Behavioral Lifestyle Intervention Program Using Mobile Application Improves Diet Quality in Adults With Prediabetes (D'LITE Study): A Randomized Controlled Trial.

BACKGROUND: Mobile health applications (mHealth apps) are increasingly being used in weight loss interventions. However, evidence on the effects of such interventions on diet quality and their correlation with weight loss is lacking. OBJECTIVE: The objective of this study was to examine whether changes in the diet quality of adults with prediabetes followed the use of an mHealth-enabled lifestyle intervention, compared with those who did not, and whether these changes correlated with weight loss. DESIGN: A secondary analysis of a 6-month randomized controlled trial Diabetes Lifestyle Intervention using Technology Empowerment (D'LITE) was conducted, with participants recruited from October 2017 to September 2019. PARTICIPANTS/SETTING: Community-dwelling adults (n = 148) in Singapore diagnosed with prediabetes and body mass index (BMI) ≥23 were included in this study. INTERVENTION: Participants were randomized to receive either a 6-month mHealth-enabled lifestyle intervention program (diet and physical activity) or standard care dietary advice. MAIN OUTCOME MEASURES: Dietary data were collected in the form of 2-day food records at baseline, 3, and 6 months. Changes in Alternate Healthy Eating Index-2010 (AHEI-2010) scores and food groups (servings/day), calculated from the dietary data, and correlation between changes in AHEI-2010 and weight loss at 3 and 6 months, were examined. STATISTICAL ANALYSES: Between-group comparisons of continuous variables and within-participants variation were performed using longitudinal mixed-effect models, intention-to-treat principles. The models included treatment groups, time (baseline, 3 months, and 6 months), and covariates (age, sex, and BMI), as well as the group × time interactions, as fixed variables and within-participant variation in outcome values as random variable. The random intercept for participants accounted for the dependence of repeated measures. A likelihood ratio test was also conducted to test random effect variance. Spearman correlation test was used to examine correlation between changes in AHEI-2010 scores and weight loss. RESULTS: There was a significant improvement in overall diet quality as ascertained by the AHEI-2010, by 6.2 points (95% confidence interval [CI], 3.8-8.7; P < 0.001) in the intervention group as compared with the control. The participants in the intervention group had a significantly greater reduction in intake of sugar-sweetened beverages (SSB) by 0.5 servings/day (95% CI, -0.8, -0.2; P < 0.001) and sodium by 726 mg/day (95% CI, -983, -468; P < .001), compared with those receiving standard care. At 3 and 6 months, a significant decrease in SSB (0.8 servings/day; 0.7 servings/day, respectively) and sodium (297 mg/day; 296 mg/day, respectively) intakes were reported compared with baseline intakes. Small positive correlations (r = 0.2; P < 0.05) were observed between changes in AHEI-2010 scores from baseline and percentage weight loss at 3 and 6 months. CONCLUSION: For adults with prediabetes in Singapore, diet quality can be improved with an mHealth-enabled lifestyle intervention program. A small positive correlation exists between AHEI-2010 scores and weight loss.

Association Between Mobile Health App Engagement and Weight Loss and Glycemic Control in Adults With Type 2 Diabetes and Prediabetes (D'LITE Study): Prospective Cohort Study.

BACKGROUND: Mobile health apps are increasingly used as early intervention to support behavior change for diabetes prevention and control, with the overarching goal of lowering the overall disease burden. OBJECTIVE: This prospective cohort study conducted in Singapore aimed to investigate app engagement features and their association with weight loss and improved glycemic control among adults with diabetes and prediabetes from the intervention arm of the Diabetes Lifestyle Intervention using Technology Empowerment randomized controlled trial. METHODS: Diabetes and prediabetes participants (N=171) with a median age of 52 years, BMI of 29.3 kg/m2, and glycated hemoglobin (HbA1c) level of 6.5% and who were being assigned the Nutritionist Buddy Diabetes app were included. Body weight and HbA1c were measured at baseline, 3 months, and 6 months. A total of 476,300 data points on daily app engagement were tracked via the backend dashboard and developer's report. The app engagement data were analyzed by quartiles and weekly means expressed in days per week. Linear mixed model analysis was used to determine the associations between the app engagements with percentage weight and HbA1c change. RESULTS: The median overall app engagement rate was maintained above 90% at 6 months. Participants who were actively engaged in ≥5 app features were associated with the greatest overall weight reduction of 10.6% from baseline (mean difference -6, 95% CI -8.9 to -3.2; P<.001) at 6 months. Adhering to the carbohydrate limit of >5.9 days per week and choosing healthier food options for >4.3 days per week had the most impact, eliciting weight loss of 9.1% (mean difference -5.2, 95% CI -8.2 to -2.2; P=.001) and 8.8% (mean difference -4.2, 95% CI -7.1 to -1.3; P=.005), respectively. Among the participants with diabetes, those who had a complete meal log for >5.1 days per week or kept within their carbohydrate limit for >5.9 days per week each achieved greater HbA1c reductions of 1.2% (SD 1.3%; SD 1.5%), as compared with 0.2% (SD 1%; SD 0.6%). in the reference groups who used the features <1.1 or ≤2.5 days per week, respectively. CONCLUSIONS: Higher app engagement led to greater weight loss and HbA1c reduction among adults with overweight or obesity with type 2 diabetes or prediabetes. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12617001112358; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12617001112358.

