Skip to main content


Log in

The Effect of Group-Based Education on Knowledge and Adherence to a Gluten-Free Diet in Patients with Celiac Disease: Randomized Controlled Clinical Trial

  • Full length manuscript
  • Published:
International Journal of Behavioral Medicine Aims and scope Submit manuscript



Considering the importance of educational programs on compliance of patients with celiac disease with a gluten-free diet (GFD), we investigated the effect of a group-based education program on knowledge and adherence to a GFD in patients with celiac disease.


In the present controlled clinical trial, patients in the intervention group (n = 66) underwent a three-session group-based educational program, and patients in the control group (n = 64) received routine education in visits to the clinic. The primary outcomes were knowledge and adherence to a GFD. Participant knowledge was assessed by a validated author-designed questionnaire. Adherence rate was evaluated by the Persian version of celiac disease adherence test (CDAT) questionnaire. Results were analyzed based on intention-to-treat (ITT) analysis.


Results of the ANCOVA test showed that the mean score of knowledge about celiac disease and gluten in the intervention group was significantly higher compared with the control group immediately after intervention (p = 0.002) and 3 months post-intervention (p = 0.03). In terms of gluten-free food item selection, the intervention group achieved a significantly better score than the control group immediately after intervention (p < 0.001) as well as 3 months post-intervention (p < 0.001). Additionally, there was a significant difference in the CDAT score between the two groups 3 months post-intervention (p = 0.02).


Evidence suggests that group-based education was an effective intervention among patients with celiac disease to improve knowledge and adherence to a GFD.

Trial registration IRCT code: IRCT20080904001197N21; registration date: 5/23/2019

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others


  1. Pozo-Rubio T, Olivares M, Nova E, et al. Immune development and intestinal microbiota in celiac disease. Clin Dev Immunol. 2012;2012.

  2. Fasano A, Catassi C. Celiac disease. N Engl J Med. 2012;367(25):2419–26.

    Article  CAS  Google Scholar 

  3. Mardini HE, Westgate P, Grigorian AY. Racial differences in the prevalence of celiac disease in the US population: National Health and Nutrition Examination Survey (NHANES) 2009–2012. Dig Dis Sci. 2015;60(6):1738–42.

    Article  Google Scholar 

  4. Nejad MR, Rostami K, Emami MH, Zali MR, Malekzadeh R. Epidemiology of celiac disease in Iran: a review. Middle East J Dig Dis. 2011;3(1):5.

    Google Scholar 

  5. Ludvigsson JF, Bai JC, Biagi F, et al. Diagnosis and management of adult coeliac disease: guidelines from the British Society of Gastroenterology. Gut. 2014;63(8):1210–28.

    Article  Google Scholar 

  6. Sainsbury K, Mullan B. Measuring beliefs about gluten free diet adherence in adult coeliac disease using the theory of planned behaviour. Appetite. 2011;56(2):476–83.

    Article  Google Scholar 

  7. Sainsbury K, Mullan B, Sharpe L. Gluten free diet adherence in coeliac disease. The role of psychological symptoms in bridging the intention–behaviour gap. Appetite. 2013a;61:52–8.

    Article  Google Scholar 

  8. McGrady ME, Ryan JL, Gutiérrez-Colina AM, Fredericks EM, Towner EK, Pai AL. The impact of effective paediatric adherence promotion interventions: systematic review and meta-analysis. Child Care Health Dev. 2015;41(6):789–802.

    Article  CAS  Google Scholar 

  9. Kahana S, Drotar D, Frazier T. Meta-analysis of psychological interventions to promote adherence to treatment in pediatric chronic health conditions. J Pediatr Psychol. 2008;33(6):590–611.

    Article  PubMed  Google Scholar 

  10. Corrao G, Corazza GR, Bagnardi V, et al. Mortality in patients with coeliac disease and their relatives: a cohort study. The Lancet. 2001;358(9279):356–61.

    Article  CAS  Google Scholar 

  11. Halmos EP, Deng M, Knowles SR, Sainsbury K, Mullan B, Tye-Din JA. Food knowledge and psychological state predict adherence to a gluten-free diet in a survey of 5310 Australians and New Zealanders with coeliac disease. Aliment Pharmacol Ther. 2018;48(1):78–86.

    Article  CAS  Google Scholar 

  12. Theethira TG, Dennis M. Celiac disease and the gluten-free diet: consequences and recommendations for improvement. Dig Dis. 2015;33(2):175–82.

    Article  PubMed  Google Scholar 

  13. Sainsbury K, Mullan B, Sharpe L. A randomized controlled trial of an online intervention to improve gluten-free diet adherence in celiac disease. Am J Gastroenterol. 2013b;108(5):811–7.

    Article  CAS  Google Scholar 

  14. Haas K, Martin A, Park KT. Text Message Intervention (TEACH) improves quality of life and patient activation in celiac disease: a randomized clinical trial. J Pediatr. 2017;185(62–7):e2.

    Article  Google Scholar 

  15. Nikniaz Z, Shirmohammadi M, Namvar ZA. Development and effectiveness assessment of a Persian-language smartphone application for celiac patients: a randomized controlled clinical trial. Couns: Patient Educ; 2020.

    Google Scholar 

  16. Odgers-Jewell K, Ball L, Kelly J, Isenring E, Reidlinger D, Thomas R. Effectiveness of group-based self-management education for individuals with Type 2 diabetes: a systematic review with meta-analyses and meta-regression. Diabet Med. 2017;34(8):1027–39.

    Article  CAS  Google Scholar 

  17. Paul-Ebhohimhen V, Avenell A. A systematic review of the effectiveness of group versus individual treatments for adult obesity. Obesity Facts. 2009;2(1):17–24.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Larsson K, Sundberg MH, Karlbom U, Nordin K, Anderberg UM, Lööf L. A group-based patient education programme for high-anxiety patients with Crohn disease or ulcerative colitis. Scand J Gastroenterol. 2003;38(7):763–9.

