Text Message Intervention (TEACH) Improves Quality of Life and Patient Activation in Celiac Disease: A Randomized Clinical Trial


      To determine the impact of the Text Message Educational Automated Compliance Help (TEACH) text message intervention as a pragmatic approach for patient engagement among adolescents with celiac disease (CD) as measured by gluten-free diet (GFD) adherence, patient activation, and quality of life (QOL).

      Study design

      Randomized controlled trial with patient recruitment at a pediatric, university-based hospital and through social media; 61 participants ages 12-24 years with CD diagnosed at least 1 year were enrolled. The TEACH intervention cohort received 45 unique text messages over a 3-month study period while the control group received standard of care treatment. Primary outcome measures included objective markers of GFD adherence included serum tissue transglutaminase IgA and deamidated gliadin peptide IgA levels. Secondary patient-reported outcomes collected via online survey included the Celiac Dietary Adherence Test, National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS) Global Short Form measure of QOL, Celiac Symptom Index, and Patient Activation Measure. All measures were assessed at enrollment and after the 3-month study period. Statistical analysis performed using the 2-tailed paired Student t test.


      Among the TEACH intervention group, there was significant improvement comparing enrollment scores with 3-month follow-up scores in patient activation (Patient Activation Measure score 63.1 vs 72.5, P = .01) and QOL (NIH PROMIS Global Mental Health 50.8 vs 53.3, P = .01 and NIH PROMIS Global Physical Health 50.8 vs 57.7, P = .03). There was no statistically significant difference in patient-reported or objectively measured GFD adherence.


      TEACH is an effective intervention among patients with CD to improve patient activation and QOL, even among a cohort with GFD adherence at baseline.

