INTRODUCTION: Adherence to a gluten-free diet (GFD) is the cornerstone of therapy for celiac disease (CD). Gluten-free products are typically less accessible than their gluten-containing counterparts. In light of COVID-19, rising income and resource insecurity have been described worldwide1. This study determined whether household income affected patients’ dietary patterns and clinical symptoms during the COVID-19 pandemic. METHODS: This is an observational study at an urban tertiary hospital. A questionnaire was designed to collect patient demographic information, dietary patterns, and access to gluten-free products during the pandemic. Two validated celiac models, the Biagi Score2 and Leffler Celiac Symptom Index3, were incorporated to evaluate GFD adherence and celiac-related symptoms. The questionnaire was distributed May 2020 to adult patients with CD at the hospital’s celiac center (n = 130). RESULTS: Among 65 respondents (50% response rate), annual income ranged from < $40,000 and >$200,000. 84.6% have lived under a “shelter-in-place” order. Respondents found it significantly more challenging finding gluten-free products since the pandemic in comparison to the pre-COVID-19 era (P = 0.018). When stratified by income into low earning (LE) and high earning (HE) groups (LE = < $80,000, HE = > $80,000), more LE than HE struggled locating gluten-free products during the pandemic (53% in LE, 25% in HE). LE had significantly lower GFD adherence on the Biagi Score than HE respondents (P = 0.0279). LE also had significantly higher scores on the Leffler Celiac Symptom Index (P = 0.0055), reflective of higher symptom-burden over a 4-week period. CONCLUSION: This study surveyed patients with CD to determine whether economic insecurities affected their dietary patterns and clinical symptoms in the midst of a pandemic. Since the pandemic, respondents described greater challenges obtaining gluten-free products. These challenges disproportionately affected the LE group. LE exhibited significantly less GFD adherence and a higher celiac-related symptom burden during the pandemic. The economic impact of COVID-19 on study participants’ health underline the importance of income and resource security in management of CD. Larger studies can further clarify socioeconomic determinants of health in CD during resource-limited circumstances like the COVID-19 pandemic.Figure 1.: (A) Survey respondents' perception of gluten-free product accessibility before and during the COVID-19 pandemic. Mean Likert scores are presented, where score of 1 equals “easy” and score of 3 equals “challenging”. (B) Respondents' reported accessibility to gluten-free products during the COVID-19 pandemic, stratified by household income. The percentage of each response to the 3-item Likert scale (easy, neutral, challenging) is shown. (C) Respondents’ mean scores on the Biagi Score and Leffler Celiac Symptom Index, stratified by household income. The Biagi Score utilizes a series of questions to predict GFD adherence on a 4-point scale, where a higher score correlates with better GFD adherence. Conversely, the Leffler Celiac Symptom Index calculates patients’ symptom burden in which a lower score correlates with better-controlled symptoms.Figure 2.: Demographic data of survey respondents.