Abstract
Background and Aims
Data on work absenteeism in celiac disease (CD) are scarce. This study aimed to evaluate the hours of work lost, reasons for work absenteeism, and their association with quality of life (QOL) and psychological morbidity in celiac patients on a gluten-free diet (GFD).
Methods
Adult celiac patients on a GFD were enrolled in a cross-sectional Italian study between October-2022 and October-2024. The survey included the Work Productivity and Activity Impairment (WPAI:CD), the Celiac Disease-specific Quality of Life scale (CD-QOL), the Beck Depression Inventory scale (BDI), and the State-Trait Anxiety Inventory scale (STAI-Y). A multivariable analysis was conducted to identify factors independently associated with work absenteeism.
Results
167 patients (121F, mean age at diagnosis of CD 32 ± 13 years) were enrolled. 23/167 (13.8%) lost working hours in the previous 30 days (mean of 6.61 h missed at work at 30 days). Reasons behind work absenteeism included outpatient clinic attendance (55.4%), symptom persistence despite a GFD (30.4%), and issues with GFD adherence (14.3%). Over a 30-day span, absentees had more ongoing symptoms despite the GFD (95.7% vs 67.4%, p = 0.05), higher scores on depression (median BDI-II score 12 vs 6, p = 0.04), and lower QOL (median CD-QOL score 79.0 vs 85.5, p = 0.015) than those who did not lose working hours. At multivariable analysis, being on a GFD for < 1 year (p = 0.001), and persistent symptoms despite a GFD (p = 0.04) were strongly associated with work absenteeism at 30 days.
Conclusions
CD can significantly impair work activities. Persistent symptoms and GFD < 1 year are strongly associated with work impairment. Clinicians should be aware of and manage these issues.
Supplementary Information
The online version contains supplementary material available at 10.1007/s10620-025-09183-9.
Keywords: Celiac disease, Work absenteeism, Gluten-free diet, Psychological burden, Quality of life
Introduction
Celiac disease (CD) is a chronic immune-mediated enteropathy triggered by the ingestion of gluten in genetically susceptible individuals and characterized by both a heterogeneous clinical picture and a high prevalence in the general population [1–4]. The mainstay for treatment of CD is a strict, lifelong gluten-free diet (GFD), which can be demanding to maintain in the long term [1–5]. The burden of CD extends beyond its physical and psychological impact, encompassing significant implications in many aspects of life [6–8], similarly to other chronic gastrointestinal diseases such as inflammatory bowel disease (IBD) and functional gastrointestinal disorders (FGID) [9, 10]. It has been reported that in patients affected by IBD, irritable bowel syndrome (IBS), and gastroesophageal reflux disease (GERD), not only was quality of life (QoL) severely affected, but working life was also significantly impaired, with increased work absenteeism being reported in these patients [11–21]. Furthermore, research has shifted its focus on the impact that CD itself and its treatment can have on patients’ global health and the subjective perception of the disease status by patients themselves. It has emerged that psychological morbidity in CD represents an important burden for patients, with anxiety, depression, fatigue, and mood disorders as the main drivers, having as triggers both the disease course itself and the effort required to maintain strict adherence to a GFD [6–8, 22–26].
On the contrary, data on work absenteeism in celiac patients are scarce [27–29]. In the general Italian working population, the weekly prevalence of medium- and long-term sickness absence was 1.2% (1.0% in men and 1.4% in women) in a nationally representative survey conducted in 2007 [30]. On the other hand, only three studies inquiring the subject of absenteeism in CD have been published so far, and their results are difficult to compare. Only one large Swedish population-based longitudinal study found that patients with CD experienced a substantial loss of working hours compared to the general population, both before and after diagnosis of CD [27].
Therefore, the aim of our study was to investigate absenteeism in adult celiac patients on a long-term GFD, and its relationship with QOL, psychological morbidity, adherence to a GFD and persistence of symptoms.
Patients and Methods
Study Design and Setting
This is a cross-sectional study conducted at two Italian referral centers for CD between October-2022 and October-2024. This study aimed to assess the amount of absenteeism over 30 days in adult celiac patients on a long-term GFD and the relationship between work absenteeism over 30 days and psychological morbidity, QoL, GFD adherence, and persistence of self-reported symptoms despite a GFD.