      Trial registration



      CD (Celiac disease), CDAT (Celiac Dietary Adherence Test), CSI (Celiac Symptom Index), DGP (Deamidated gliadin peptide), GFD (Gluten-free diet), NIH (National Institutes of Health), PAM (Patient Activation Measure), PROMIS (Patient-Reported Outcomes Measurement Information System), QOL (Quality of life), REDCap (Research Electronic Data Capture), TEACH (Text Message Educational Automated Compliance Help), TTG (Tissue transglutaminase)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Pediatrics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Guandalini S.
        • Assiri A.
        Celiac disease: a review.
        JAMA Pediatr. 2014; 168: 272-278
        • Hill I.D.
        • Dirks M.H.
        • Liptak G.S.
        • Colletti R.B.
        • Fasano A.
        • Guandalini S.
        • et al.
        Guideline for the diagnosis and treatment of celiac disease in children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.
        J Pediatr Gastroenterol Nutr. 2005; 40: 1-19
        • Lebwohl B.
        • Granath F.
        • Ekbom A.
        • Smedby K.E.
        • Murray J.A.
        • Neugut A.I.
        • et al.
        Mucosal healing and risk for lymphoproliferative malignancy in celiac disease: a population-based cohort study.
        Ann Intern Med. 2013; 159: 169-175
        • Fasano A.
        • Berti I.
        • Gerarduzzi T.
        • Not T.
        • Colletti R.B.
        • Drago S.
        • et al.
        Prevalence of celiac disease in at-risk and not-at-risk groups in the United States: a large multicenter study.
        Arch Intern Med. 2003; 163: 286-292
        • McGrady M.E.
        • Hommel K.A.
        Medication adherence and health care utilization in pediatric chronic illness: a systematic review.
        Pediatrics. 2013; 132: 730-740
        • Hanghøj S.
        • Boisen K.A.
        Self-reported barriers to medication adherence among chronically ill adolescents: a systematic review.
        J Adolesc Health. 2014; 54: 121-138
        • McGrady M.E.
        • Ryan J.L.
        • Gutiérrez-Colina A.M.
        • Fredericks E.M.
        • Towner E.K.
        • Pai A.L.H.
        The impact of effective paediatric adherence promotion interventions: systematic review and meta-analysis.
        Child Care Health Dev. 2015; 41: 789-802
        • Kurppa K.
        • Lauronen O.
        • Collin P.
        • Ukkola A.
        • Laurila K.
        • Huhtala H.
        • et al.
        Factors associated with dietary adherence in celiac disease: a nationwide study.
        Digestion. 2012; 86: 309-314
        • Ljungman G.
        • Myrdal U.
        Compliance in teenagers with coeliac disease—a Swedish follow-up study.
        Acta Paediatr. 1993; 82: 235-238
        • Panzer R.M.
        • Dennis M.
        • Kelly C.P.
        • Weir D.
        • Leichtner A.
        • Leffler D.A.
        Navigating the gluten-free diet in college.
        J Pediatr Gastroenterol Nutr. 2012; 55: 740-744
        • MacCulloch K.
        • Rashid M.
        Factors affecting adherence to a gluten-free diet in children with celiac disease.
        Paediatr Child Health. 2014; 19: 305-309
        • 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: 590-611
        • 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. 2013; 108: 811-817
        • Webb T.L.
        • Joseph J.
        • Yardley L.
        • Michie S.
        Using the internet to promote health behavior change: a systematic review and meta-analysis of the impact of theoretical basis, use of behavior change techniques, and mode of delivery on efficacy.
        J Med Internet Res. 2010; 12: e4
        • Palermo T.M.
        • Wilson A.C.
        • Peters M.
        • Lewandowski A.
        • Somhegyi H.
        Randomized controlled trial of an Internet-delivered family cognitive-behavioral therapy intervention for children and adolescents with chronic pain.
        Pain. 2009; 146: 205-213
        • de Jongh T.
        • Gurol-Urganci I.
        • Vodopivec-Jamsek V.
        • Car J.
        • Atun R.
        Mobile phone messaging for facilitating self-management of long-term illnesses.
        Cochrane Database Syst Rev. 2012; (CD007459)
        • Partridge S.R.
        • McGeechan K.
        • Hebden L.
        • Balestracci K.
        • Wong A.T.
        • Denney-Wilson E.
        • et al.
        Effectiveness of a mHealth lifestyle program with telephone support (TXT2BFiT) to prevent unhealthy weight gain in young adults: randomized controlled trial.
        JMIR Mhealth Uhealth. 2015; 3: e66
        • Lenhart A.
        Teens, Social Media & Technology Overview 2015 [Internet].
        (Pew Research Center) (Accessed December 29, 2016)
        • McGillicuddy J.W.
        • Gregoski M.J.
        • Weiland A.K.
        • Rock R.A.
        • Brunner-Jackson B.M.
        • Patel S.K.
        • et al.
        Mobile health medication adherence and blood pressure control in renal transplant recipients: a proof-of-concept randomized controlled trial.
        JMIR Res Protoc. 2013; 2: e32
        • Lua P.L.
        • Neni W.S.
        A randomised controlled trial of an SMS-based mobile epilepsy education system.
        J Telemed Telecare. 2013; 19: 23-28
        • Arora S.
        • Peters A.L.
        • Burner E.
        • Lam C.N.
        • Menchine M.
        Trial to examine text message-based mHealth in emergency department patients with diabetes (TExT-MED): a randomized controlled trial.
        Ann Emerg Med. 2014; 63 (e6): 745-754
        • Lv Y.
        • Zhao H.
