Adherence to a GFD is widely accepted to be challenging. Adherence amongst patients with coeliac disease (CD) ranges between 42% and 91%, dependent on patient group and method of recruitment. Reasons for poorer dietary compliance include coexisting depression, level of symptoms on ingestion of gluten, knowledge of GF foods, understanding of food labels, cost and availability of GF foods (including receiving GF foods on prescription) and membership of a coeliac society. International guidelines advocate long-term follow-up to facilitate dietary adherence.
Globally, a range of methods are used to enable clinicians to follow-up and review patients, including one-to one appointments, group sessions, telephone clinics and online interfaces. Further work is required to establish a cost-effective way of delivering CD follow-up care, which is acceptable to both patients and healthcare professionals. The current COVID-19 pandemic has resulted in many face-to-face clinics being undertaken via the telephone. However, there remains gaps in the evidence base as to whether such an intervention is effective in CD management. This prospective controlled study aimed to evaluate the effect of a telephone clinic and accompanying leaflet on GFD knowledge and GF dietary adherence in adults with CD.
Inclusion criteria required patients to be over the age of 18 years, resident in Dudley, and have histologically confirmed CD. All eligible patients with CD (n=195) were approached via postal invitation. In total, 125 adult patients with CD participated in the study (a 64% return rate; responders and non-responders were similar in age, sex and ethnicity: NS). All participants who had a CDAT score of ≥13 were classified as not adhering to the GF diet and were included in the intervention group (n=30), and all patients with a CDAT score of <13 formed the control group (n=95). Primary outcome was a change in GF dietary adherence assessed by Coeliac Disease Adherence Test (CDAT) score. Information on demographics and circumstances relevant to CD were collected. GF dietary adherence, as per CDAT questionnaire, GFD knowledge and Coeliac Disease Quality of Life (Coeliac Disease Assessment Questionnaire (CDAQ)) validated questionnaires were completed by participants. Thereafter, the CDAT and change in circumstances questionnaires were collected at 6, 9 and 12 months. The intervention group had a 100% completion rate at 3M, 6M, 9M and 12M. From the control group, 60% (n=57) completed all the questionnaires at baseline and 3 months.
The study leaflet on CD and GFD was posted to participants ahead of the telephone clinic. The leaflet contained images relating to knowledge, motivation and behaviour change to facilitate discussion, giving the clinic a standardised structure, agreed by a registered dietitian. A consultant gastroenterologist, with a Clinical Nutrition MSc and expertise in CD led the telephone consultations. The telephone clinic was a personalised intervention focusing on areas of knowledge or behaviour that were important to the participant. The mean call duration was 49min (range 33–63min).
The majority of the intervention group (90%; n=27) reported an ‘excellent’ or ‘high’ level of satisfaction with the telephone clinic. During the telephone clinic, 11 participants (37%) reported habitually consuming gluten-containing foods. Lack of motivation to adhere to a GF diet was reported as an issue by 70% (n=21) of participants. A significant improvement in GF dietary adherence scores was observed at 3 and 6 months after the telephone clinic compared with baseline scores. GF dietary adherence score improved in 83% of participants at 3 months compared with baseline values; the score remained over 13 in 36% of participants. GF dietary adherence score remained similar over time in the control group. At 9 and 12 months post telephone clinic, the median GF dietary adherence CDAT scores for the intervention group was 15.5 (15.0–18.8) and 14.0 (13.8–17), respectively, which did not differ significantly from baseline values. This demonstrates that the changes were most effective for 6 months, thus patients not adhering to a GF diet need regular follow-up
This study provides clinically useful data to demonstrate the effectiveness of using such an intervention in clinic. Globally, the use of telemedicine and video conferencing to replace face-to-face consultations has become more commonplace due to the COVID-19 pandemic.