Effect of a Smartphone App on Weight Change and Metabolic Outcomes in Asian Adults With Type 2 Diabetes: A Randomized Clinical Trial.

Importance: Lifestyle interventions are effective in diabetes management, with smartphone apps that manage health data and dietary and exercise schedules gaining popularity. However, limited evidence from randomized clinical trials exists regarding the effectiveness of smartphone-based interventions among Asian adults with type 2 diabetes. Objective: To compare the effects of a culturally contextualized smartphone-based intervention with usual care on weight and metabolic outcomes. Design, Setting, and Participants: This randomized clinical trial conducted at multiple primary care centers in Singapore included 305 adults with type 2 diabetes and body mass index (BMI) of 23 or greater who had literacy in English and smartphone access. Participants were recruited between October 3, 2017, and September 9, 2019, and were randomly assigned (1:1; stratified by gender, age, and BMI) to intervention (99 participants) or control (105 participants) groups. Participants' data were analyzed using intention-to-treat analysis. Interventions: Both control and intervention participants received diet and physical activity advice from a dietitian at a baseline face-to-face visit. Intervention participants additionally used a smartphone app to track weight, diet, physical activity, and blood glucose and then communicated with dietitians for 6 months. Main Outcomes and Measures: Primary outcome was change in body weight, while secondary outcomes were changes in hemoglobin A1c (HbA1c), fasting blood glucose, blood pressure, lipids, and diet. Post hoc analyses included glycemic changes in the subgroup with HbA1c levels of 8% or greater and diabetes medication changes. Results: Among the 204 randomized participants (mean [SD] age, 51.2 [9.7] years; 132 [64.7%] men), baseline mean (SD) BMI was 30.6 (4.3). Compared with the control group, intervention participants achieved significantly greater reductions in weight (mean [SD] change, -3.6 [4.7] kg vs -1.2 [3.6] kg) and HbA1c levels (mean [SD] change, -0.7% [1.2] vs -0.3% [1.0]), with a greater proportion having a reduction in diabetes medications (17 participants [23.3%] vs 4 participants [5.4%]) at 6 months. The intervention led to a greater HbA1c reduction among participants with HbA1c levels of 8% or higher (mean [SD] change, -1.8% [1.4] vs -1.0% [1.4]; P = .001). Intergroup differences favoring the intervention were also noted for fasting blood glucose, diastolic blood pressure, and dietary changes. Conclusions and Relevance: In this study, a smartphone-based lifestyle intervention was more effective in achieving weight and glycemic reductions among Asian adults with type 2 diabetes compared with usual care, supporting the use of apps in lifestyle intervention delivery. Trial Registration: anzctr.org.au Identifier: ACTRN12617001112358.

A Smartphone App-Based Lifestyle Change Program for Prediabetes (D'LITE Study) in a Multiethnic Asian Population: A Randomized Controlled Trial.

INTRODUCTION: Landmark studies have established that lifestyle interventions focused on weight loss, diet modification and physical activity can prevent diabetes progression. However, the effectiveness of mobile health application among Asians with prediabetes remains largely unexamined. We aimed to assess whether a smartphone app-based lifestyle intervention program would lead to weight loss, normoglycemia and improved metabolic indices in a multiethnic Asian population with prediabetes. RESEARCH DESIGN AND METHODS: This multicentre prediabetes RCT is part of the Diabetes Lifestyle Intervention using Technology Empowerment (D'LITE) trial. Adults (n = 148) with prediabetes and BMI ≥ 23 kg/m2 were randomly allocated either to the intervention group (n = 72) empowered by self-monitoring features of the Nutritionist Buddy Diabetes app with in-app dietitian coaching for 6 months, or the control group (n = 76) receiving standard diet counseling at baseline. Primary outcome was defined as change in body weight at 6 months, while secondary outcomes included glycemic control and other metabolic indices analyzed using Generalized Linear Mixed Model analysis with intention-to-treat approach. RESULTS: Intervention group achieved a significantly greater weight loss of 4.2 vs. 1.3 kg [mean difference of -3.1 kg (95% CI -4.5 to -1.7), p < 0.001], and a 4.3-fold increased likelihood of achieving ≥ 5% weight loss, as compared to the control group at 6 months. The likelihood of achieving normoglycemia (defined as HbA1c < 5.7%) was 2.1 times higher in intervention group than in the control group (p < 0.018). Changes to blood pressure, total and LDL cholesterol were not statistically significant. CONCLUSION: An app-based lifestyle program led to clinically significant weight loss and improved glycemia, and can potentially augment current standard care in the prevention of diabetes among an Asian multiethnic population. CLINICAL TRIAL REGISTRATION: anzctr.org.au, identifier: ACTRN12617001112358.

