly important in the Indian context, where shared kitchens, local mills, and bulk food purchasing are common, increasing the risk of inadvertent gluten exposure. Theme 4: Social Media, Wellness Trends, and the ‘Anti-Inflammatory’ Narrative Participants observed that gluten-free diets were frequently discussed alongside other wellness trends such as lactose-free diets, intermittent fasting, and anti-inflammatory eating, often without scientific grounding. Celebrity endorsements, influencer content, and fear-based messaging and anecdotal success stories were discussed as reinforcements of the perception that gluten is inherently harmful, even for healthy individuals. “Instagram and YouTube have become the primary nutrition educators, unfortunately without accountability.” “Thanks to social media, there’s a lot of buzz about inflammation. People are harping on the term and saying gluten causes inflammation, so you must go gluten-free.” “Gluten is perceived as pro-inflammatory …social narratives promote gluten avoidance as a preventive or universally beneficial practice”. Another concern raised was the growing trend of labelling naturally gluten-free foods as “gluten-free” for marketing purposes. This practice may mislead consumers into perceiving these products as specially modified or healthier alternatives, potentially creating unnecessary fear around regular staples and inflating prices without adding real nutritional value. Theme 5: Concerns Regarding Nutritional Adequacy and Quality of Gluten-Free Diets When individuals eliminate gluten-containing staples such as whole wheat without carefully selecting suitable replacements, they may inadvertently reduce their intake of essential nutrients commonly found in whole grain products ( “ Gluten-free does not automatically mean nutritious—many products are highly refined.”) . If not planned well, GFDs tend to be low in dietary fibre and key micronutrients and higher in refined carbohydrates and fats (“ Individuals following GFDs require targeted counselling to ensure dietary adequacy through appropriate substitutions ”). The importance of individualized dietary counselling to ensure that gluten-free diets remain balanced, diverse, and nutritionally adequate, particularly for individuals following them long-term was reiterated in the discussions. Theme 6: Need to leverage traditional diets and develop context-specific public awareness Dietitians highlighted the unique Indian dietary contexts wherein traditional diets already include a variety of naturally gluten-free grains such as millets, rice, and pulses. However, this advantage was often underutilized due to limited awareness among general public ( “ India has always had gluten-free foods—what we lack is clarity about when and why to use them .” ) Several participants described GFDs as part of a broader “ modern wellness identity ,” and “ largely confined to urban, higher socioeconomic groups ” with limited penetration into rural or socioeconomically diverse populations. This urban concentration is typically reflected in access to GFPs, awareness of food labels, and exposure to online health narratives. Results of the cross-sectional survey Among the 285 survey respondents, 64.6% were women, and 49.8% belonged to the age category 18-25 years. More than half (57.5%) held a bachelor’s degree and 64.8% resided in the western regions of India. Regarding dietary preferences, 26.7% reported following a vegetarian diet, while 58.9% identified as non-vegetarian INSERT TABLE 1. Knowledge related to gluten and gluten-free diets Table 2 presents the proportion of participants who provided correct responses to the knowledge items in the questionnaire. Only 50.9% and 38.6% of participants were able to correctly identify the definition of gluten and GFD, respectively. A majority of participants identified only 0–3 gluten-containing breakfast recipes (67.7%), lunch/dinner recipes (73.0%), dessert recipes (80.0%), and hidden sources of gluten (62.8%). Less than half (45.3%) correctly identified the medical conditions for which a GFD is recommended. However, recognition of GRD symptoms was comparatively better, with 64.2% of participants correctly identifying at least three out of six symptoms. Gender-based comparisons indicated that women demonstrated significantly greater proficiency than men in identifying gluten-containing food items and breakfast recipes (p < 0.001), recognizing hidden sources of gluten (p = 0.019), accurately describing a GFD (p = 0.030), identifying medical indications for a GFD (p < 0.001), and recognizing symptoms associated with GRDs (p < 0.001). INSERT TABLE 2. Attitudes towards gluten-free diets Nearly one-third of participants (29.1%) agreed or strongly agreed that gluten-free foods are healthier than gluten-containing foods and 38.9% believed that gluten-free diets help with weight loss (Table 3). Almost half of the participants felt that individuals with digestive discomfort should avoid gluten (46.6%), that small amounts of gluten can cause symptoms in sensitive individuals (47.3%) and that only individuals with a medical diagnosis should follow a GFD (48.7%). Less than one thirds (29.1%) agreed that a GFD can be followed as a regular diet while 49.5% perceived social influences as primary drivers of GFD adoption. Most participants (67.0%) believed that community awareness about GRDs is inadequate and 54.7% reported lacking sufficient knowledge to make informed choices about gluten-free options. INSERT TABLE 3. Preferences and purchasing behaviours A significantly greater preference for gluten-free products over gluten-containing foods was observed among women (46.2%) as compared to men (20.8%, p <0.001). Among those who reported preferring GFPs, the most common reasons included healthier option (19.8%), weight loss (26.4%) and no reasons (32.1%). Overall, 21 (7.4%) participants reported currently following GFDs. Of these, 7 (30.0%) were following GFD for weight loss, 6 (28.6%) for improved GI symptoms and only 3 (14.3%) for medically indicated reasons. While 69.1% reported ‘rarely’ or ‘never’ purchasing gluten-free labelled products, 23.5% mentioned that they purchased GF foods ‘sometimes’ or ‘regularly’ and 7.4% reported ‘always’ purchasing them. Among those who purchased GF products, supermarkets (11.2%) and online platforms (7.4%) were the most common places of purchase. The food label-reading practices varied, with the most frequently checked information being ingredients (63.9%), sugar content (62.5%), and low-fat/fat-free claims (42.5%). Women were more likely than men to check gluten-free claims, ingredient lists, vegan/plant-based labels, and allergen information. INSERT TABLE 4 Consumption patterns of gluten-free foods The frequency of consumption of selected gluten free food items as reported by participants is presented in Table 5. Rice (58.9%) and lentils (55.8%) were the most frequently (daily) consumed naturally gluten-free staples. Millets such as finger millets or ragi (26.6%), sorghum or jowar (16.9%), pearl millet or bajra (16.5%), and other minor millets such as little, kodo or barnyard millets (14.0%) were reported to be consumed at least 3-4 times per week. Oats/ oat flour (27.4%), rice flakes/ puffed rice (23.9%), chick pea flour or besan (28.1%) and soybean/ soy flour (19.3%) were consumed 1-2 times per week. Other gluten free food items such as potato flour (80.7%), tapioca/tapioca flour (88.4%), barley/quinoa (62.8%) and almond/peanut powders (44.9%) were reported to be rarely/ never consumed by participants. INSERT TABLE 5. DISCUSSION To gather a comprehensive understanding of professional perspectives and public knowledge, attitudes, and practices related to gluten and GFDs, we mapped the themes derived from the in-depth interviews with the findings reported in the cross-sectional survey. Overall, the interviews with experts revealed concerns over the normalization of unnecessary dietary restriction, misinformation-driven food choices, and the nutritional consequences of poorly planned GFDs. While dietitians agreed that awareness of the term gluten has increased, they emphasized that the general public understanding remains fragmented and influenced by social media narratives rather than clinical evidence. This limited understanding often results in partial or incorrect dietary restriction and nutritional inadequacies, undermining both clinical management and nutrition counselling efforts. A particular concern was the growing reliance on processed gluten-free alternatives—such as packaged breads, snacks, and baked goods—which are often lower in fibre and protein but higher in sugar, saturated fat, and sodium. Although qualitative investigations related to expert perspectives on non-medically indicated adoption of GFDs among general population are limited (33), previous studies conducted with patients having celiac diseases concur with our findings, suggesting several psychosocial, practical, and food environment (availability, price and quality) related barriers to adherence and acceptance of gluten-free diets(6–8). Additionally, the interviews highlighted that traditional Indian diets naturally include several gluten-free staples such as rice, lentils, chickpea flour (besan), and millets like ragi, jowar, and bajra. These foods have been integral to regional cuisines for centuries and provide diverse, nutrient-rich alternatives to wheat-based products. In contrast to many western countries where gluten avoidance can be challenging due to pervasiveness