Pocket coach: Smartphone app supports weight, blood sugar management in Asians with T2D

A culturally contextualized smartphone-based lifestyle intervention helps Asian adults with type 2 diabetes (T2D) shed excess pounds and improve glycaemic outcomes within 3 months, according to data from the D’LITE* study.

The improvements were sustained through 6 months, said a team of Singapore-based researchers. Additionally, the intervention helped cut the doses and costs of diabetes medications, as compared with usual care.

Adapted to suit the needs of a multicultural Singaporean population, the “Nutritionist Buddy Diabetes” app integrates behavioural treatment, evidence-based diabetes management strategies, and dietitian support to promote weight and glycaemic control. [Health Psychol 2015;34:971-982; J Med Internet Res 2011;13:e30; Psychiatr Clin North Am 2011;34:841-859]

The app features a local food database that generates healthier alternatives based on the selection of foods keyed in by users. On top of this, local dietitians familiar with cultural practices and festivities of local ethnic groups provide recommendations that align with the cultural norms of users.

In D’LITE, 204 adults with T2D (mean age 51.2 years, 64.7 percent men, mean body mass index [BMI] 30.6 kg/m²) were randomly assigned to the intervention (n=99) or the control arm (n=105). All participants received diet and physical activity coaching from a dietitian at a baseline face-to-face visit. Those in the intervention arm were required to use the app for 6 months to track weight, diet, physical activity daily, and blood glucose, as well as to communicate regularly with the study dietitians via the app.

App users could choose a weight loss goal of 3 percent to 10 percent, depending on individual preferences. They were encouraged to work on their individualized calorie and carbohydrate goals, and an activity target of 10,000 steps daily. Three-minute educational videos developed locally were also pushed weekly in the first 3 months. The dietitians messaged the users every few days in the first 3 months, then weekly in the subsequent 3 months, to review goals and provide tailored feedback.

At 6 months, the intervention vs the control arm had greater reductions in body weight (mean change, –3.6 vs –1.2 kg) and HbA1c levels (mean change, –0.7 percent vs –0.3 percent). Furthermore, patients who used the app saw reduced medication burden (proportion of patients with reduced medications, 23.3 percent vs 5.4 percent), which yielded substantial annual cost savings (mean difference, −$145.30; p=0.01). [JAMA Netw Open 2021;4:e2112417]

Of note, the app-led lifestyle intervention conferred greater HbA1c reduction among patients with HbA1c levels of ≥8 percent (mean change, –1.8 percent vs –1.0 percent; p=0.001). Intergroup differences favouring the intervention over control were also observed for fasting blood glucose, diastolic blood pressure, and dietary changes.

Finally, intakes of total energy, carbohydrate, sugar, total fat, and saturated fat all changed for the better in patients who used the app, with a parallel increase in physical activity (mean difference, 62.4 min/wk; p=0.009) compared with those in the control group.

Weight loss and glycaemic improvements obtained with app use in the current study were similar to that achieved with previous face-to-face lifestyle and smartphone-based interventions in individuals with diabetes. This is despite reduced face-to-face interactions, according to the researchers. [J Acad Nutr Diet 2017;117:1659-1679; Diabetes Obes Metab 2015;17:371-378; Prim Care Diabetes 2019;13:399-408; Diabetes Care 2019;42:3-9; JMIR Mhealth Uhealth 2020;8:e16266; J Med Internet Res 2019;21:e15401]

“Typically, lifestyle intervention studies involve 3 to 12 visits in the initial 3 to 6 months, with a total duration of 2 to 16 hours,” they said, suggesting that face-to-face support from healthcare professionals is essential to maintaining weight loss over the long term. The success in D’LITE, the researchers pointed out, lies in the ease of communication in the app interface, allowing an increased frequency of touch points between the dietitians and app users. In effect, timely advice can be provided at the point of decision-making, and this is able to “mitigate the potential effects of reduced face-to-face interactions, leading to comparable outcomes.” 

Despite the presence of limitations, including the use of self-reporting and lack of a validated measure, D’LITE indicates that a self-management app featuring self-monitoring, automated feedback, prompts, and educational videos may foster self-empowerment among T2D patients and reduce their reliance on healthcare professionals over time, which can potentially translate to lower healthcare expenditure, the researchers said.

“Future research can investigate the specific combination of app features that are most likely to achieve successful outcomes, as well as the effectiveness of such apps in other Asian populations,” they added.

*The Diabetes Lifestyle Intervention using Technology Empowerment