A Randomized Controlled Trial to Evaluate the Effects of a Smartphone Application-Based Lifestyle Coaching Program on Gestational Weight Gain, Glycemic Control, and Maternal and Neonatal Outcomes in Women With Gestational Diabetes Mellitus: The SMART-GDM Study.

OBJECTIVE: SMART-GDM examined whether Habits-GDM, a smartphone application (app) coaching program, can prevent excessive gestational weight gain (EGWG) and improve glycemic control and maternal and neonatal outcomes in gestational diabetes mellitus (GDM). RESEARCH DESIGN AND METHODS: In this randomized controlled trial, women diagnosed with GDM between 12 and 30 weeks were randomly assigned to usual care (control) or to additional support from Habits-GDM that integrated dietary, physical activity, weight, and glucose monitoring (intervention). The primary outcome was the proportion of participants with EGWG. Secondary outcomes included absolute gestational weight gain (GWG), glycemic control, and maternal, delivery, and neonatal outcomes. RESULTS: In total, 340 women were randomized (170 intervention, 170 control; mean ± SD age 32.0 ± 4.2 years; mean BMI 25.6 ± 5.6 kg/m2). There were no statistically significant differences in the proportions of women with EGWG, absolute GWG, or maternal and delivery outcomes between experimental groups. Average glucose readings were lower in the intervention group (mean difference -0.15 mmol/L [95% CI -0.26; -0.03], P = 0.011) as were the proportions of glucose above targets (premeal: 17.9% vs. 23.3%, odds ratio 0.68 [95% CI 0.53; 0.87], P = 0.003; 2-h postmeal: 19.9% vs. 50%, 0.54 [0.42; 0.70], P < 0.001). When regarded as a composite (although not prespecified), the overall neonatal complications (including birth trauma, neonatal hypoglycemia, hyperbilirubinemia, respiratory distress, neonatal intensive care unit admission, and perinatal death) were significantly lower in the intervention group (38.1% vs. 53.7%, 0.53 [0.34; 0.84], P = 0.006). CONCLUSIONS: When added to usual care, Habits-GDM resulted in better maternal glycemic control and composite neonatal outcomes (nonprespecified) but did not reduce EGWG among women with GDM.

Lifestyle Intervention Enabled by Mobile Technology on Weight Loss in Patients With Nonalcoholic Fatty Liver Disease: Randomized Controlled Trial.

BACKGROUND: The prevalence of nonalcoholic fatty liver disease (NAFLD) reaches up to 30% in the Asian adult population, with a higher prevalence in obese patients. Weight reduction is typically recommended for patients at high risk or diagnosed with NAFLD, but is a challenge to achieve. OBJECTIVE: We aimed to evaluate the effect of a lifestyle intervention with a mobile app on weight loss in NAFLD patients. METHODS: This prospective randomized controlled trial included 108 adults with NAFLD confirmed by steatosis on ultrasound and a body mass index ≥23 kg/m2 who were recruited from a fatty liver outpatient clinic. The patients were randomly allocated to either a control group (n=53) receiving standard care, consisting of dietary and lifestyle advice by a trained nurse, or an intervention group (n=55) utilizing the Nutritionist Buddy (nBuddy) mobile app in addition to receiving dietary and lifestyle advice by a dietitian. Body weight, alanine aminotransferase (ALT), aspartate aminotransferase (AST), waist circumference, and blood pressure were measured at baseline, and then at 3 and 6 months. Intention-to-treat and per-protocol analyses were used for statistical comparisons. RESULTS: The intervention group had a 5-fold higher likelihood (relative risk 5.2, P=.003, 95% CI 1.8-15.4) of achieving ≥5% weight loss compared to the control group at 6 months. The intervention group also showed greater reductions in weight (mean 3.2, SD 4.1 kg vs mean 0.5, SD 2.9 kg; P<.001), waist circumference (mean 2.9, SD 5.0 cm vs mean -0.7, SD 4.4 cm; P<.001), systolic blood pressure (mean 12.4, SD 14.8 mmHg vs mean 2.4, SD 12.4 mmHg; P=.003), diastolic blood pressure (mean 6.8, SD 8.9 mmHg vs mean -0.9, SD 10.0 mmHg; P=.001), ALT (mean 33.5, SD 40.4 IU/L vs mean 11.5, SD 35.2 IU/L; P=.004), and AST (mean 17.4, SD 27.5 U/L vs mean 7.4, SD 17.6 IU/L, P=.03) at 6 months. CONCLUSIONS: Lifestyle intervention enabled by a mobile app can be effective in improving anthropometric indices and liver enzymes in patients with NAFLD. This treatment modality has the potential to be extended to a larger population scale. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12617001001381; https://tinyurl.com/w9xnfmp.