of wheat-based convenience foods, and commercially prepared breads, snacks, and ready-to-eat products (9,34,35), home-cooked meals are still common in India and traditional grains and legumes are frequently consumed in most households(36,37), potentially making medically indicated gluten restriction more feasible when guided appropriately. Public health education efforts should therefore emphasize and leverage these traditional staples to promote balanced, naturally gluten-free eating patterns rather than encouraging reliance on expensive, packaged gluten-free–labelled products. The results of consumer survey indicated that the knowledge regarding gluten and GFDs was modest with only about half of participants correctly identifying what gluten is, and fewer than half being able to accurately describe a GFD or identify appropriate medical indications. Practical knowledge deficits were also observed as most participants scored poorly when asked to identify gluten-containing food items, breakfast recipes, desserts, and hidden gluten sources in common packaged foods. These results are consistent with earlier evidence suggesting that public understanding of gluten and its medical relevance remains inadequate despite growing exposure to gluten-free marketing(20–22). Previous studies have reported that gluten-free diets are often adopted without sufficient understanding of their clinical relevance and highlighted persistent misconceptions about gluten sensitivity in the absence of celiac disease (7,12,38). Recent regional evidence from the Middle East also indicates that insufficient knowledge about celiac disease and GFPs remains pervasive in people with diagnosed gluten sensitivity and the general public (26,38,39). Furthermore, we observed gender differences in several knowledge domains, with women, in general, demonstrating greater awareness related to gluten and GFDs. While these findings align with previous nutrition literacy studies as women are typically more involved in food purchasing and preparation practices(40–42), the persistence of substantial knowledge gaps across both men and women indicate the need for population-wide educational strategies. Attitudes regarding preferences for gluten free foods and beverages, self-efficacy in making informed choices and recognition of the need for better education were mixed. A considerable proportion of participants perceived gluten-free foods as healthier and beneficial for weight loss, reflecting the widely described “health halo” effect(11), and the influence of social media and popular narratives around gluten-free foods(6,8). At the same time, nearly half of participants agreed that only individuals with a confirmed medical diagnosis should follow a GFD. This finding suggests a nuanced and evolving public understanding regarding GFDs in India, where misconceptions about generalised health benefits coexist with appropriate recognition of their clinical indications. While aspirational and lifestyle-driven beliefs about gluten-free diets are evident, they do not appear to have entirely displaced awareness of their medical necessity in specific conditions such as celiac disease or NCGS. Furthermore, participants expressed concern that online messaging frequently promoted GFDs as universally beneficial. These observations are particularly relevant in the Indian context, where increasing exposure to digital health information intersects with traditional dietary practices and emerging wellness trends, reflecting a transitional phase in public understanding that continues to be shaped by expanding scientific communication, commercial marketing, and media discourse. Additionally, most participants acknowledged limited community awareness and reported inadequate personal knowledge to make informed choices about GFPs. This self-recognition of knowledge limitations represents an important finding, as earlier studies from other countries have reported high consumer confidence despite poor objective knowledge (2,12,43). Another notable finding was that the consumption patterns were largely rooted in traditional, naturally gluten free staples such as rice, millets, chick pea flour and soybeans rather than a deliberate adoption of less familiar foods such as quinoa, barley or commercially marketed gluten-free specialty flours (almond/ tapioca/ potato flours). This pattern underscores an important regional distinction to findings from western countries, where reliance on processed and specialty GFPs is reported to be substantially high among both patients and wellness seeking general public (24,33,44). Our findings suggest that naturally gluten-free dietary patterns may already be prevalent in Indian households, even in the absence of intentional adherence to a formally prescribed or preferred GFD. Clinically, these findings have pertinent implications for dietary counselling, as patients diagnosed with celiac disease or NCGS in India may be able to adapt more readily by modifying existing traditional food patterns rather than depending heavily on relatively more expensive, processed alternatives to gluten containing foods. From a nutritional standpoint, consumption of minimally processed, traditional staples may also support better dietary quality and nutritional adequacy as compared to highly processed GFPs, which are often lower in fibre and essential micronutrients. Overall, these results indicate that the growth of packaged GFPs in India may not completely mirror consumption patterns and market demand trajectories observed in western countries. The duality of established traditional gluten free dietary practices intersecting with emerging ‘health driven, modern’ food choices reflect evolving food belief systems shaped by globalization, urbanization, and shifting perceptions of wellness in non-Western contexts. From a public health perspective, these findings emphasize the need for context specific, evidence-based communication strategies to address common misconceptions regarding GFDs and prevent unnecessary dietary restrictions. Efforts should focus on clearly identifying populations who derive medical benefit from GFDs and promoting balanced dietary practices rooted in culturally appropriate traditional foods and clinical guidance rather than social media–driven trends. The findings of our study must be interpreted in light of a few limitations. First, the survey data were collected electronically, which may have limited the access to individuals with digital literacy and engagement with online platforms, reflecting the views of relatively more educated or urban respondents and potentially underrepresenting populations from lower socioeconomic strata and rural settings. Second, although the sample size met the a priori power calculations for the survey and the sample adequacy recommendations for conducting qualitative studies with experts(45), the overall sample size remains modest. Future studies must consider a larger and more diverse sample to allow for granular subgroup analyses and better understanding of region-specific comparisons of GFD related beliefs and practices. Third, the KAP questionnaire was self-designed based on existing literature. While care was taken to ensure content relevance using pilot testing, rigorous psychometric validation could not be undertaken due to time and resource constraints. Finally, we employed a purposive sampling method using digital flyers, so it is likely that individuals with a prior interest in health or nutrition may have participated in the study. Despite these limitations, this study has several strengths. The use of a mixed-methods design enabled triangulation of findings by integrating quantitative survey data with qualitative insights from expert interviews. While the survey provided estimates of knowledge, attitudes, and practices, the interviews offered contextual depth and revealed underlying motivations, misconceptions, and systemic drivers shaping gluten-free diet adoption in clinical and community settings. Another novel aspect of the present study was the detailed, meal-based evaluation of gluten identification (breakfast, lunch/dinner, desserts) and a comparison of KAP between men and women. The sample comprised adults, aged 18–45 years, ensuring representation from both younger adults, who are often influenced by social media and popular health narratives, and middle-aged adults, who may adopt dietary modifications for perceived health or preventive reasons. Additionally, participants were selected across the four regions of India, enhancing the scientific rigor, cultural relevance, and robustness of the study findings. Finally, the study provides timely insights into the drivers of gluten free dietary trend in India, including media influence, perceived health benefits, and market expansion of specialty foods. Understanding these factors can inform the development of targeted nutrition communication strategies to mitigate misinformation and promote balanced, culturally appropriate diets. The findings may also guide regulatory discussions on food labelling, health claims, and marketing practices related to gluten-free alternatives. CONCLUSION This study is one of the few studies globally to examine KAP related to gluten and GFDs in non-medically indicated general population and to our knowledge the first to provide a comprehensive overview of both expert perspectives and consumer perceptions and practices in the Indian context. Overall, the interviews revealed a disconnect between clinical evidence