Study Population
The study included adult celiac patients (age ≥ 18 years) on a GFD and under regular follow-up at participating centers. Patients were enrolled in the study during follow-up medical consultations at each participating center between October-2022 and October-2024. After a simple explanation of the study’s objectives as part of informed consent for participation, patients who agreed to participate in the study were asked to complete an anonymous online questionnaire, which surveyed the amount of work absenteeism and the reasons underlying it, QOL, psychological status, and persistence of symptoms despite a GFD. Answers were automatically and electronically collected in an ad hoc Excel file and subsequently statistically analyzed.
For each patient, diagnosis of CD was based on positive endomysial/tissue transglutaminase antibodies and a certain degree of villous atrophy (VA) on biopsies taken from the second duodenal portion, while patients were on a gluten-containing diet, in accordance with international guidelines [1–3].
Development of the Survey Questionnaire
The survey consisted of five previously validated independent questionnaires investigating specific domains. These questionnaires included a modified Work Productivity and Activity Impairment (WPAI) [31], the Celiac Disease-specific Quality of Life Scale (CD-QOL) [32, 33], the State-Trait Anxiety Inventory (STAI-Y) [34], the Beck Depression Inventory (BDI) [35], and the Pavia Score for evaluating GFD adherence [36]. Some of these questionnaires were already adopted by a similar study by our groups investigating resilience in celiac patients [26].
The Work Productivity and Activity Impairment: General Health (WPAI:GH), based on general health and modified for CD, was used, which yields four types of scores: absenteeism (missed work time), presenteeism (impairment at work/reduced on-the-job effectiveness), work productivity loss (overall work impairment/absenteeism plus presenteeism), and activity impairment, through 6 questions [31]. For a better understanding of the impact of both absenteeism and presenteeism in celiac patients life, and to increase the statistical power of our study, we adapted this questionnaire to inquire about celiac-related impairment over a 30-day span (primary endpoint). Work absenteeism was calculated as both the absolute number of hours of work lost due to CD over the 30-day timespan and also as a percentage of total hours worked plus hours of work lost. Patients were considered to be affected by absenteeism if they report at least 1 h of work missed due to CD during the 30-day timespan. Presenteeism and impairment of daily activities were assessed using a numerical rating scale from 0 (no impairment) to 10 (complete impairment). We specify the original questions over a 7-day timespan were also included in the questionnaire to allow post hoc analyses to be conducted if necessary and compared with the results of the questionnaire adapted to a 30-day recall period.
The Celiac Disease-specific Quality of Life Scale (CD-QOL) is a widely used questionnaire to measure CD-related QoL and it is based on the analysis of patients’ perception of their life during treatment with a GFD. This questionnaire takes into account 20 items across four clinically relevant subscales (limitations, dysphoria, health concerns, and inadequate treatment) [32]. For the specific purpose of our study, we have used the Italian version of the CD-QOL questionnaire [33].
The form Y of the State-Trait Anxiety Inventory (STAI-Y) is a commonly used measure of trait and state anxiety [34] consisting of 40 self-report items on a 4-point Likert scale. This form Y version has 20 items for assessing state anxiety (STAI-Y 1) and 20 for trait anxiety (STAI-Y 2). Higher scores are positively correlated with higher levels of anxiety.
The Beck Depression Inventory (BDI) is a 21-item, self-reported rating inventory that measures characteristic attitudes and symptoms of depression. Each item is rated on a scale ranging from 0 to 3. The higher the final cumulative score, the greater the depressive state [35].
Adherence to a GFD was evaluated using the Pavia questionnaire. This is a five-level score (0 to 4), developed and previously validated in Pavia, Italy [36] to assess GFD adherence. Patients scoring between 0 and 2 were considered not adherent to a GFD, while patients scoring 3 or 4 were considered adherent.
Severity of gastrointestinal symptoms despite a GFD was assessed by means of a numerical rating scale (NRS) ranging from 0 (no symptoms) to 10 (worst of symptoms).
Reasons behind cumulative absenteeism were also assessed, with a multiple choice question, with also an open option for patients to report additional reasons for absenteeism in addition to proposed answers.
Data Collection
Clinical and socio-demographic data were collected, including sex, age at diagnosis of CD, time on a GFD, membership to the Italian Association for Celiac Disease (AIC), persistence and severity of symptoms despite a GFD, marital status, and educational level. Data deriving from the survey questionnaires (WPAI, CD-QOL, STAI-Y, BDI, GFD questionnaire, and NRS for self-reported symptoms) were also collected and automatically entered in an ad hoc Excel spreadsheet, preserving patient anonymity.