Development of a Healthy Lifestyle Mobile App for Overweight Pregnant Women: Qualitative Study.

BACKGROUND: Mobile apps are becoming an increasingly ubiquitous platform for delivery of health behavior interventions among overweight and obese perinatal women. However, only a few methodological guidelines on integrating theory, evidence, and qualitative research for their designs are available. OBJECTIVE: The aim of this study was to develop a theory-based, evidence-driven, and user-centered healthy lifestyle app targeting overweight and obese multiethnic pregnant women. METHODS: This paper illustrates how intervention development may be enriched with theoretical basis, systematic review, and qualitative study. An individual face-to-face interview was performed to incorporate the user's involvement in the design. These interviews were audiotaped and transcribed. Thematic analysis technique was used for emerging themes. RESULTS: Integrated concepts of social cognitive theory of self-regulation, self-regulation model, and strength model of self-control were selected as bases of the intervention. Evidence from our systematic review and meta-analysis provided the strongest evidence for the development of intervention. We invited 16 obese or overweight pregnant women to participate in a semistructured interview . The following key themes emerged: content, platform, interactivity, format, and functionality. Apps are a favorable technology platform for healthy diet advice, appropriate physical exercise, and weight management because they are user-friendly and convenient. The app used in this study contains culture-specific, pregnancy-related, and credible contents, including educational, professional and peer support, and self-monitoring domains. The design should include aesthetic appeal, visualized features, and interactive multimedia. CONCLUSIONS: A 3-step process integrating theoretical basis, evidence from systematic review, and research findings from target users can be considered a guide for future app development.

Breastfeeding attitude, health-related quality of life and maternal obesity among multi-ethnic pregnant women: A multi-group structural equation approach.

BACKGROUND: Identifying the factors influencing breastfeeding attitude is significant for the implementation of effective promotion policies and counselling activities. To our best knowledge, no previous studies have modelled the relationships among breastfeeding attitude, health-related quality of life and maternal obesity among multi-ethnic pregnant women; the current study attempts to fill this research gap. OBJECTIVES: This study investigated the relationships among maternal characteristics, health-related quality of life and breastfeeding attitude amidst normal weight and overweight/obese pregnant women using a multi-group structural equation modelling approach. DESIGN: Exploratory cross-sectional design was used. SETTING: Antenatal clinics of a university-affiliated hospital PARTICIPANTS: Pregnant women were invited to participate; 708 (78.8%) agreed to participate in the study. METHODS: We examined a hypothetical model on the basis of integrating the concepts of a breastfeeding decision-making model, theory of planned behaviour-based model for breastfeeding and health-related quality of life model among 708 multi-ethnic pregnant women in Singapore. The Iowa Infant Feeding Attitude Scale and Medical Outcomes Study Short Form Health Survey were used to measure breastfeeding attitude and health-related quality of life, respectively. RESULTS: Two structural equation models demonstrated that better health-related quality of life, higher monthly household income, planned pregnancy and previous exclusive breastfeeding experience were significantly associated with positive breastfeeding attitude among normal and overweight/obese pregnant women. Among normal weight pregnant women, those who were older with higher educational level were more likely to have positive breastfeeding attitude. Among overweight/obese pregnant women, Chinese women with confinement nanny plan were less likely to have positive breastfeeding attitude. No significant difference existed between normal weight and overweight/obese pregnant women concerning estimates of health-related quality of life on breastfeeding attitude (Critical Ratio=-0.193). The model satisfactorily fitted the data (Incremental Fit Index=0.924, Tucker-Lewis Index=0.905, Comparative Fit Index=0.921 and Root Means Square Error of Approximation=0.025). Health-related quality of life was found to affect breastfeeding attitude in multi-ethnic pregnant women. CONCLUSIONS: This relationship implied the importance of early culturally specific interventions to enhance health-related quality of life for improving positive breastfeeding attitude among pregnant women across different ethnic groups.