and public perception regarding gluten and GFDs in India. These findings underscore the need for context-specific public education, clearer differentiation between medical and non-medical indications for GFDs, and stronger emphasis on culturally relevant counselling approaches that align consumer awareness, clinical guidance, and consumption practices in a rapidly evolving urban nutrition landscape in India. The triangulation of qualitative and quantitative data highlighted the opportunity to leverage India’s traditional food systems and professional counselling to support informed and evidence-based dietary decisions. Declarations Data Availability Statement - All data generated and /or analyzed during the present study are provided as a part of the manuscript. Additional information is available from the corresponding author upon reasonable request Acknowledgements: The authors sincerely thank the practicing nutrition and dietetic professionals for sharing their time, insights, and professional experiences. We are also grateful to Ms. Krisha Shah for assistance in data analysis and the participants for their active participation and enthusiastic cooperation. Author Contributions - Conceptualization, methodology, investigations, project management, and writing of the original draft of the manuscript were performed by PM. Supervision of fieldwork, resources, participant recruitment, and data management was done by BQ. Both authors have read the final version and approve of the final manuscript submitted for consideration. Competing interests - The authors declare that they have no competing interests as defined by Nature Research, or other interests that might be perceived to influence the results and/or discussion reported in this paper. Funding: This research received no specific grant from any funding agency, commercial or not-for-profit sectors. Declaration of generative AI and AI-assisted technologies: During the preparation of this work, the author(s) used ChatGPT (OpenAI) in order to assist with grammar correction and language refinement. After using this tool/service, the author(s) reviewed and edited the content as needed and take(s) full responsibility for the content of the published article. Ethics Declaration : All procedures were followed as per the ethical standards of conducting research in human participants under the Helsinki Declaration of 1975, as revised in 2000. The study protocol was approved by an independent ethics committee (ISBEC/ NR-30/KM-KM/2025). All participants provided informed consent prior to participation and data confidentiality and participant anonymity were maintained throughout the study. References Abu-Janb, N., & Jaana, M. (2020). Facilitators and Barriers to Adherence to Gluten-free Diet among Adults with Celiac Disease: A Systematic Review. J. Hum. Nutr. Diet , 33 (6), 786–810. https://doi.org/10.1111/jhn.12754 Ahmed, S. K. (2024). How to choose a sampling technique and determine sample size for research: A simplified guide for researchers. Oral Oncology Reports , 12 (1), 100662. https://doi.org/10.1016/j.oor.2024.100662 Alhusseini, N., Bajaber, M. O., Shabi, S. M., Saeedu, S. S. Bin, Aljejakli, R. A. H., Alsharimi, E. M., & Alabadi-Bierman, A. (2023). Awareness of gluten-free diet among the general public in Saudi Arabia. Nutricion Clinica y Dietetica Hospitalaria , 43 (4), 66–71. https://doi.org/10.12873/434alhusseini Alkhalifa, F. M., Abu Deeb, F. A., Al-Saleh, W. M., Al Hamad, S. S., & Adams, C. (2023). Knowledge of and behaviors toward a gluten-free diet among women at a health sciences university. Journal of Taibah University Medical Sciences , 18 (6), 1567. https://doi.org/10.1016/j.jtumed.2023.07.012 Amugsi, D. A., Lartey, A., Kimani, E., & Mberu, B. U. (2016). Women’s participation in household decision-making and higher dietary diversity: findings from nationally representative data from Ghana. Journal of Health, Population, and Nutrition , 35 (1), 16. https://doi.org/10.1186/s41043-016-0053-1 Arias-Gastelum, M., Cabrera-Chávez, F., Vergara-Jiménez, M. de J., & Ontiveros, N. (2018). The gluten-free diet: access and economic aspects and impact on lifestyle. 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PeerJ , 2018 (11). https://doi.org/10.7717/peerj.5875 Kaur, S., Kumar, K., Singh, L., Sharanagat, V. S., Nema, P. K., Mishra, V., & Bhushan, B. (2024). Gluten-free grains: Importance, processing and its effect on quality of gluten-free products. Critical Reviews in Food Science and Nutrition , 64 (7), 1988–2015. https://doi.org/10.1080/10408398.2022.2119933 Lerner, B. A., Green, P. H. R., & Lebwohl, B. (2019). Going Against the Grains: Gluten-Free Diets in Patients Without Celiac Disease—Worthwhile or Not? Digestive Diseases and Sciences , 64 (7), 1740–1747. https://doi.org/10.1007/s10620-019-05663-x Malterud, K., Siersma, V. D., & Guassora, A. D. (2016). Sample Size in Qualitative Interview Studies: Guided by Information Power. Qualitative Health Research , 26 (13), 1753–1760. https://doi.org/10.1177/1049732315617444 Manza, F., Lungaro, L., Costanzini, A., Caputo, F., Carroccio, A., Mansueto, P., Seidita, A., Raju, S. A., Volta, U., De Giorgio, R., Sanders, D. S., & Caio, G. (2025). Non-Celiac Gluten/Wheat Sensitivity—State of the Art: A Five-Year Narrative Review. Nutrients , 17 (2). https://doi.org/10.3390/nu17020220 Muhammad, H., Reeves, S., & Jeanes, Y. M. (2019). Identifying and improving adherence to the gluten-free diet in people with coeliac disease. Proceedings of the Nutrition Society , 78 (3), 418–425. https://doi.org/10.1017/S002966511800277X Myhrstad, M. C. W., Slydahl, M., Hellmann, M., Garnweidner-Holme, L., Lundin, K. E. A., Henriksen, C., & Telle-Hansen, V. H. (2021). Nutritional quality and costs of gluten-free products: A case-control study of food products on the norwegian marked. Food and Nutrition Research , 65 . https://doi.org/10.29219/fnr.v65.6121 Pohoreski, K., Horwitz, S. L., & Gidrewicz, D. (2023). Gluten-Free Diet Knowledge and Adherence in Adolescents with Celiac Disease: A Cross-Sectional Study. JPGN Rep. , 4 (3), e330. https://doi.org/10.1097/pg9.0000000000000330 R Green, J. M. E. J. S. A. A. D. (2016). Dietary patterns in India: a systematic review. Br J Nutr , 116 (1), 142–148. Reilly, N. R. (2016). The Gluten-Free Diet: Recognizing Fact, Fiction, and Fad. Journal of Pediatrics , 175 , 206–210. https://doi.org/10.1016/j.jpeds.2016.04.014 Rothburn, N., Fairchild, R. M., & Morgan, M. Z. (2022). Gluten-free foods: a “health halo” too far for oral health? British Dental Journal 2022 , 1–7. https://doi.org/10.1038/s41415-022-4424-2 Sahin, Y., Sevinc, E., Bayrak, N. A., Varol, F. I., Akbulut, U. E., & Bükülmez, A. (2022). Knowledge Regarding Celiac Disease among Healthcare Professionals, Patients and Their Caregivers in Turkey. World J. Gastrointest. Pathophysiol. , 13 (6), 178–185. https://doi.org/10.4291/wjgp.v13.i6.178 Segal, M. T., & Demos, V. (Eds.). (2016). Gender and Food: From Production to Consumption and After . Advances in Gender Research , 22 . https://doi.org/10.1108/S1529-2126201622 Sharma, M., Kishore, A., Roy, D., & Joshi, K. (2020). A comparison of the Indian diet with the EAT-Lancet reference diet. BMC Public Health 2020 20:1 , 20 (1), 812-. https://doi.org/10.1186/S12889-020-08951-8 Shiha, M. G., Manza, F., Figueroa-Salcido, O. G., Ontiveros, N., Caio, G., Jansson-Knodell, C. L., Rubio-Tapia, A., Aziz, I., & Sanders, D. S. (2025). Global prevalence of self-reported non-coeliac gluten and wheat sensitivity: a systematic review and meta-analysis. Gut . https://doi.org/10.1136/gutjnl-2025-336304 Silvester, J. A., Weiten, D., Graff, L. A., Walker, J. R., & Duerksen, D. R. (2016). Is it gluten-free? Relationship between self-reported gluten-free diet adherence and knowledge of gluten content of foods. Nutrition , 32 (7–8), 777–783. https://doi.org/10.1016/j.nut.2016.01.021 Simón, E., Molero-Luis, M., Fueyo-Díaz, R., Costas-Batlle, C., Crespo-Escobar, P., & Montoro-Huguet, M. A. (2023). The Gluten-Free Diet for Celiac Disease: Critical Insights to Better Understand Clinical Outcomes. Nutrients , 15 (18), 4013. https://doi.org/10.3390/nu15184013 Taraghikhah, N., Ashtari, S., Asri, N., Shahbazkhani, B., Al-Dulaimi, D., Rostami-Nejad, M., Rezaei-Tavirani, M., Razzaghi, M. R., & Zali, M. R. (2020). An updated overview of spectrum of gluten-related disorders: Clinical and diagnostic aspects. BMC Gastroenterology , 20 (1). https://doi.org/10.1186/s12876-020-01390-0 Taşkin, B., & Savlak, N. (2021). Public awareness, knowledge and sensitivity towards celiac disease and gluten-free diet is insufficient: A survey from Turkey. Food Science and Technology (Brazil) , 41 (1), 218–224. https://doi.org/10.1590/fst.07420 Tables Tables 1 to 5 are available in the Supplementary Files section. Additional Declarations No competing interests reported. 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While celiac disease affects approximately 1% of the global population(4), the prevalence of NCGS is estimated to range between 2 to 14% depending on the region, definition, diagnostic method and the population studied (5). In recent years, gluten-free diets (GFDs) have gained considerable popularity beyond clinically indicated contexts, with many individuals adopting them for perceived benefits such as weight management, improved gastrointestinal health, and enhanced energy levels (6\u0026ndash;8). However, most of the existing evidence originates from the United States, Europe, and Australia (9\u0026ndash;12), limiting its generalizability to socio-culturally and nutritionally diverse settings such as India where dietary practices are known to be shaped by cultural, regional, and socioeconomic factors and wheat and other gluten-containing staples constitute an important component of habitual diets (13,14).