Statistical Analysis
Statistical analysis was performed using R version 4.3.1 (R Core Team (2022). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL https://www.R-project.org/). Data were summarized as counts and percentages for categorical variables, and for continuous variables as mean and standard deviation (SD), or as median and interquartile range (IQR), as appropriate. Categorical variables were compared among groups with Fisher’s exact test. Continuous variables were compared among groups with the Wilcoxon rank-sum test or Kruskal–Wallis test, as appropriate. Correlation between variables was assessed with Spearman’s rank correlation coefficient. Multivariable logistic regression was performed to identify factors independently associated with 30-day work absenteeism. Variables for the multivariable model were selected based on statistical significance at uncorrected univariable analysis, effect size, and clinical relevance. Multicollinearity between variables was ruled out by visual inspection of diagnostic plots and by calculating variance inflation factors (VIF) using the R ‘vif’ function from the ‘car’ package (VIF > 5 was considered suggestive of multicollinearity). To address concerns regarding reliability of our adaptation of the WPAI:CD over a 30-day timespan, we also conducted a post hoc sensitivity analysis comparing patients with and without absenteeism over a 7-day timespan. For all analyses, a two-sided p value < 0.05 was considered statistically significant.
Ethics
The study protocol was approved by the Ethical Review Boards of the participating centers (protocol number 4680/AO/19, approved on 11th April 2019, extension approved on 5th May 2022 for Padova; Protocol 2721 CE Pavia, approved on 25th January 2023).
The study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki (6th revision, 2008) as reflected in a prior approval by the institution’s human research committee. All the patients answering the questionnaire gave their written consent to participate in the study. All data were collected and analyzed in anonymous form.
Results
Two hundred celiac patients on a GFD replied to the survey, although 33 patients were not employed at time of survey, so only the remaining 167 employed patients (121 F, mean age at diagnosis of CD 32 ± 13 years) were considered for the purpose of evaluating work absenteeism.
Baseline demographic and clinical features of the enrolled patients are summarized in Table 1. Overall, 23/167 (13.8%) were absent in the 30 days before the survey, with a median of 6 working hours lost (IQR 2–8). Among these 23 patients, reasons for work absenteeism included medical consultations in 12 (54.5%), persistent symptoms in 8 (36.4%), and meal-related issues at work in 2 (9.1%). Patients who experienced absenteeism over 30 days had more impairment in daily activities (p < 0.001), self-reported more persistence of symptoms despite a GFD in the last 30 days (95.7% vs 67.4%, p < 0.01), had lower scores for QOL (median CD-QOL score 79.0 vs 85.5, p = 0.02), and higher depression scores (median BDI score 12 vs 6, p < 0.01) than those who did not lose working hours at 30 days. Also, duration of a GFD differed significantly among patients with and without work absenteeism over 30 days (p < 0.01), with nearly one third of patients with work absenteeism being on a GFD for less than one year and figures stabilizing as time on a GFD increased.
Table 1.
Baseline demographic and clinical features of working celiac patients enrolled in the study and compared according to the amount of hours lost at work at 30 days
| Variable | All working pts on a GFD N = 167 |
No Absenteeism (past 30 days) N = 144 |
Absenteeism (past 30 days) N = 23 |
p value |
|---|---|---|---|---|
| Age at diagnosis of CD (mean (SD)) | 32 (13) | 31.87 (13.32) | 33.22 (11.16) | 0.647 |
