Reviewer ’s report  
 
Title: The impact of diagnosis on health -related quality of life in people with coeliac disease: a 
UK popu lation -based longitudinal perspective  
 
Version: 1 Date: 24 Jan 2019  
 
Reviewer: Carlo Catassi  
 
Reviewer's report:  
 
Authors of this study performed a mail survey on a large sample of patients affected with celiac 
disease (CD) to investigate issues related to the diagnosis (presenting symptoms and duration of 
disease) and their quality of life pre - and pos t-diagnosis using the EQ -5D instrument. Data were 
analyzed and compared with results from a similar survey conducted in 2006. Sixty -five percent 
of respondents reported at least 4 symptoms pre -diagnosis, a significant reduction by 13 
percentage points comp ared to 2006. Pre -diagnosis mean duration of symptoms was 12.8 years, a 
non-significant reduction of 0.6 years compared to 2006. There was a significant improvement of 
0.20 in quality of life from pre - (0.65) to post -diagnosis. Pre -diagnosis values were si gnificantly 
higher by 0.09 than in 2006. Authors conclude that undiagnosed CD is associated with a 
substantial decrement in quality of life. Time to diagnosis has not significantly shortened over 
the decade 2006 -2015, but symptoms are less severe when diag nosis occurs.  
This is an interesting study analyzing demographical and clinical factors related to the diagnosis, 
course, and quality of life of a disease that has a deep impact on the daily life, particularly after 
the lifelong treatment with the gluten f ree diet has been started. The comparison of the 2015 with 
the 2006 survey offers an interesting opportunity to investigate changes of the investigated 
variables over time, and this is an original aspect of this study instead than a duplication of 
previous ly published data.  
As such, this study is certainly interesting for the medical reader. There are some weaknesses of 
the study that are properly discussed by the authors. In my opinion the overall quality of the 
manuscript has improved following the change s suggested by previous referees, therefore I have 
no further criticisms.    
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are yo u able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
I am able  to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have  you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content o f the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any  non-financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
YES to question #1  
Scientific consultant for  
Dr Schar (gluten -free food producers)  
NOOS srl (probiotic producers)  
 
I agree to the open peer review policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along with the authors'  
responses. I agree for my report to be made available under an Open Access Creative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments  
which I do not wish to be included i n my named report can be included as confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Reviewer ’s report  
 
Title: The impact of diagnosis on health -related quality of life in people with coeliac disease: a 
UK popu lation -based longitudinal perspective  
 
Version: 1 Date: 24 Jan 2019  
 
Reviewer: Carlo Catassi  
 
Reviewer's report:  
 
Authors of this study performed a mail survey on a large sample of patients affected with celiac 
disease (CD) to investigate issues related to the diagnosis (presenting symptoms and duration of 
disease) and their quality of life pre - and pos t-diagnosis using the EQ -5D instrument. Data were 
analyzed and compared with results from a similar survey conducted in 2006. Sixty -five percent 
of respondents reported at least 4 symptoms pre -diagnosis, a significant reduction by 13 
percentage points comp ared to 2006. Pre -diagnosis mean duration of symptoms was 12.8 years, a 
non-significant reduction of 0.6 years compared to 2006. There was a significant improvement of 
0.20 in quality of life from pre - (0.65) to post -diagnosis. Pre -diagnosis values were si gnificantly 
higher by 0.09 than in 2006. Authors conclude that undiagnosed CD is associated with a 
substantial decrement in quality of life. Time to diagnosis has not significantly shortened over 
the decade 2006 -2015, but symptoms are less severe when diag nosis occurs.  
This is an interesting study analyzing demographical and clinical factors related to the diagnosis, 
course, and quality of life of a disease that has a deep impact on the daily life, particularly after 
the lifelong treatment with the gluten f ree diet has been started. The comparison of the 2015 with 
the 2006 survey offers an interesting opportunity to investigate changes of the investigated 
variables over time, and this is an original aspect of this study instead than a duplication of 
previous ly published data.  
As such, this study is certainly interesting for the medical reader. There are some weaknesses of 
the study that are properly discussed by the authors. In my opinion the overall quality of the 
manuscript has improved following the change s suggested by previous referees, therefore I have 
no further criticisms.    
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are yo u able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
I am able  to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have  you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content o f the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any  non-financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
YES to question #1  
Scientific consultant for  
Dr Schar (gluten -free food producers)  
NOOS srl (probiotic producers)  
 
I agree to the open peer review policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along with the authors'  
responses. I agree for my report to be made available under an Open Access Creative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments  
which I do not wish to be included i n my named report can be included as confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Please review this paper.
user
Reviewer ’s report  
 
Title: The impact of diagnosis on health -related quality of life in people with coeliac disease: a 
UK popu lation -based longitudinal perspective  
 
Version: 1 Date: 24 Jan 2019  
 
Reviewer: Carlo Catassi  
 
Reviewer's report:  
 
Authors of this study performed a mail survey on a large sample of patients affected with celiac 
disease (CD) to investigate issues related to the diagnosis (presenting symptoms and duration of 
disease) and their quality of life pre - and pos t-diagnosis using the EQ -5D instrument. Data were 
analyzed and compared with results from a similar survey conducted in 2006. Sixty -five percent 
of respondents reported at least 4 symptoms pre -diagnosis, a significant reduction by 13 
percentage points comp ared to 2006. Pre -diagnosis mean duration of symptoms was 12.8 years, a 
non-significant reduction of 0.6 years compared to 2006. There was a significant improvement of 
0.20 in quality of life from pre - (0.65) to post -diagnosis. Pre -diagnosis values were si gnificantly 
higher by 0.09 than in 2006. Authors conclude that undiagnosed CD is associated with a 
substantial decrement in quality of life. Time to diagnosis has not significantly shortened over 
the decade 2006 -2015, but symptoms are less severe when diag nosis occurs.  
This is an interesting study analyzing demographical and clinical factors related to the diagnosis, 
course, and quality of life of a disease that has a deep impact on the daily life, particularly after 
the lifelong treatment with the gluten f ree diet has been started. The comparison of the 2015 with 
the 2006 survey offers an interesting opportunity to investigate changes of the investigated 
variables over time, and this is an original aspect of this study instead than a duplication of 
previous ly published data.  
As such, this study is certainly interesting for the medical reader. There are some weaknesses of 
the study that are properly discussed by the authors. In my opinion the overall quality of the 
manuscript has improved following the change s suggested by previous referees, therefore I have 
no further criticisms.    
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are yo u able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
I am able  to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have  you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content o f the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any  non-financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
YES to question #1  
Scientific consultant for  
Dr Schar (gluten -free food producers)  
NOOS srl (probiotic producers)  
 
I agree to the open peer review policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along with the authors'  
responses. I agree for my report to be made available under an Open Access Creative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments  
which I do not wish to be included i n my named report can be included as confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
assistant