\u003c/p\u003e \u003cp\u003eIn India, the epidemiology of gluten-related disorders (GRDs) is evolving, with emerging evidence indicating increased recognition of gluten sensitivity (15) concurrent with the rapid expansion of the market for gluten-free products (GFPs)(India Gluten Free Product Market - Revenue, Size \u0026amp; Growth, 2026.; India Gluten-Free Products Market Size \u0026amp; Outlook, 2033, 2025.). Recent market research analyses indicate that the gluten-free foods and beverages sector in India is already valued in the several hundred million USD range and is projected to grow substantially over the coming decade (India Gluten Free Product Market - Revenue, Size \u0026amp; Growth, 2025.; India Gluten-Free Products Market Size, Share Trends By 2035, 2026). As diagnostic infrastructure improves and awareness of GRDs and associated gastrointestinal disorders increase, the number of individuals diagnosed with celiac disease or NCGS is likely to further escalate, particularly in the wheat-consuming regions of northern India. Market trends also reflect the emergence of a \u0026ldquo;wellness-driven\u0026rdquo; consumer segment that increasingly adopts gluten-free alternatives as part of broader health and lifestyle choices rather than for clinically diagnosed conditions (18). This shift\u0026mdash;from GFPs as a medical necessity to their positioning as mainstream lifestyle choices\u0026mdash;is considered to be influenced by urbanization, global health and fitness trends, rising disposable incomes, expanding retail and e-commerce platforms, and a growing population of health-conscious consumers. Furthermore, this GFP market momentum is being reinforced by government initiatives promoting traditional, naturally gluten-free grains such as millets as modern and accessible staples (19), alongside private-sector innovation aimed at diversifying convenient and health-oriented gluten-free offerings. Against this backdrop of dietary landscape in India, there is a need for comprehensive, context specific investigations so that public perceptions, motivations, and professional challenges related to both medically and non-medically indicated GFD adoption are better understood.\u003c/p\u003e \u003cp\u003eExisting research on knowledge, attitudes, and practices (KAP) related to gluten and GFDs reveals significant gaps in knowledge and persistent misconceptions among the general public (20\u0026ndash;22). For instance, cross sectional surveys conducted outside India have reported that a substantial proportion of consumers perceive gluten-free options as integral to healthy eating patterns, wellness routines, and digestive health management(6,12). Findings from several narrative reviews of consumer perceptions indicate challenges such as limited availability and variety of GFPs, higher prices compared to gluten containing counterparts, concerns regarding product quality and difficulties in interpreting food labels(3,23\u0026ndash;25). A cross-sectional study assessing the GFD awareness among people with celiac diseases demonstrated inadequate knowledge regarding gluten-free alternatives to staple foods in patients and physicians(26). Healthcare professionals have also reported challenges in counselling patients due to limited understanding of gluten free food alternatives, divergent patient beliefs, dietary trends and influence of social media and self-diagnosis, and persistent confusion regarding the appropriate clinical indications for gluten restriction (7,12,27). These findings underscore the need for targeted professional training and structured public nutrition education efforts to improve dietary adherence and clinical counselling. However, to design these interventions, the existing knowledge and attitudes toward gluten and GFDs in the general population must be examined and the beliefs and counselling practices of nutrition and dietetic professionals related to gluten and GFDs must be explored.\u003c/p\u003e \u003cp\u003eDespite the increasing adoption of GFDs, there are, to our knowledge, no studies that have assessed public awareness, underlying motivations for GFP preferences, and the clinical and nutritional considerations influencing consumer purchasing and consumption behaviours in India. Therefore, this mixed method study was designed to explore the perspectives of practicing dietetic professionals and concurrently assess the KAP related to gluten and GFDs among adults aged 18\u0026ndash;45 years in India. We hypothesized that a mixed-methods approach integrating quantitative consumer survey data with in-depth professional insights would offer a nuanced and contextually grounded understanding of both individual behaviors and expert interpretations. Such evidence would be critical for developing culturally relevant public health strategies, clinical guidance, and responsible market communication in India.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis study employed a mixed-methods design using a convergent parallel approach, integrating qualitative and quantitative methods to comprehensively address the study objectives. The professional perspectives on awareness, attitudes, and practices related to gluten and GFDs were explored using a series of in-depth interviews (IDIs) with practicing registered dietitians and a cross-sectional survey was conducted among adults aged 18\u0026ndash;45 years residing in India to assess their KAP related to gluten and GFDs. Both qualitative and quantitative investigations were performed concurrently, analysed independently, and subsequently interpreted together to allow triangulation and complementarity of findings.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Setting and Sampling\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eIn-depth Interviews with experts\u003c/h2\u003e \u003cp\u003eThe interviews were conducted face to face using video-conferencing platforms between January and April 2025 in India. To seek participation for the IDIs, invitations were circulated through professional networks, and interested individuals meeting the inclusion criteria were contacted by the research team to discuss the study protocol in detail and seek informed consent for participation. Eligibility criteria included: (i) being a registered dietitian, currently practising in India, (ii) having a minimum of five years of clinical experience in a tertiary-care hospital setting and iii) prior experience of counselling patients with gastrointestinal or related clinical conditions including celiac disease, wheat allergy, irritable bowel syndrome (IBS) and NCGS. Of 12 experts who were contacted, eleven met the eligibility criteria, and nine provided informed consent and completed the interviews.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCross sectional survey among adults\u003c/h3\u003e\n\u003cp\u003eThe cross-sectional study was administered online among adults aged 18\u0026ndash;45 years residing in India using a secure web-based platform. The age group of 18\u0026ndash;45 years was intentionally selected as this population is most likely to be exposed to and influenced by dietary trends such as gluten-free diets, actively seek nutrition-related information and make independent food purchasing and consumption decisions (Dunn et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Participants were invited through social media platforms using a digital flyer that provided detailed information about the study objectives, eligibility criteria, voluntary nature of participation, and the contact information of researchers for queries. Eligibility screening was conducted through an initial section of the online questionnaire, where respondents self-reported age and confirmed residence in India.\u003c/p\u003e \u003cp\u003eThe sample size was determined using standard sample size estimation methods for proportion-based surveys. Assuming a conservative prevalence of 50% for adequate knowledge (as prior prevalence estimates of GFDs were limited in India), a 95% confidence interval and 80% statistical power, the sample size was calculated to be approximately 196 participants using Cochran\u0026rsquo;s formula for cross-sectional studies (29). To account for an anticipated 20% non-response or incomplete response rate, the target sample size was inflated to 235 participants to ensure adequate power to describe key knowledge, attitude, and practice indicators, and robustness against potential non-response bias. In our study, a total of 285 participants completed the online survey and were included in the final statistical analysis and data interpretation.\u003c/p\u003e\n\u003ch3\u003eData Collection Procedures\u003c/h3\u003e\n\u003cp\u003eThe interviews were conducted by the Principal Investigator, proficient in qualitative research data collection, and supported by a research assistant having postgraduate degree in clinical nutrition, using a semi-structured interview guide. The questions and probes were developed a priori by the research team based on the study objectives and a review of relevant literature to explore expert perspectives on patterns of GFD adoption, emerging trends, and clinical and counselling challenges encountered in routine practice(20,24,30). The guide comprised open-ended questions related to participants\u0026rsquo; professional experience in counselling individuals with gastrointestinal disorders, including celiac disease, NCGS, and irritable bowel syndrome. Participants were asked to reflect on public awareness, motivations, and perceptions regarding gluten and GFDs, as well as temporal trends observed in both clinical practice and broader community contexts.