| Sex, F | 121 (72.5%) | 102 (70.8%) | 19 (82.6%) | 0.318 |
| Work impairment (30 days) | ||||
| Absenteeism, hours of work lost (median [IQR]) | 0 [0–0] | 0 [0–0] | 6 [2–8] | < 0.001 |
| Absenteeism, work hours lost (%) (median [IQR]) | 0 [0–0] | 0 [0–0] | 3.6 [1.4–6.6] | < 0.001 |
| Absence Vacation (median [IQR]) | 0 [0–13.50] | 0 [0–11.25] | 3 [0–15] | 0.261 |
| Hours Worked (median [IQR]) | 135 [93–160] | 133.5 [96–160] | 140 [80–159] | 0.677 |
| Work impairment while working (%, median [IQR]) | 10 [10–20] | 10 [10–20] | 40 [25–70] | < 0.001 |
| Percent overall work impairment (%, median [IQR]) | 10 [10–20] | 10 [10–12.5] | 51.9 [26.8–72.4] | < 0.001 |
| Activities of daily living impairment (%, median [IQR]) | 10 [10–20] | 10 [10–20] | 50 [20–70] | < 0.001 |
| Reasons for work absenteeism* | ||||
| Gluten-free food shopping | 5 (8.9%) | 5 (14.7%) | 0 (0.0%) | 0.204 |
| Meal related | 3 (5.4%) | 1 (2.9%) | 2 (9.1%) | |
| Medical appointment | 31 (55.4%) | 19 (55.9%) | 12 (54.5%) | |
| Symptoms | 17 (30.4%) | 9 (26.5%) | 8 (36.4%) | |
| Recent symptoms (last 30 days) | 119 (71.3%) | 97 (67.4%) | 22 (95.7%) | 0.005 |
| Symptoms, numerical rating scale (last 30 days) | ||||
| Nausea/vomiting (median [IQR]) | 1 [1–1] | 1 [1–1] | 1 [1–4.5] | < 0.001 |
| Bloating (median [IQR]) | 3 [1–6] | 2 [1–5] | 5 [1.5–7.5] | 0.011 |
| Abdominal pain (median [IQR]) | 1 [1–3] | 1 [1–3] | 4 [1–7] | 0.001 |
| Diarrhea (median [IQR]) | 1 [1–2] | 1 [1–2] | 4 [1–6.5] | 0.001 |
| Constipation (median [IQR]) | 1 [1–3] | 1 [1–3] | 1 [1–4] | 0.231 |
| Difficulty focusing (median [IQR]) | 2 [1–5] | 1 [1–4] | 5 [2–7] | 0.001 |
| Tiredness (median [IQR]) | 4 [1–7] | 3 [1–6] | 7 [5.5–8] | < 0.001 |
| Quality of life and mental health | ||||
| Quality of Life Score (median [IQR]) | 84 [74.5–91] | 85.5 [75–92] | 79 [64.5–86.5] | 0.015 |
| State-Trait Anxiety Inventory (STAI-Y1) (mean (SD)) | 43.46 (5.61) | 43.74 (5.44) | 41.65 (6.42) | 0.097 |
| State-Trait Anxiety Inventory (STAI-Y2) (mean (SD)) | 43.54 (5.83) | 43.82 (5.53) | 41.83 (7.33) | 0.128 |
| Beck Depression Inventory (BDI-2) (median [IQR]) | 7 [3–14] | 6 [2–12] | 12 [6–20] | 0.004 |
| Education | ||||
| Secondary school diploma | 68 (40.7%) | 60 (41.7%) | 8 (34.8%) | 0.771 |
| University degree | 80 (47.9%) | 68 (47.2%) | 12 (52.2%) | |
| Doctorate (PhD) | 3 (1.8%) | 3 (2.1%) | 0 (0.0%) | |
| Mandatory education only | 16 (9.6%) | 13 (9.0%) | 3 (13.0%) | |
| Marital status | ||||
| Married | 93 (55.7%) | 79 (54.9%) | 14 (60.9%) | 0.933 |
| In relationship | 22 (13.2%) | 20 (13.9%) | 2 (8.7%) | |
| Separated/divorced | 12 (7.2%) | 11 (7.6%) | 1 (4.3%) | |
| Single | 40 (24.0%) | 34 (23.6%) | 6 (26.1%) | |
| Time on GFD | ||||
| Less than 1 year | 13 (7.8%) | 7 (4.9%) | 6 (26.1%) | 0.005 |
| More than 5 years | 104 (62.3%) | 94 (65.3%) | 10 (43.5%) | |
| 1 to 5 years | 50 (29.9%) | 43 (29.9%) | 7 (30.4%) | |
| AIC membership | ||||
| No | 64 (38.3%) | 54 (37.5%) | 10 (43.5%) | 0.504 |
| Previously | 38 (22.8%) | 35 (24.3%) | 3 (13.0%) | |
| Yes | 65 (38.9%) | 55 (38.2%) | 10 (43.5%) | |
| GFD adherence** | ||||
| Good | 146 (87.4%) | 127 (88.2%) | 19 (82.6%) | 0.497 |
| Poor | 21 (12.6%) | 17 (11.8%) | 4 (17.4%) | |
Bold values indicate statistical significance (p < 0.05)
F females, SD standard deviation, IQR interquartile range, AIC Italian Association for Celiac disease, GFD gluten-free diet
*Includes also reasons for work absenteeism outside of the last 30 days period
**Adherence to a gluten-free diet was considered good for score 3–4 and poor for score 0–2 [see reference 36]
No significant difference between patients who lost working hours over 30 days and those who did not was found for age, gender, level of education, marital status, membership to the Italian national Society for Celiac Disease (AIC), and adherence to a GFD.