        • Liang Z.
        • Dong H.
        • Liu L.
        • Zhang D.
        • et al.
        A mobile phone short message service improves perceived control of asthma: a randomized controlled trial.
        Telemed J E Health. 2012; 18: 420-426
        • Chow C.K.
        • Redfern J.
        • Hillis G.S.
        • Thakkar J.
        • Santo K.
        • Hackett M.L.
        • et al.
        Effect of lifestyle-focused text messaging on risk factor modification in patients with coronary heart disease: a randomized clinical trial.
        JAMA. 2015; 314: 1255-1263
        • Franklin V.L.
        • Greene A.
        • Waller A.
        • Greene S.A.
        • Pagliari C.
        Patients' engagement with “Sweet Talk” — a text messaging support system for young people with diabetes.
        J Med Internet Res. 2008; 10: e20
        • Franklin V.L.
        • Waller A.
        • Pagliari C.
        • Greene S.A.
        A randomized controlled trial of Sweet Talk, a text-messaging system to support young people with diabetes.
        Diabet Med. 2006; 23: 1332-1338
        • Rami B.
        • Popow C.
        • Horn W.
        • Waldhoer T.
        • Schober E.
        Telemedical support to improve glycemic control in adolescents with type 1 diabetes mellitus.
        Eur J Pediatr. 2006; 165: 701-705
        • Wolff M.
        • Balamuth F.
        • Sampayo E.
        • Mollen C.
        Improving adolescent pelvic inflammatory disease follow-up from the emergency department: randomized controlled trial with text messages.
        Ann Emerg Med. 2016; 67 (e3): 602-609
        • Suffoletto B.
        • Kristan J.
        • Chung T.
        • Jeong K.
        • Fabio A.
        • Monti P.
        • et al.
        An interactive text message intervention to reduce binge drinking in young adults: a randomized controlled trial with 9-month outcomes.
        PLoS ONE. 2015; 10: e0142877
        • O'Leary S.T.
        • Lee M.
        • Lockhart S.
        • Eisert S.
        • Furniss A.
        • Barnard J.
        • et al.
        Effectiveness and cost of bidirectional text messaging for adolescent vaccines and well care.
        Pediatrics. 2015; 136: e1220-7
        • Garofalo R.
        • Kuhns L.M.
        • Hotton A.
        • Johnson A.
        • Muldoon A.
        • Rice D.
        A randomized controlled trial of personalized text message reminders to promote medication adherence among HIV-positive adolescents and young adults.
        AIDS Behav. 2016; 20: 1049-1059
        • Johnson K.B.
        • Patterson B.L.
        • Ho Y.-X.
        • Chen Q.
        • Nian H.
        • Davison C.L.
        • et al.
        The feasibility of text reminders to improve medication adherence in adolescents with asthma.
        J Am Med Inform Assoc. 2016; 23: 449-455
        • Leffler D.A.
        • Dennis M.
        • Edwards George J.B.
        • Jamma S.
        • Magge S.
        • Cook E.F.
        • et al.
        A simple validated gluten-free diet adherence survey for adults with celiac disease.
        Clin Gastroenterol Hepatol. 2009; 7: 530-536
        • Hays R.D.
        • Bjorner J.B.
        • Revicki D.A.
        • Spritzer K.L.
        • Cella D.
        Development of physical and mental health summary scores from the patient-reported outcomes measurement information system (PROMIS) global items.
        Qual Life Res. 2009; 18: 873-880
        • Leffler D.A.
        • Dennis M.
        • Edwards George J.
        • Jamma S.
        • Cook E.F.
        • Schuppan D.
        • et al.
        A validated disease-specific symptom index for adults with celiac disease.
        Clin Gastroenterol Hepatol. 2009; 7: 1328-1334
        • Huang J.S.
        • Terrones L.
        • Tompane T.
        • Dillon L.
        • Pian M.
        • Gottschalk M.
        • et al.
        Preparing adolescents with chronic disease for transition to adult care: a technology program.
        Pediatrics. 2014; 133: e1639-46
        • Hibbard J.H.
        • Stockard J.
        • Mahoney E.R.
        • Tusler M.
        Development of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumers.
        Health Serv Res. 2004; 39: 1005-1026
      1. NIH PROMIS pediatric instrument banks [Internet].
        (National Institutes of Health) (Accessed December 29, 2016)
        • Greene J.
        • Hibbard J.H.
        Why does patient activation matter? An examination of the relationships between patient activation and health-related outcomes.
        J Gen Intern Med. 2012; 27: 520-526
        • Bacigalupe G.
        • Plocha A.
        Celiac is a social disease: family challenges and strategies.
        Fam Syst Health. 2015; 33: 46-54
        • Simsek S.
        • Baysoy G.
        • Gencoglan S.
        • Uluca U.
        Effects of gluten-free diet on quality of life and depression in children with celiac disease.
        J Pediatr Gastroenterol Nutr. 2015; 61: 303-306
        • Shah S.
        • Akbari M.
        • Vanga R.
        • Kelly C.P.
        • Hansen J.
        • Theethira T.
        • et al.
        Patient perception of treatment burden is high in celiac disease compared with other common conditions.
        Am J Gastroenterol. 2014; 109: 1304-1311
        • Sugai E.
        • Nachman F.
        • Váquez H.
        • González A.
        • Andrenacci P.
        • Czech A.
        • et al.
        Dynamics of celiac disease-specific serology after initiation of a gluten-free diet and use in the assessment of compliance with treatment.
        Dig Liver Dis. 2010; 42: 352-358