\u003c/p\u003e \u003cp\u003eAdditional domains included counselling practices related to gluten restriction, dietary substitutions recommended, perceptions of the nutritional adequacy of GFPs, and clinical considerations such as diagnostic approaches for celiac disease or gluten sensitivity and nutrients commonly monitored in patients following GFDs. The views on the growing popularity of GFDs, and the role of social media were also discussed. All interviews were conducted in English, audio-recorded with participants\u0026rsquo; permission, and lasted approximately 30\u0026ndash;45 minutes. The discussions were kept informal, allowing for clarification and follow-up questions where appropriate to enable an in-depth exploration of participants\u0026rsquo; perspectives. The semi structured interview guide is provided as Supplementary File 1.\u003c/p\u003e \u003cp\u003eTo assess KAP related to gluten and GFDs among general population, a self-reported, structured questionnaire was developed in English and administered electronically using Google Forms to facilitate broad geographic reach and ease of response. The survey included questions related to sociodemographic characteristics and KAP regarding gluten and GFDs. The knowledge regarding gluten and gluten-containing foods, common symptoms and underlying mechanisms of gluten consumption-related disorders, and potential effects of following a GFD on health were assessed in a multiple-choice or multiple select question option format. Each correct response was scored 1 and incorrect and/or don\u0026rsquo;t know options were marked as 0.\u003c/p\u003e \u003cp\u003eThe attitude section comprised of ten statements, rated on a five-point Likert scale ranging from \u0026ldquo;strongly disagree\u0026rdquo; to \u0026ldquo;strongly agree. Items assessed perceptions of the nutritional quality of gluten-free foods, beliefs regarding the role of GFDs in weight management and gut health, views on who should adopt a GFD, and opinions regarding GFDs as a lifestyle or preventive approach to better health. Additional items explored perceived social influences and reliable sources of nutrition information, benefits and risks of self-adoption of GFDs, and confidence in personal nutrition knowledge.\u003c/p\u003e \u003cp\u003eTo evaluate purchasing and consumption practices, participants were asked to report their frequency of intake of gluten-free food items over the preceding month. An 18-item qualitative food frequency questionnaire (FFQ) including most commonly consumed gluten-free foods in India was administered. The list of selected food items was developed based on previous literature (13,31), and our insights drawn from in-depth interviews. Consumption frequency was recorded using a five-point scale ranging from \u0026lsquo;everyday\u0026rsquo; to \u0026lsquo;never or rarely (less than once a month)\u0026rsquo;. Also, purchasing behaviors, reasons for selecting gluten-free foods, and food label\u0026ndash;reading practices were assessed. The questionnaire draft was piloted among 18 adults, aged 18\u0026ndash;45 years to check for clarity, comprehensibility, content relevance, and the time required for completion. Based on participant feedback, minor rephrasing was undertaken before administering the final version to study participants.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003e The interview transcripts were reviewed initially by the investigators for familiarisation and then analysed using an inductive thematic analysis approach. Codes were assigned iteratively to describe actions, perceptions, beliefs, or experiences, and then reviewed and refined by comparing them across transcripts, merging the overlapping or redundant codes and grouping related codes into sub themes and overarching themes to capture recurrent pattern in the data. These emergent themes were further refined to ensure coherence, credibility and alignment with the study objectives. Representative quotations were identified to support each theme and are presented in the Results section.\u003c/p\u003e \u003cp\u003eData collected from the survey were analysed using Jamovi version 2.6.17 (The Jamovi Project, Australia)(32). Continuous variables were summarised as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation and analysed using independent-samples t-tests. Categorical variables were expressed as frequencies and percentages and compared using chi-square tests. Gender differences in questions with multiple responses (such as reasons for preferring gluten-free foods or adoption of GFDs) were analysed using separate chi-square tests for each response option, with adjustment for multiple comparisons using the Bonferroni correction. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of nine registered dietitians participated in the in-depth interviews. All participants were women with at least a postgraduate degree in clinical nutrition, 77.8% were \u0026gt;35 years old, and 33.3% had \u0026gt;10 years of professional experience (Table 1).INSERT TABLE 1\u003c/p\u003e\n\u003cp\u003eThe results of the qualitative and quantitative data are provided separately in this section.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults of the thematic analysis of IDI data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThematic analysis of interview data identified six interrelated themes describing registered dietitians’ perspectives on public knowledge, attitudes, and practices related to gluten and GFDs in India. A summary of the main themes and illustrative quotes reflecting the dominant and recurrent insights are provided below:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 1: Limited and Fragmented Public Understanding of Gluten\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDietitians reported that although most individuals were familiar with the term \u003cem\u003egluten\u003c/em\u003e, their understanding of its sources, physiological role, and clinical relevance was superficial. Gluten was commonly perceived as synonymous with \u003cem\u003eroti\u003c/em\u003e, bread, or bakery items, with minimal recognition of its presence in a wider range of foods\u0026nbsp;(\u003cem\u003e“Most patients know the word gluten, but very few can actually identify where it comes from or who really needs to avoid it.”).\u003c/em\u003eParticipants noted that gluten was frequently perceived as an inherently “unhealthy” component of the diet rather than a protein relevant primarily to specific medical conditions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 2: Symptom-Led Self-Diagnosis and Clinical Counselling Challenges\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA recurrent observation that emerged from the interviews was the increasing adoption of GFDs without medical indication or proper diagnosis \u003cem\u003e(\u003c/em\u003e\u003cem\u003e“Quite often an individual would have initiated gluten avoidance for reasons unrelated to diagnosed celiac disease or gluten sensitivity.”)\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eReported motivations included perceived weight loss benefits, improved digestion, better skin health, and alignment with wellness trends. Participants expressed concern that such symptom-led self-diagnosis tends to complicate clinical evaluation, delays diagnosis of celiac disease or non-celiac gluten sensitivity, and poses challenges for effective counselling—particularly when individuals had already eliminated gluten from their diets. All experts agreed that GFDs should be prescribed cautiously and primarily for individuals with confirmed diagnoses such as celiac disease, NCGS, or wheat allergy. Several dietitians highlighted the need for interdisciplinary coordination with gastroenterologists for early flagging of symptoms and subsequent management strategies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 3: Poor Recognition of Hidden Gluten and Cross-Contamination Risks\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDiscussions with dietitians revealed that awareness of hidden gluten sources and cross-contamination risks remains limited in general public but also among dietitians who are not actively involved in gastrointestinal disorders or celiac disease management. Participants highlighted significant gaps in public understanding around non-food sources of gluten exposure, such as medications, nutritional supplements, and even personal care products like lip balms.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“In several processed foods, gluten may appear as stabilizers, thickeners, flavourings, or additives (e.g., malt extract, modified food starch, soy sauce, and certain spice blends).”\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“The products labelled as “wheat-free” are often mistakenly assumed to be gluten-free, creating confusion between wheat exclusion and complete gluten elimination\u003c/em\u003e”.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e“\u003cem\u003eInterpreting ingredient lists can be challenging, particularly when gluten-containing derivatives are listed under unfamiliar names\u003c/em\u003e”.