Correlation Between Absenteeism, Quality of Life, and Psychological Morbidity
As shown in Fig. 1, a direct correlation emerged between absenteeism (work hours lost) over 30 days and depression scores (rho = 0.24, p = 0.002), while an inverse relationship was found between work hours lost over 30 days and CD-QOL score (rho = − 0.20, p = 0.01). No correlation was found between working hours lost over 30 days and both state and trait anxiety (STAY-1 and STAY-2). Significant positive correlations were found between work hours lost and self-reported work impairment due to CD (evaluated with a NRS) over 30 days (rho = 0.47; p < 0.001), as well as with non-working activities of daily living due to CD impairment (rho = 0.43; p < 0.001).
Fig. 1.
Correlation between working hours lost over 30 days, quality of life, depression, and anxiety scores
Multivariable Logistic Regression Analysis
Multivariable logistic regression analysis (Table 2) showed that being on a GFD for less than 1 year (p = 0.001) and persistence of symptoms despite a GFD (p = 0.042) were independently associated with work absenteeism at 30 days. Depression was only borderline significant (p = 0.06), whereas GFD adherence and quality of life did not reach statistical significance.
Table 2.
Multivariable logistic regression analysis showing factors independently associated with work absenteeism over 30 days
| Association with work absenteeism over 30 days | ||||||
|---|---|---|---|---|---|---|
| Uncorrected univariable analysis | Multivariable analysis | |||||
| Variable | Odds Ratio (OR) | 95% CI | p value | Odds ratio (OR) | 95% CI | p value |
| CD-QOL | 0.97 | 0.95–0.99 | 0.04 | 0.99 | 0.95–1.02 | 0.42 |
| BDI-II | 1.05 | 1.01–1.10 | < 0.01 | 1.05 | 1.00–1.10 | 0.06 |
| GFD adherence (poor) | 1.57 | 0.48–5.18 | 0.46 | 3.13 | 0.75–13.00 | 0.12 |
| Time on GFD < 1 year | 6.91 | 2.08–23.00 | < 0.01 | 8.87 | 2.36–33.30 | 0.001 |
| Symptoms over 30 days | 10.70 | 1.39–81.50 | 0.02 | 10.20 | 1.09–96.50 | 0.04 |
Post hoc Sensitivity Analysis
Supplementary Table 1 shows a comparison of the clinical and demographic features of working celiac patients enrolled in the study with and without work absenteeism over a 7-day timespan instead of the 30-day timespan used for the primary endpoint of the study. The overall results were substantially similar to those found over the 30-day timespan, although certain analyses did not reach statistical significance due to the lower number of patients reporting absenteeism over a 7-day span compared to the 30-day timespan.
Discussion
This is a cross-sectional study conducted at two Italian centers for CD, which evaluated the relationship between work absenteeism, QOL, psychological morbidity, and persistence of symptoms in adult celiac patients on a long-term GFD.
We found that nearly 15% of celiac patients experienced loss of working hours over the 30 days prior to the survey, with persistence of CD-related symptoms, medical consultations, and dietary restrictions being the main reasons behind work absenteeism. Compared to the 1.2% weekly absence rate observed in the general Italian population (30), our celiac cohort experienced more absenteeism over the preceding 30 days, suggesting a substantially higher burden in CD patients.
Moreover, patients who experienced work absenteeism over the 30 days prior to taking the survey were more likely to have ongoing symptoms despite the GFD, they were more depressed (higher BDI-II scores) and overall had a lower QOL (lower CD-QOL scores) than those who did not.
We also identified being on a GFD for less than one year and the persistence of symptoms despite a GFD as being strongly associated with work absenteeism at multivariable logistic regression, whereas depression was only borderline significant.
The results of our study, although based on a limited cohort, highlight that the burden of CD also includes work absenteeism and impairment of work activity and productivity (presenteeism). Work impairment was also found to be associated to persistence of symptoms despite a GFD and psychological morbidity. Our results regarding work impairment in CD are also analogous to findings by other authors in other gastrointestinal conditions such as IBD, IBS, and GORD [11–21].
