A gluten-free diet effectively reduces symptoms and health care consumption in a Swedish celiac disease population
© Norström et al.; licensee BioMed Central Ltd. 2012
Received: 16 December 2011
Accepted: 30 August 2012
Published: 17 September 2012
A gluten-free diet is the only available treatment for celiac disease. Our aim was to investigate the effect of a gluten-free diet on celiac disease related symptoms, health care consumption, and the risk of developing associated immune-mediated diseases.
A questionnaire was sent to 1,560 randomly selected members of the Swedish Society for Coeliacs, divided into equal-sized age- and sex strata; 1,031 (66%) responded. Self-reported symptoms, health care consumption (measured by health care visits and hospitalization days), and missed working days were reported both for the year prior to diagnosis (normal diet) and the year prior to receiving the questionnaire while undergoing treatment with a gluten-free diet. Associated immune-mediated diseases (diabetes mellitus type 1, rheumatic disease, thyroid disease, vitiligo, alopecia areata and inflammatory bowel disease) were self-reported including the year of diagnosis.
All investigated symptoms except joint pain improved after diagnosis and initiated gluten-free diet. Both health care consumption and missed working days decreased. Associated immune-mediated diseases were diagnosed equally often before and after celiac disease diagnosis.
Initiated treatment with a gluten-free diet improves the situation for celiac disease patients in terms of reduced symptoms and health care consumption. An earlier celiac disease diagnosis is therefore of great importance.
In celiac disease (CD), gluten triggers an autoimmune reaction in the small intestinal mucosa which results in inflammation, villous atrophy, and malabsorption. A gluten-free diet is the only effective treatment for CD, and it usually results in recovery of the small intestinal mucosa .
During the last 30 years the clinical spectrum of CD has changed from mainly being comprised of young children with overt malabsorption to often affecting adults, with mild or atypical symptoms, and some of those diagnosed with the disease are even asymptomatic . Despite an increased awareness of symptoms related to CD, the delay from the first appearance of CD related symptoms to diagnosis is still long [3–5]. Economic consequences of CD for individuals and society have undergone little study. It has been shown, however, that the cost of food for CD patients is higher than for non-CD persons , and that women with CD consume more health care than other women . CD diagnosis and treatment has also been shown to decrease the costs for medical care in the United States, suggesting that a diagnosis can convey economic savings for society [8, 9]. There is an association between CD and other immune-mediated diseases, with CD being more prevalent among diabetes mellitus type 1 and thyroid disease patients [10–12] and inflammatory bowel disease and thyroid disease being more prevalent among CD patients [13–15]. A protective effect of a gluten-free diet on the risk of developing these related diseases has been proposed [16, 17], but there is uncertainty in this regard [15, 18–20].
The aim of this study was to investigate the effect of a gluten-free diet on CD related symptoms, health care consumption, and the risk of developing associated immune-mediated diseases.
A cross-sectional questionnaire survey among Swedish adults with CD was performed during 2009 . The questionnaire was approved by the Regional Ethical Review Board at Umeå University and an English translation is available online at Biomed Central .
Characteristics of celiac disease subjects
Age when responding (years)
Age at diagnosis (years)
Duration of celiac disease diagnosis (years)a
Compliance with a gluten-free diet
Respondents reported whether they had the following immune-mediated diseases: diabetes (both insulin and non-insulin dependent; the latter is not autoimmune in nature), rheumatic disease, thyroid disease, vitiligo, alopecia areata, or inflammatory bowel disease. Regarding these diseases the respondents were also asked for the year of diagnosis. As respondents were asked about insulin or non-insulin dependent diabetes, we cannot with certainty differentiate between diabetes mellitus type 1 and 2.
Results are presented using descriptive statistics. The sign-test was used for comparisons between pre-treatment and today. Time between diagnoses was calculated as time from CD diagnosis to other disease diagnosis. When both diagnoses occurred during the same year, time was defined as 0 years. Differences in symptoms between members with a recent diagnosis (2005–2009) and members with earlier diagnosis were performed using Students t-test. Comparisons of health care visits, hospitalization days, and missed working days between the groups were performed using Wilcoxon rank-sum test. To test if a gluten-free diet might decrease the risk for associated diseases, the proportions of diagnoses of associated diseases before or during the same year as the CD diagnosis were compared with the proportions after CD diagnosis using Students t-test. We excluded comparisons for vitiligo and alopecia areata due to too few complete answers. Statistical significance was defined at the 5% level. Microsoft Access was used for data handling, while Stata 11.2 (StataCorp LP, College Station, TX) was used for statistical analysis and figures.