\u003c/p\u003e\n\u003cp\u003eAdditionally, cross-contamination risks during food preparation and storage were discussed as areas of concern. Shared toasters, cutting boards, cooking water (e.g., for pasta), bulk food bins, and deep fryers are not always identified as potential contamination points. This gap was considered particularly important in the Indian context, where shared kitchens, local mills, and bulk food purchasing are common, increasing the risk of inadvertent gluten exposure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 4: Social Media, Wellness Trends, and the ‘Anti-Inflammatory’ Narrative\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants observed that gluten-free diets were frequently discussed alongside other wellness trends such as lactose-free diets, intermittent fasting, and anti-inflammatory eating, often without scientific grounding. Celebrity endorsements, influencer content, and fear-based messaging and anecdotal success stories were discussed as reinforcements of the perception that gluten is inherently harmful, even for healthy individuals.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Instagram and YouTube have become the primary nutrition educators, unfortunately without accountability.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Thanks to social media, there’s a lot of buzz about inflammation. People are harping on the term and saying gluten causes inflammation, so you must go gluten-free.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Gluten is perceived as pro-inflammatory …social narratives promote gluten avoidance as a preventive or universally beneficial practice”.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAnother concern raised was the growing trend of labelling naturally gluten-free foods as “gluten-free” for marketing purposes. This practice may mislead consumers into perceiving these products as specially modified or healthier alternatives, potentially creating unnecessary fear around regular staples and inflating prices without adding real nutritional value.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 5: Concerns Regarding Nutritional Adequacy and Quality of Gluten-Free Diets\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhen individuals eliminate gluten-containing staples such as whole wheat without carefully selecting suitable replacements, they may inadvertently reduce their intake of essential nutrients commonly found in whole grain products (\u003cem\u003e“\u003c/em\u003e\u003cem\u003eGluten-free does not automatically mean nutritious—many products are highly refined.”)\u003c/em\u003e.\u0026nbsp;If not planned well, GFDs tend to be low in dietary fibre and key micronutrients and higher in refined carbohydrates and fats\u0026nbsp;(“\u003cem\u003eIndividuals following GFDs require targeted counselling to ensure dietary adequacy through appropriate substitutions\u003c/em\u003e\u003cem\u003e”).\u0026nbsp;\u003c/em\u003eThe importance of individualized dietary counselling to ensure that gluten-free diets remain balanced, diverse, and nutritionally adequate, particularly for individuals following them long-term was reiterated in the discussions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 6: Need to leverage traditional diets and develop context-specific public awareness\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDietitians highlighted the unique Indian dietary contexts wherein traditional diets already include a variety of naturally gluten-free grains such as millets, rice, and pulses. However, this advantage was often underutilized due to limited awareness among general public (\u003cem\u003e“\u003c/em\u003e\u003cem\u003eIndia has always had gluten-free foods—what we lack is clarity about when and why to use them\u003c/em\u003e\u003cem\u003e.”\u003c/em\u003e) Several participants described GFDs as part of a broader “\u003cem\u003emodern wellness identity\u003c/em\u003e,” and “\u003cem\u003elargely confined to urban, higher socioeconomic groups\u003c/em\u003e”\u0026nbsp;with limited penetration into rural or socioeconomically diverse populations. This urban concentration is typically reflected in access to GFPs, awareness of food labels, and exposure to online health narratives.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults of the cross-sectional survey\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the 285 survey respondents, 64.6% were women, and 49.8% belonged to the age category 18-25 years. More than half (57.5%) held a bachelor’s degree and 64.8% resided in the western regions of India. Regarding dietary preferences, 26.7% reported following a vegetarian diet, while 58.9% identified as non-vegetarian\u0026nbsp;INSERT TABLE 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKnowledge related to gluten and gluten-free diets\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 presents the proportion of participants who provided correct responses to the knowledge items in the questionnaire. Only 50.9% and 38.6% of participants were able to correctly identify the definition of gluten and GFD, respectively. A majority of participants identified only 0–3 gluten-containing breakfast recipes (67.7%), lunch/dinner recipes (73.0%), dessert recipes (80.0%), and hidden sources of gluten (62.8%). Less than half (45.3%) correctly identified the medical conditions for which a GFD is recommended. However, recognition of GRD symptoms was comparatively better, with 64.2% of participants correctly identifying at least three out of six symptoms.\u003c/p\u003e\n\u003cp\u003eGender-based comparisons indicated that women demonstrated significantly greater proficiency than men in identifying gluten-containing food items and breakfast recipes (p \u0026lt; 0.001), recognizing hidden sources of gluten (p = 0.019), accurately describing a GFD (p = 0.030), identifying medical indications for a GFD (p \u0026lt; 0.001), and recognizing symptoms associated with GRDs (p \u0026lt; 0.001). INSERT TABLE 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAttitudes towards gluten-free diets\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNearly one-third of participants (29.1%) agreed or strongly agreed that gluten-free foods are healthier than gluten-containing foods and 38.9% believed that gluten-free diets help with weight loss (Table 3). Almost half of the participants felt that individuals with digestive discomfort should avoid gluten (46.6%), that small amounts of gluten can cause symptoms in sensitive individuals (47.3%) and that only individuals with a medical diagnosis should follow a GFD (48.7%). Less than one thirds (29.1%) agreed that a GFD can be followed as a regular diet while 49.5% perceived social influences as primary drivers of GFD adoption. Most participants (67.0%) believed that community awareness about GRDs is inadequate and 54.7% reported lacking sufficient knowledge to make informed choices about gluten-free options. INSERT TABLE 3.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePreferences and purchasing behaviours\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA significantly greater preference for gluten-free products over gluten-containing foods was observed among women (46.2%) as compared to men (20.8%, p \u0026lt;0.001). Among those who reported preferring GFPs, the most common reasons included healthier option (19.8%), weight loss (26.4%) and no reasons (32.1%). Overall, 21 (7.4%) participants reported currently following GFDs. Of these, 7 (30.0%) were following GFD for weight loss, 6 (28.6%) for improved GI symptoms and only 3 (14.3%) for medically indicated reasons. While 69.1% reported ‘rarely’ or ‘never’ purchasing gluten-free labelled products, 23.5% mentioned that they purchased GF foods ‘sometimes’ or ‘regularly’ and 7.4% reported ‘always’ purchasing them. Among those who purchased GF products, supermarkets (11.2%) and online platforms (7.4%) were the most common places of purchase. The food label-reading practices varied, with the most frequently checked information being ingredients (63.9%), sugar content (62.5%), and low-fat/fat-free claims (42.5%). Women were more likely than men to check gluten-free claims, ingredient lists, vegan/plant-based labels, and allergen information. INSERT TABLE 4\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsumption patterns of gluten-free foods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe frequency of consumption of selected gluten free food items as reported by participants is presented in Table 5. Rice (58.9%) and lentils (55.8%) were the most frequently (daily) consumed naturally gluten-free staples. Millets such as finger millets or ragi (26.6%), sorghum or jowar (16.9%), pearl millet or bajra (16.5%), and other minor millets such as little, kodo or barnyard millets (14.0%) were reported to be consumed at least 3-4 times per week. Oats/ oat flour (27.4%), rice flakes/ puffed rice (23.9%), chick pea flour or \u003cem\u003ebesan\u003c/em\u003e (28.1%) and soybean/ soy flour (19.3%) were consumed 1-2 times per week. Other gluten free food items such as potato flour (80.7%), tapioca/tapioca flour (88.4%), barley/quinoa (62.8%) and almond/peanut powders (44.9%) were reported to be rarely/ never consumed by participants. INSERT TABLE 5.