The impact of CD on work disability is poorly understood as, so far, only three studies, all conducted in Scandinavian Countries, have investigated this aspect [27–29]. The most robust estimates on work disability in CD are provided by a large Swedish population-based study showing that celiac patients experienced significant work absenteeism compared to the general population before diagnosis of CD and even further increased during follow-up [27]. This group also found that increased work absenteeism in the year of diagnosis was mainly driven by sick leave, whereas the post-diagnostic increase was predominantly explained by an increase in disability leave [27]. Differently, our results show that work absenteeism was linked to depression scores and a lower QOL score, even though the effect sizes were small compared to those of persistent symptoms and being on a GFD for less than a year. Bozorg et al. hypothesized that this particular feature was due to inadequate response to a GFD [27], whereas our data shed light not only on the role of becoming familiar with dietary issues in the first years after diagnosis, but also on the persistence of symptoms despite a GFD. The results from the other two Scandinavian studies are more difficult to interpreted, as one found that the number of lost work days decreased upon diagnosis [28] and the other found that patients with CD had less work absenteeism than unmatched comparators before and after diagnosis [29]. However, in general, the discrepancies between our results and what has been previously reported are likely to be due to the different study designs and populations under investigation.
Furthermore, our results seem to be in line with similar studies conducted on other chronic gastrointestinal conditions, such as GERD, IBD, and IBS. Patients affected by these gastrointestinal disorders tend to have higher levels of both absenteeism and presenteeism, which impacts not only their overall QOL, but also encompasses heavy socio-economic burdens. The concordance between our conclusions, the other previously mentioned studies on CD, and the ones conducted on other GI conditions may suggest that it is the chronic nature of these disorders that leads to such work/life-related findings [11–21].
Finally, the identification of persistent symptoms despite a GFD and issues with the GFD in the first year after CD diagnosis as factors associated with work absenteeism can provide useful applications for clinicians. Healthcare providers should pay attention to patients facing barriers when adhering to a GFD, and a personalized dietetic counseling should be offered, particularly in the first year after diagnosis of CD, as we previously shown that GFD adherence can improve over the long term [5]. Although GFD adherence itself was not significantly related to work absenteeism, targeted dietary counseling may nevertheless help patients to adjust to following a GFD in this crucial early period, potentially reducing work absenteeism. Similarly, the appropriate management of persistent symptoms despite a GFD is a crucial requirement, as it has been shown that up to 30–50% of patients can experience unsatisfactory clinical response to a GFD [37, 38]. Identifying patients with an increased risk of work absenteeism may serve as a target to mitigate work disability, and thereby reduce work absenteeism, in patients with CD.
The clinical design of our study and the use of previously validated questionnaires for psychological morbidity, QOL, represent major strengths of our study. We also employed a validated questionnaire for work absenteeism, which was adapted to cover a 30-day timespan in addition to the original 7-day timespan. We also have to acknowledge some limitations due to the relatively small sample size, with a low number of events overall. Despite the WPAI being a questionnaire item originally investigating only a 7-day period, we administered it to evaluate a 30-day period with no previous examples of this in literature, with the results being possibly affected by a recall bias over this longer period. However, comparing the 30-day data with the 7-day responses, we found no substantial inconsistencies between the two recall periods (see Supplementary Table 1). Finally, although unavoidable, as part of the informed consent process participants were explained the objectives of the study beforehand, and we cannot completely rule out that this may have in some way impacted participant responses. However, unemployment in our cohort was comparable with the unemployment rate of the Italian general population [30], so we think our recruitment strategy is unlikely to have substantially affected our results.
In conclusion, our clinical-based study confirms that the burden of CD extends beyond dietary issues by significantly impacting the work life of celiac patients, in addition to physical and mental health. Work absenteeism and impairment, and their relationship with persistence of symptoms and psychological morbidity should be considered when developing personalized strategies for the individual management and follow-up of celiac patients. Moreover, healthcare providers should pay special attention to patients who have recently begun a GFD, as they may be at higher risk for work impairment, highlighting the importance of effective symptoms management.
Supplementary Information
Below is the link to the electronic supplementary material.
Author Contributions
MD, AS, and FZ planned the study. MD, LR, AS, GM, CS, PIB, SM, FB, and FZ took care of the patients and collected the data. SM performed the statistical analysis. MD, LR, and AS interpreted the data and drafted the manuscript. All the authors revised and approved the final version of the manuscript. Guarantor of the article: Prof. Fabiana Zingone, MD, PhD.
Funding
This work was partially supported through the Ricerca Corrente Funding of the Italian Ministry of Health.
Data Availability
No datasets were generated or analyzed during the current study.