Patients with symptoms today , also presenting for patients asymptomatic pre-treatment
Abdominal pain (n = 918)
Flatulence (n = 897)
Hard stool (n = 879)
Soft stool (n = 926)
Fatigue (n = 927)
Weight loss (n = 903)
Mood swings (n = 903)
Depression (n = 913)
Headache (n = 894)
Joint pain (n = 897)
Body pain (n = 897)
Heartburn (n = 891)
Nausea (n = 898)
Vomiting (n = 910)
Skin rash (n = 898)
Mouth ulcer (n = 904)
Hair loss (n = 880)
Health care consumption
Health care consumption pre-treatment and today
Health care visits
Missed working daysb
Health care visits
Missed working daysb
Health care visits
Missed working daysb
Self-reported immune-mediated diseases
Proportion of immune-mediated diseases and time development in relation to celiac disease (CD) diagnosis
Inflammatory bowel disease
Any immune-mediated disease e
CD patients suffer from more symptoms and consume more health care before diagnosis and initiated gluten-free diet than they do afterwards. However, we did not observe a difference in the risk of developing other immune-mediated diseases after initiated treatment with a gluten-free diet.
This study is one of the largest of its kind and it has a high response rate. Its unique contribution is that it compares the situation before and after initiation of a gluten-free diet, including symptoms and health care consumption, which adds valuable information about individual and societal costs of untreated CD.
Our retrospective approach involves the risk of recall bias. We observed a similar pattern for symptom relief, health care visits, and missed working days when restricting our analysis to screened and recently diagnosed (2005–2009) CD patients. There was not a significant reduction in hospitalization days for the recently diagnosed (2005–2009) CD patients. This could indicate an improved situation due to earlier diagnosis, which we have reported earlier in the same population , or it might be due to problems remembering hospitalization days if diagnosed earlier than 2005. In an attempt to assess if the risk of developing associated immune-mediated diseases is affected by a gluten-free diet, we assumed that if fewer were diagnosed with the related disease after the CD diagnosis this would indicate a protective effect. The patient is likely to remember which disease was diagnosed first, but if there is a delay in diagnosis for one of the diseases the association could still be incorrect. A causal relation cannot be determined with certainty by a cross-sectional questionnaire study. An examination of hospital files would have been a valuable addition in this respect, but that was not within the scope of this study.
Retrospectively reported symptoms prior to a CD diagnosis have been studied previously , as have symptoms at the time of CD diagnosis [22–25]. Most studies have reported symptoms at the time of diagnosis that were obtained from medical records, making comparisons with our results difficult. Our main interest was to detect experienced changes in symptoms after initiated treatment with a gluten-free diet. Previously, similar comparisons were done for a more limited number of symptoms by Murray and colleagues in the United States, showing a similar positive pattern for investigated symptoms after initiated treatment for CD . Also Ukkola with colleagues showed an improvement in symptoms after initiated treatment with a gluten-free diet for Finnish CD patients . Little is known about the added costs of CD for individuals and society. Although many participants had their CD for a long time, and therefore were considerably older today, their health consumption was significantly lower today than prior to the CD diagnosis, indicating a decreased need for health care after initiated treatment with a gluten-free diet.
There is a well-known association between CD and other immune-mediated diseases . A protective effect of a gluten-free diet was proposed more than a decade ago [16, 28], but later studies have shown conflicting results [15, 18]. In our study 25% of the individuals reported associated immune-mediated diseases. The prevalences of autoimmune thyroid disease and diabetes mellitus type 1 were similar to figures previously reported in a Swedish CD population study based on patient chart reviews . Our results could not verify or reject a risk reduction effect of a gluten-free diet on the development of any of the associated immune-mediated diseases that were studied. Further studies are needed to investigate this relationship.
In a previous publication based on the same study population and questionnaire, we reported that there is a long delay until CD diagnosis and that CD patients experience a poor health-related quality of life that is significantly improved after initiation of a gluten-free diet . Considering this and the results of the present study, there is a strong implication that greater effort must be made to diagnose CD earlier to decrease the burden of both poorer health-related quality of life and CD-related symptoms. This would also result in economic savings for society in terms of a reduction in health care consumption and missed working days.
Recent studies have indicated that the extent of symptoms that patients detected through a population-based CD screening might have may be similar to that of non-CD persons [29, 30]. The screening-detected cases in our study were mainly from risk groups. They reported the same positive effect of symptom relief after diagnosis and initiated treatment with a gluten-free diet as the CD patients who had their primary investigation due to symptoms.
In conclusion, CD patients profit from being diagnosed and treated with a gluten-free diet, since this reduces both symptoms and health care consumption. An earlier celiac disease diagnosis is therefore of great importance. The possible protective role of a gluten-free diet regarding the development of other immune-mediated diseases remains to be demonstrated.
We thank all who responded to the questionnaire, as well as the Swedish Society for Coeliacs for their assistance in improving the questionnaire and their crucial administrative help. The study was funded by the Swedish Research Council, the Swedish Research Council for Environment, Agricultural Sciences and Spatial Planning, and the Swedish Council for Working Life and Social Research. The study was undertaken at the Umeå Centre for Global Health Research at Umeå University.
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