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eTo gather a comprehensive understanding of professional perspectives and public knowledge, attitudes, and practices related to gluten and GFDs, we mapped the themes derived from the in-depth interviews with the findings reported in the cross-sectional survey. Overall, the interviews with experts revealed concerns over the normalization of unnecessary dietary restriction, misinformation-driven food choices, and the nutritional consequences of poorly planned GFDs. While dietitians agreed that awareness of the term \u003cem\u003egluten\u003c/em\u003e has increased, they emphasized that the general public understanding remains fragmented and influenced by social media narratives rather than clinical evidence. This limited understanding often results in partial or incorrect dietary restriction and nutritional inadequacies, undermining both clinical management and nutrition counselling efforts. A particular concern was the growing reliance on processed gluten-free alternatives\u0026mdash;such as packaged breads, snacks, and baked goods\u0026mdash;which are often lower in fibre and protein but higher in sugar, saturated fat, and sodium. Although qualitative investigations related to expert perspectives on non-medically indicated adoption of GFDs among general population are limited (33), previous studies conducted with patients having celiac diseases concur with our findings, suggesting several psychosocial, practical, and food environment (availability, price and quality) related barriers to adherence and acceptance of gluten-free diets(6\u0026ndash;8).\u003c/p\u003e \u003cp\u003eAdditionally, the interviews highlighted that traditional Indian diets naturally include several gluten-free staples such as rice, lentils, chickpea flour (besan), and millets like ragi, jowar, and bajra. These foods have been integral to regional cuisines for centuries and provide diverse, nutrient-rich alternatives to wheat-based products. In contrast to many western countries where gluten avoidance can be challenging due to pervasiveness of wheat-based convenience foods, and commercially prepared breads, snacks, and ready-to-eat products (9,34,35), home-cooked meals are still common in India and traditional grains and legumes are frequently consumed in most households(36,37), potentially making medically indicated gluten restriction more feasible when guided appropriately. Public health education efforts should therefore emphasize and leverage these traditional staples to promote balanced, naturally gluten-free eating patterns rather than encouraging reliance on expensive, packaged gluten-free\u0026ndash;labelled products.\u003c/p\u003e \u003cp\u003eThe results of consumer survey indicated that the knowledge regarding gluten and GFDs was modest with only about half of participants correctly identifying what gluten is, and fewer than half being able to accurately describe a GFD or identify appropriate medical indications. Practical knowledge deficits were also observed as most participants scored poorly when asked to identify gluten-containing food items, breakfast recipes, desserts, and hidden gluten sources in common packaged foods. These results are consistent with earlier evidence suggesting that public understanding of gluten and its medical relevance remains inadequate despite growing exposure to gluten-free marketing(20\u0026ndash;22). Previous studies have reported that gluten-free diets are often adopted without sufficient understanding of their clinical relevance and highlighted persistent misconceptions about gluten sensitivity in the absence of celiac disease (7,12,38). Recent regional evidence from the Middle East also indicates that insufficient knowledge about celiac disease and GFPs remains pervasive in people with diagnosed gluten sensitivity and the general public (26,38,39). Furthermore, we observed gender differences in several knowledge domains, with women, in general, demonstrating greater awareness related to gluten and GFDs. While these findings align with previous nutrition literacy studies as women are typically more involved in food purchasing and preparation practices(40\u0026ndash;42), the persistence of substantial knowledge gaps across both men and women indicate the need for population-wide educational strategies.\u003c/p\u003e \u003cp\u003eAttitudes regarding preferences for gluten free foods and beverages, self-efficacy in making informed choices and recognition of the need for better education were mixed. A considerable proportion of participants perceived gluten-free foods as healthier and beneficial for weight loss, reflecting the widely described \u0026ldquo;health halo\u0026rdquo; effect(11), and the influence of social media and popular narratives around gluten-free foods(6,8). At the same time, nearly half of participants agreed that only individuals with a confirmed medical diagnosis should follow a GFD. This finding suggests a nuanced and evolving public understanding regarding GFDs in India, where misconceptions about generalised health benefits coexist with appropriate recognition of their clinical indications. While aspirational and lifestyle-driven beliefs about gluten-free diets are evident, they do not appear to have entirely displaced awareness of their medical necessity in specific conditions such as celiac disease or NCGS. Furthermore, participants expressed concern that online messaging frequently promoted GFDs as universally beneficial. These observations are particularly relevant in the Indian context, where increasing exposure to digital health information intersects with traditional dietary practices and emerging wellness trends, reflecting a transitional phase in public understanding that continues to be shaped by expanding scientific communication, commercial marketing, and media discourse. Additionally, most participants acknowledged limited community awareness and reported inadequate personal knowledge to make informed choices about GFPs. This self-recognition of knowledge limitations represents an important finding, as earlier studies from other countries have reported high consumer confidence despite poor objective knowledge (2,12,43).\u003c/p\u003e \u003cp\u003eAnother notable finding was that the consumption patterns were largely rooted in traditional, naturally gluten free staples such as rice, millets, chick pea flour and soybeans rather than a deliberate adoption of less familiar foods such as quinoa, barley or commercially marketed gluten-free specialty flours (almond/ tapioca/ potato flours). This pattern underscores an important regional distinction to findings from western countries, where reliance on processed and specialty GFPs is reported to be substantially high among both patients and wellness seeking general public (24,33,44). Our findings suggest that naturally gluten-free dietary patterns may already be prevalent in Indian households, even in the absence of intentional adherence to a formally prescribed or preferred GFD. Clinically, these findings have pertinent implications for dietary counselling, as patients diagnosed with celiac disease or NCGS in India may be able to adapt more readily by modifying existing traditional food patterns rather than depending heavily on relatively more expensive, processed alternatives to gluten containing foods. From a nutritional standpoint, consumption of minimally processed, traditional staples may also support better dietary quality and nutritional adequacy as compared to highly processed GFPs, which are often lower in fibre and essential micronutrients.\u003c/p\u003e \u003cp\u003eOverall, these results indicate that the growth of packaged GFPs in India may not completely mirror consumption patterns and market demand trajectories observed in western countries. The duality of established traditional gluten free dietary practices intersecting with emerging \u0026lsquo;health driven, modern\u0026rsquo; food choices reflect evolving food belief systems shaped by globalization, urbanization, and shifting perceptions of wellness in non-Western contexts. From a public health perspective, these findings emphasize the need for context specific, evidence-based communication strategies to address common misconceptions regarding GFDs and prevent unnecessary dietary restrictions. Efforts should focus on clearly identifying populations who derive medical benefit from GFDs and promoting balanced dietary practices rooted in culturally appropriate traditional foods and clinical guidance rather than social media\u0026ndash;driven trends.\u003c/p\u003e \u003cp\u003eThe findings of our study must be interpreted in light of a few limitations. First, the survey data were collected electronically, which may have limited the access to individuals with digital literacy and engagement with online platforms, reflecting the views of relatively more educated or urban respondents and potentially underrepresenting populations from lower socioeconomic strata and rural settings. Second, although the sample size met the a priori power calculations for the survey and the sample adequacy recommendations for conducting qualitative studies with experts(45), the overall sample size remains modest. Future studies must consider a larger and more diverse sample to allow for granular subgroup analyses and better understanding of region-specific comparisons of GFD related beliefs and practices. Third, the KAP questionnaire was self-designed based on existing literature. While care was taken to ensure content relevance using pilot testing, rigorous psychometric validation could not be undertaken due to time and resource constraints. Finally, we employed a purposive sampling method using digital flyers, so it is likely that individuals with a prior interest in health or nutrition may have participated in the study.