Declarations
Conflict of interest
FZ has served as a consultant for Takeda and Tillotts Pharma. AS has served as a consultant for Tillotts Pharma. No other COI to declare.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Michele Dota and lorenzo Rubbini contributed equally to this study.
References
- 1.Rubio-Tapia A, Hill ID, Semrad C et al. American College of Gastroenterology Guidelines Update: diagnosis and management of celiac disease. Am J Gastroenterol 2023;118:59–76. [DOI] [PubMed] [Google Scholar]
- 2.Zingone F, Maimaris S, Auricchio R et al. Guidelines of the Italian societies of gastroenterology on the diagnosis and management of coeliac disease and dermatitis herpetiformis. Dig Liver Dis. 2022;54:1304–1319. [DOI] [PubMed] [Google Scholar]
- 3.Al-Toma A, Volta U, Auricchio R et al. European Society for the Study of Coeliac Disease (ESsCD) guideline for coeliac disease and other gluten-related disorders. United European Gastroenterol J. 2019;7:583–613. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Singh P, Arora A, Strand TA et al. Global prevalence of celiac disease: systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2018;16:823-836.e2. [DOI] [PubMed] [Google Scholar]
- 5.Schiepatti A, Maimaris S, Nicolardi ML et al. Determinants and trends of adherence to a gluten-free diet in adult celiac patients on a long-term follow-up (2000–2020). Clin Gastroenterol Hepatol 2022;20:e741–e749. [DOI] [PubMed] [Google Scholar]
- 6.Zingone F, Swift GL, Card TR et al. Psychological morbidity of celiac disease: a review of the literature. United European Gastroenterol J 2015;3:136–145. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Möller SP, Hayes B, Wilding H et al. Systematic review: exploration of the impact of psychosocial factors on quality of life in adults living with coeliac disease. J Psychosom Res 2021;147:110537. [DOI] [PubMed] [Google Scholar]
- 8.Mearns ES, Taylor A, Boulanger T et al. Systematic literature review of the economic burden of celiac disease. Pharmacoeconomics 2019;37:45–61. [DOI] [PubMed] [Google Scholar]
- 9.Gordon H, Burisch J, Ellul P et al. ECCO guidelines on extraintestinal manifestations in inflammatory bowel disease. J Crohns Colitis 2024;18:1–37. [DOI] [PubMed] [Google Scholar]
- 10.Palsson OS, Whitehead WE, van Tilburg MA et al. Rome IV diagnostic questionnaires and tables for investigators and clinicians. Gastroenterology 2016;150:1481–1491. [DOI] [PubMed] [Google Scholar]
- 11.Floyd DN, Langham S, Séverac HC et al. The economic and quality-of-life burden of Crohn’s disease in Europe and the United States, 2000 to 2013: a systematic review. Dig Dis Sci 2015;60:299–312. 10.1007/s10620-014-3368-z. [DOI] [PubMed] [Google Scholar]
- 12.Kuenzig ME, Lee L, El-Matary W et al. The impact of inflammatory bowel disease in Canada 2018: indirect costs of IBD care. J Can Assoc Gastroenterol 2019;2:S34–S41. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Everhov ÅH, Khalili H, Askling J et al. sick leave and disability pension in prevalent patients with Crohn’s disease. J Crohns Colitis. 2018;12:1418–1428. [DOI] [PubMed] [Google Scholar]
- 14.Le Berre C, Peyrin-Biroulet L, Buisson A et al. Impact of inflammatory bowel diseases on working life: a French nationwide survey. Dig Liver Dis 2019;51:961–966. [DOI] [PubMed] [Google Scholar]
- 15.Everhov ÅH, Khalili H, Askling J et al. Work loss before and after diagnosis of Crohn’s disease. Inflamm Bowel Dis 2019;25:1237–1247. [DOI] [PubMed] [Google Scholar]
- 16.Kim YS, Jung SA, Lee KM et al. Impact of inflammatory bowel disease on daily life: an online survey by the Korean Association for the Study of Intestinal Diseases. Intest Res 2017;15:338–344. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Fróes RSB, Carvalho ATP, Carneiro AJV et al. The socio-economic impact of work disability due to inflammatory bowel disease in Brazil. Eur J Health Econ 2018;19:463–470. [DOI] [PubMed] [Google Scholar]
- 18.Zand A, van Deen WK, Inserra EK et al. Presenteeism in inflammatory bowel diseases: a hidden problem with significant economic impact. Inflamm Bowel Dis 2015;21:1623–1630. [DOI] [PubMed] [Google Scholar]
