Gluten-Free Diet Adherence and Long-Term Health Outcomes in People with Celiac Disease (+Video)

Celiac.com 10/02/2025 - Celiac disease is an autoimmune condition triggered by gluten, a protein found in wheat, rye, and barley. When gluten is consumed, the immune system attacks the lining of the small intestine, causing damage and interfering with nutrient absorption. This can result in a wide range of symptoms such as diarrhea, bloating, abdominal pain, fatigue, skin conditions, and neurological issues. The only effective treatment is a lifelong strict gluten-free diet, but following such a diet can be difficult. This study examined how well people with celiac disease followed a gluten-free diet and how adherence affected their symptoms, lab values, and overall health over time.

Methods

The study was conducted between November 2022 and June 2023 and involved 300 adults with confirmed celiac disease. Participants were selected from an initial pool of more than 1,200 patients and completed a structured telephone survey. The survey included questions on demographics, diet adherence, gastrointestinal and non-gastrointestinal symptoms, and barriers to following the diet. Medical records were also reviewed to provide baseline lab values and clinical information. Adherence to the gluten-free diet was measured using the validated Biagi questionnaire, which categorizes patients into groups based on how strictly they follow the diet.

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Participants were divided into three groups based on the length of time they had followed the diet: short or medium-term (six months or less), long-term (six to 24 months), and very long-term (24 months or more). The study analyzed trends in symptoms, lab values, and comorbidities across these groups.

Results

The average age of participants was 41 years, and most were women (nearly three-quarters). Slightly more than half of the patients (55%) showed strict adherence to the gluten-free diet according to the Biagi questionnaire. Around 28% showed worse adherence as time went on, while about 29% improved. The remainder showed no major changes. Interestingly, some patients who believed they were strictly following the diet were found to have errors when objectively assessed, pointing to a gap between self-perception and actual adherence.

Symptom improvement was observed across many areas. Gastrointestinal symptoms such as abdominal pain, diarrhea, and vomiting improved the longer patients followed the diet. For example, the percentage of patients without abdominal pain rose from 71% in the short-term group to 85% in the very long-term group. Non-gastrointestinal symptoms also improved. Depression showed the most striking change, with the proportion of patients without depression increasing from about 64% in the short-term group to almost 90% in the very long-term group. Anemia and neurological symptoms also showed better outcomes with longer adherence.

Laboratory values reflected improvements as well. Vitamin D and measures of red blood cell health improved, while other values, such as thyroid hormone markers, showed declines that need further exploration. The number of comorbidities decreased over time, suggesting that sticking to the diet helps lower the overall burden of additional health problems. Disorders related to the liver, heart, and gastrointestinal tract (aside from celiac disease itself) became less common in patients who had followed the diet for a long time.

Discussion

This study highlights the challenges and benefits of adhering to a gluten-free diet in real-world conditions. Even though strict adherence is the goal, only about half of patients were able to achieve this. Many reported difficulty due to factors such as limited food availability, high cost of gluten-free options, and confusion from unclear food labeling. Adolescents and young adults often face additional difficulties in social situations, making adherence even more complex. These findings underline the importance of ongoing support from healthcare professionals to help patients manage dietary restrictions.

The improvements in symptoms, mental health, and lab values confirm the critical role of the gluten-free diet in celiac disease management. However, not all symptoms resolved completely, and issues like bloating and constipation remained common. These persistent problems may be linked to gut bacteria changes or other mechanisms not fully addressed by the diet alone. Mental health improvements were particularly encouraging, as depression and anxiety are common among people with celiac disease. Improved mood and reduced fatigue may reflect both physical healing and psychological adjustment to life after diagnosis.

The study also noted the gap between self-reported adherence and objective measures. Some patients believed they were strictly following the diet, but careful assessment revealed ongoing mistakes or cross-contamination. This suggests that regular, structured dietary evaluation should be part of celiac disease follow-up, rather than relying only on patient self-assessment.

Conclusions

This research shows that adherence to a gluten-free diet is challenging but essential for people with celiac disease. Even though many patients struggle, those who successfully follow the diet over time experience meaningful improvements in both physical and mental health. Symptoms such as abdominal pain and depression become less frequent, laboratory markers of nutrient absorption improve, and the overall burden of other health problems decreases. At the same time, persistent difficulties like bloating remind us that diet alone may not address all concerns, and further research is needed to understand these issues better.

For people with celiac disease, this study reinforces the importance of receiving ongoing care that includes not only medical monitoring but also support from dietitians and mental health professionals. Strict gluten-free diet adherence improves quality of life, but patients need guidance and encouragement to overcome the many challenges involved. By addressing barriers such as food access, social pressures, and dietary confusion, healthcare providers can help patients manage their condition more effectively and prevent long-term complications.

Read more: bmcgastroenterol.biomedcentral.com

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