\u003c/p\u003e \u003cp\u003eDespite these limitations, this study has several strengths. The use of a mixed-methods design enabled triangulation of findings by integrating quantitative survey data with qualitative insights from expert interviews. While the survey provided estimates of knowledge, attitudes, and practices, the interviews offered contextual depth and revealed underlying motivations, misconceptions, and systemic drivers shaping gluten-free diet adoption in clinical and community settings. Another novel aspect of the present study was the detailed, meal-based evaluation of gluten identification (breakfast, lunch/dinner, desserts) and a comparison of KAP between men and women. The sample comprised adults, aged 18\u0026ndash;45 years, ensuring representation from both younger adults, who are often influenced by social media and popular health narratives, and middle-aged adults, who may adopt dietary modifications for perceived health or preventive reasons. Additionally, participants were selected across the four regions of India, enhancing the scientific rigor, cultural relevance, and robustness of the study findings. Finally, the study provides timely insights into the drivers of gluten free dietary trend in India, including media influence, perceived health benefits, and market expansion of specialty foods. Understanding these factors can inform the development of targeted nutrition communication strategies to mitigate misinformation and promote balanced, culturally appropriate diets. The findings may also guide regulatory discussions on food labelling, health claims, and marketing practices related to gluten-free alternatives.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis study is one of the few studies globally to examine KAP related to gluten and GFDs in non-medically indicated general population and to our knowledge the first to provide a comprehensive overview of both expert perspectives and consumer perceptions and practices in the Indian context. Overall, the interviews revealed a disconnect between clinical evidence and public perception regarding gluten and GFDs in India. These findings underscore the need for context-specific public education, clearer differentiation between medical and non-medical indications for GFDs, and stronger emphasis on culturally relevant counselling approaches that align consumer awareness, clinical guidance, and consumption practices in a rapidly evolving urban nutrition landscape in India. The triangulation of qualitative and quantitative data highlighted the opportunity to leverage India\u0026rsquo;s traditional food systems and professional counselling to support informed and evidence-based dietary decisions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Availability Statement -\u0026nbsp;\u003c/strong\u003eAll data generated and /or analyzed during the present study are provided as a part of the manuscript. Additional information is available from the corresponding author upon reasonable request\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e The authors sincerely thank the practicing nutrition and dietetic professionals for sharing their time, insights, and professional experiences. We are also grateful to Ms. Krisha Shah for assistance in data analysis and the participants for their active participation and enthusiastic cooperation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions -\u0026nbsp;\u003c/strong\u003eConceptualization, methodology,\u0026nbsp;investigations, project management, and writing of the original draft of the manuscript were performed by PM. Supervision of fieldwork, resources, participant recruitment, and data management was done by BQ. \u0026nbsp;Both authors have read the final version and approve of the final manuscript submitted for consideration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e-\u0026nbsp;The authors declare that they have no competing interests as defined by Nature Research, or other interests that might be perceived to influence the results and/or discussion reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis research received no specific grant from any funding agency, commercial or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of generative AI and AI-assisted technologies:\u003c/strong\u003e During the preparation of this work, the author(s) used ChatGPT (OpenAI) in order to assist with grammar correction and language refinement. After using this tool/service, the author(s) reviewed and edited the content as needed and take(s) full responsibility for the content of the published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Declaration :\u0026nbsp;\u003c/strong\u003eAll procedures were followed as per the ethical standards of conducting research in human participants under the Helsinki Declaration of 1975, as revised in 2000. The study protocol was approved by an independent ethics committee (ISBEC/ NR-30/KM-KM/2025). All participants provided informed consent prior to participation and data confidentiality and participant anonymity were maintained throughout the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAbu-Janb, N., \u0026amp; Jaana, M. (2020). Facilitators and Barriers to Adherence to Gluten-free Diet among Adults with Celiac Disease: A Systematic Review. \u003cem\u003eJ. Hum. Nutr. 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An updated overview of spectrum of gluten-related disorders: Clinical and diagnostic aspects. \u003cem\u003eBMC Gastroenterology\u003c/em\u003e, \u003cem\u003e20\u003c/em\u003e(1). https://doi.org/10.1186/s12876-020-01390-0\u003c/li\u003e\n\u003cli\u003eTaşkin, B., \u0026amp; Savlak, N. (2021). Public awareness, knowledge and sensitivity towards celiac disease and gluten-free diet is insufficient: A survey from Turkey. \u003cem\u003eFood Science and Technology (Brazil)\u003c/em\u003e, \u003cem\u003e41\u003c/em\u003e(1), 218\u0026ndash;224. https://doi.org/10.1590/fst.07420\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 5 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Gluten, Gluten- free diet, Celiac disease, Gluten related diseases, Health knowledge, attitudes and practices, dietitians, health education, India","lastPublishedDoi":"10.21203/rs.3.rs-9052215/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9052215/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eRecent evidence suggests a growing popularity of gluten-free diets (GFDs) beyond clinically indicated contexts in low middle income countries. However, a comprehensive investigation of public perceptions, motivations, and professional challenges related to both medically and non-medically indicated GFD adoption remains limited. Therefore, we conducted a mixed method study to explore the perspectives of dietetic professionals and assess the knowledge, attitudes, and practices (KAP) related to gluten and GFDs among adults aged 18\u0026ndash;45 years in India. The clinical and nutritional considerations for GFD were examined through in-depth interviews (n\u0026thinsp;=\u0026thinsp;9) and an online survey was conducted among adults (n\u0026thinsp;=\u0026thinsp;285) to assess their KAP. Thematic analyses revealed fragmented public understanding, symptom-led self-diagnosis, influence of \u0026ldquo;anti-inflammatory\u0026rdquo; narratives, concerns regarding nutritional adequacy of GFDs, and the need to leverage traditional food systems. Data highlighted limited knowledge regarding gluten (50.9%), and GFDs (38.6%). Reasons for GFD adoption included perceived health benefits (19.8%), weight loss (26.4%) and no reasons (32.1%). Consumption of naturally gluten-free staples such as rice (58.9%), lentils (55.8%) and millets (30.9%) was higher than that of oats (7.7%), barley/ quinoa (2.8%), and speciality flours (2.1%). The study provides timely insights into the drivers of the GFD trend within India\u0026rsquo;s rapidly evolving urban nutrition landscape.\u003c/p\u003e","manuscriptTitle":"A Mixed-Methods Study of Knowledge, Attitudes, and Practices Related to Gluten- Free Diets in India","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-24 18:00:27","doi":"10.21203/rs.3.rs-9052215/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"95827717976888885713918814823883538941","date":"2026-03-20T07:30:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-18T12:39:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"221936597933217981453794617227461910281","date":"2026-03-18T07:28:29+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-18T07:23:46+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-10T12:03:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-07T04:52:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-07T04:51:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2026-03-06T15:28:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dfd4b1f3-48e9-4555-a583-1e495ca6b260","owner":[],"postedDate":"March 24th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":64995289,"name":"Health sciences/Diseases"},{"id":64995290,"name":"Health sciences/Health care"},{"id":64995291,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2026-03-24T18:00:27+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-24 18:00:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9052215","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9052215","identity":"rs-9052215","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}