- 19.Manceur AM, Ding Z, Muser E et al. Burden of Crohn’s disease in the United States: long-term healthcare and work-loss related costs. J Med Econ 2020;23:1092–1101. [DOI] [PubMed] [Google Scholar]
- 20.Dubois RW, Aguilar D, Fass R et al. Consequences of frequent nocturnal gastro-oesophageal reflux disease among employed adults: symptom severity, quality of life and work productivity. Aliment Pharmacol Ther 2007;25:487–500. [DOI] [PubMed] [Google Scholar]
- 21.Frändemark Å, Törnblom H, Jakobsson S, Simrén M. Work productivity and activity impairment in irritable bowel syndrome (IBS): a multifaceted problem. Am J Gastroenterol 2018;113:1540–1549. [DOI] [PubMed] [Google Scholar]
- 22.Ciacci C, Zingone F. The perceived social burden in celiac disease. Diseases 2015;3:102–110. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Canova C, Rosato I, Marsilio I et al. Quality of life and psychological disorders in coeliac disease: a prospective multicentre study. Nutrients 2021;13:3233. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Zingone F, Secchettin E, Marsilio I et al. Clinical features and psychological impact of celiac disease at diagnosis. Dig Liver Dis 2021;53:1565–1570. [DOI] [PubMed] [Google Scholar]
- 25.Marsilio I, Canova C, D’Odorico A et al. Quality-of-life evaluation in coeliac patients on a gluten-free diet. Nutrients 2020;12:2981. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Schiepatti A, Maimaris S, Randazzo S et al. Resilience in adult coeliac patients on a gluten-free diet: a cross-sectional multicentre Italian study. Nutrients. 2024;16:2595. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Bozorg SR, Söderling J, Everhov ÅH et al. Work loss in patients with celiac disease: a population-based longitudinal study. Clin Gastroenterol Hepatol. 2022;20:1068-1076.e6. [DOI] [PubMed] [Google Scholar]
- 28.Norström F, Sandström O, Lindholm L et al. A gluten-free diet effectively reduces symptoms and health care consumption in a Swedish celiac disease population. BMC Gastroenterol 2012;12:125. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Ukkola A, Kurppa K, Collin P et al. Use of health care services and pharmaceutical agents in coeliac disease: a prospective nationwide study. BMC Gastroenterol. 2012;12:136. 10.1186/1471-230X-12-136. (PMID: 23031447). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.d’Errico A, Costa G. Socio-demographic and work-related risk factors for medium- and long-term sickness absence among Italian workers. Eur J Public Health. 2012;22:683–688. [DOI] [PubMed] [Google Scholar]
- 31.Reilly MC, Zbrozek AS, Dukes EM. The validity and reproducibility of a work productivity and activity impairment instrument. PharmacoEconomics 1993;4:353–365. [DOI] [PubMed] [Google Scholar]
- 32.Dorn SD, Hernandez L, Minaya MT et al. The development and validation of a new coeliac disease quality of life survey (CD-QOL). Aliment Pharmacol Ther 2010;31:666–675. [DOI] [PubMed] [Google Scholar]
- 33.Zingone F, Iavarone A, Tortora R et al. The Italian translation of the celiac disease-specific quality of life scale in celiac patients on gluten free diet. Dig Liver Dis 2013;45:115–118. [DOI] [PubMed] [Google Scholar]
- 34.Spielberger CD, Gorsuch RL, Lushene R et al. Manual for the State-Trait Anxiety Inventory. Palo Alto: Consulting Psychologists Press; 1983. [Google Scholar]
- 35.Beck AT, Ward CH, Mendelson M et al. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561–571. [DOI] [PubMed] [Google Scholar]
- 36.Biagi F, Andrealli A, Bianchi PI et al. A gluten-free diet score to evaluate dietary compliance in patients with coeliac disease. Br J Nutr 2009;102:882–887. [DOI] [PubMed] [Google Scholar]
- 37.Schiepatti A, Maimaris S, Lusetti F et al. High prevalence of functional gastrointestinal disorders in celiac patients with persistent symptoms on a gluten-free diet: a 20-year follow-up study. Dig Dis Sci 2023;68:3374–3382. 10.1007/s10620-022-07727-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Penny HA, Baggus EMR, Rej A et al. Non-responsive coeliac disease: a comprehensive review from the NHS England National Centre for Refractory Coeliac Disease. Nutrients 2020;12:216. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
No datasets were generated or analyzed during the current study.