    Article  CAS  Google Scholar 

  19. Urnes J, Farup PG, Lydersen S, Petersen H. Patient education in gastro-oesophageal reflux disease: a randomized controlled trial. Eur J Gastroenterol Hepatol. 2007;19(12):1104–10.

    Article  Google Scholar 

  20. World Health Organization. Peer support programmes in diabetes. Geneva: Switzerland; 2007.

    Google Scholar 

  21. Cooper H, Booth K, Gill G. Patients’ perspectives on diabetes health care education. Health Educ Res. 2003;18(2):191–206.

    Article  CAS  Google Scholar 

  22. Jacobsson LR, Friedrichsen M, Göransson A, Hallert C. Impact of an active patient education program on gastrointestinal symptoms in women with celiac disease following a gluten-free diet: a randomized controlled trial. Gastroenterol Nurs. 2012;35(3):200–6.

    Article  Google Scholar 

  23. Rej A, Trott N, Kurien M, et al. Is peer support in group clinics as effective as traditional individual appointments? The first study in patients with celiac disease. Clin Transl Gastroenterol. 2020;11(1):e00121-e.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Barzegar F, Rostami-Nejad M, Shalmani HM, Sadeghi A, Khani MA. The effect of education on the knowledge of patients with Celiac disease. Gastroenterol Hepatol Bed Bench. 2017;10(Suppl1):S15.

    PubMed  PubMed Central  Google Scholar 

  25. Consort BCONSORT. statement: updated guidelines for reporting parallel group randomized trials. Ann Intern Med. 2010;2010:152.

    Google Scholar 

  26. Nikniaz Z, Jafarabadi MA, Ghaffarifar S, Saeedi Z, Namvar ZA, Shirmohammadi M. Psychometric properties of the Persian version of the celiac disease adherence test questionnaire. BMC Gastroenterol. 2020;20(1):1–6.

    Article  Google Scholar 

  27. Leffler DA, Dennis M, Edwards George JB, et al. A simple validated gluten-free diet adherence survey for adults with celiac disease. Clin Gastroenterol Hepatol. 2009;7(5):530–6, 6.e1–2

  28. Senn S. Change from baseline and analysis of covariance revisited. Stat Med. 2006;25(24):4334–44.

    Article  Google Scholar 

  29. Cohen J. The t test for means. Statistical power analysis for the behavioural sciences. éd: Hillsdale, NJ: Lawrence Erlbaum Associates. 1988.

  30. Whigham L, Joyce T, Harper G, et al. Clinical effectiveness and economic costs of group versus one-to-one education for short-chain fermentable carbohydrate restriction (low FODMAP diet) in the management of irritable bowel syndrome. J Hum Nutr Diet. 2015;28(6):687–96.

    Article  CAS  Google Scholar 

  31. Ringström G, Störsrud S, Posserud I, Lundqvist S, Westman B, Simrén M. Structured patient education is superior to written information in the management of patients with irritable bowel syndrome: a randomized controlled study. Eur J Gastroenterol Hepatol. 2010;22(4):420–8.

    Article  Google Scholar 

  32. Nielsen D, Ryg J, Nielsen W, Knold B, Nissen N, Brixen K. Patient education in groups increases knowledge of osteoporosis and adherence to treatment: a two-year randomized controlled trial. Patient Educ Couns. 2010;81(2):155–60.

    Article  PubMed  Google Scholar 

  33. Villafuerte-Galvez J, Vanga RR, Dennis M, et al. Factors governing long-term adherence to a gluten-free diet in adult patients with coeliac disease. Aliment Pharmacol Ther. 2015;42(6):753–60.

    Article  CAS  PubMed  Google Scholar 

  34. Leffler DA, Edwards-George J, Dennis M, et al. Factors that influence adherence to a gluten-free diet in adults with celiac disease. Dig Dis Sci. 2008;53(6):1573–81.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Ciacci C, Cirillo M, Cavallaro R, Mazzacca G. Long-term follow-up of celiac adults on gluten-free diet: prevalence and correlates of intestinal damage. Digestion. 2002;66(3):178–85.

    Article  CAS  PubMed  Google Scholar 

  36. Lee SK, Lo W, Memeo L, Rotterdam H, Green PHR. Duodenal histology in patients with celiac disease after treatment with a gluten-free diet. Gastrointest Endosc. 2003;57(2):187–91.

    Article  PubMed  Google Scholar 

Download references


We thank the East Azerbaijan patients with celiac disease who participated in the study. The results of the present study are derived from the Zahra Akbari Namvar MSc thesis in gastroenterology.


This study was funded by the Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.

Author information

Authors and Affiliations



ZN and RM were responsible for the conception and design of the study. MSh and ZAN were responsible for data acquisition. ZAN and ZN were responsible for data analysis. ZN, RM, ZAN, and MSh were responsible for data interpretation. ZAN and ZN drafted the manuscript; all other authors revised and commented on the draft. All authors read and approved the final version of the manuscript.

Corresponding author

Correspondence to Zeinab Nikniaz.

Ethics declarations

Competing Interests

The authors declare that they have no competing interests.


The funder had no role in the study design, data collection, and analysis, decision to publish, or preparation of the manuscript.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 15.7 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Akbari Namvar, Z., Mahdavi, R., Shirmohammadi, M. et al. The Effect of Group-Based Education on Knowledge and Adherence to a Gluten-Free Diet in Patients with Celiac Disease: Randomized Controlled Clinical Trial. Int.J. Behav. Med. 28, 583–590 (2021).

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: