Digital Behavior Change Interventions for the Prevention and Management of Type 2 Diabetes: Systematic Market Analysis

The effectiveness of digital twins in promoting precision health across the entire population: a systematic review

Digital twins represent a promising technology within the domain of precision healthcare, offering significant prospects for individualized medical interventions. Existing systematic reviews, however, mainly focus on the technological dimensions of digital twins, with a limited exploration of their impact on health-related outcomes. Therefore, this systematic review aims to explore the efficacy of digital twins in improving precision healthcare at the population level. The literature search for this study encompassed PubMed, Embase, Web of Science, Cochrane Library, CINAHL, SinoMed, CNKI, and Wanfang Database to retrieve potentially relevant records. Patient health-related outcomes were synthesized employing quantitative content analysis, whereas the Joanna Briggs Institute (JBI) scales were used to evaluate the quality and potential bias inherent in each selected study. Following established inclusion and exclusion criteria, 12 studies were screened from an initial 1321 records for further analysis. These studies included patients with various conditions, including cancers, type 2 diabetes, multiple sclerosis, heart failure, qi deficiency, post-hepatectomy liver failure, and dental issues. The review coded three types of interventions: personalized health management, precision individual therapy effects, and predicting individual risk, leading to a total of 45 outcomes being measured. The collective effectiveness of these outcomes at the population level was calculated at 80% (36 out of 45). No studies exhibited unacceptable differences in quality. Overall, employing digital twins in precision health demonstrates practical advantages, warranting its expanded use to facilitate the transition from the development phase to broad application.PROSPERO registry: CRD42024507256.

Engagement With a Relaxation and Mindfulness Mobile App Among People With Cancer: Exploratory Analysis of Use Data and Self-Reports From a Randomized Controlled Trial

BACKGROUND

Mobile health (mHealth) apps offer unique opportunities to support self-care and behavior change, but poor user engagement limits their effectiveness. This is particularly true for fully automated mHealth apps without any human support. Human support in mHealth apps is associated with better engagement but at the cost of reduced scalability.

OBJECTIVE

This work aimed to (1) describe the theory-informed development of a fully automated relaxation and mindfulness app to reduce distress in people with cancer (CanRelax app 2.0), (2) describe engagement with the app on multiple levels within a fully automated randomized controlled trial over 10 weeks, and (3) examine whether engagement was related to user characteristics.

METHODS

The CanRelax app 2.0 was developed in iterative processes involving input from people with cancer and relevant experts. The app includes evidence-based relaxation exercises, personalized weekly coaching sessions with a rule-based conversational agent, 39 self-enactable behavior change techniques, a self-monitoring dashboard with gamification elements, highly tailored reminder notifications, an educational video clip, and personalized in-app letters. For the larger study, German-speaking adults diagnosed with cancer within the last 5 years were recruited via the web in Switzerland, Austria, and Germany. Engagement was analyzed in a sample of 100 study participants with multiple measures on a micro level (completed coaching sessions, relaxation exercises practiced with the app, and feedback on the app) and a macro level (relaxation exercises practiced without the app and self-efficacy toward self-set weekly relaxation goals).

RESULTS

In week 10, a total of 62% (62/100) of the participants were actively using the CanRelax app 2.0. No associations were identified between engagement and level of distress at baseline, sex assigned at birth, educational attainment, or age. At the micro level, 71.88% (3520/4897) of all relaxation exercises and 714 coaching sessions were completed in the app, and all participants who provided feedback (52/100, 52%) expressed positive app experiences. At the macro level, 28.12% (1377/4897) of relaxation exercises were completed without the app, and participants' self-efficacy remained stable at a high level. At the same time, participants raised their weekly relaxation goals, which indicates a potential relative increase in self-efficacy.

CONCLUSIONS

The CanRelax app 2.0 achieved promising engagement even though it provided no human support. Fully automated social components might have compensated for the lack of human involvement and should be investigated further. More than one-quarter (1377/4897, 28.12%) of all relaxation exercises were practiced without the app, highlighting the importance of assessing engagement on multiple levels.

Which behaviour change techniques work best for diabetes self-management mobile apps? Results from a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Self-management is pivotal in addressing noncommunicable diseases, such as diabetes. The increased availability of digital behaviour change interventions (DBCIs) delivered through mobile health apps offers unprecedented opportunities to enhance self-management and improve health outcomes. However, little is known about the characteristics of DBCIs for diabetes that significantly impact glycaemic control. Therefore, our systematic review with meta-analysis aimed to summarize characteristics and behaviour change components in DBCIs for diabetes self-management and explore potential associations with metabolic outcomes.

METHODS

A systematic search was conducted in PubMed, Embase, the Cochrane Central Register of Controlled Trials, and Scopus to identify randomized controlled trials published until November 2023. The main outcome variable was the change in the mean difference of HbA1c levels between baseline and follow-up across intervention and control groups. Random-effects meta-regression was used to explore variation in glycaemic control as a function of prespecified characteristics of study designs and app interventions.

FINDINGS

A total of 57 studies was included in the analysis, showing a statistically significant percentage point reduction in HbA1c for the intervention group compared to the control arm (-0.36, 95% CI = -0.46 to -0.26, p < 0.001). The inclusion of "self-monitoring of behaviour" as a behaviour change technique (β = -0.22, p = 0.04) and "taking medication" as a target behaviour (β = -0.20, p = 0.05) was associated with improved metabolic outcomes.

INTERPRETATION

Our analyses endorse the use of diabetes self-management apps, highlighting characteristics statistically associated with intervention effectiveness and guiding the design of more effective DBCIs.

FUNDING

This project received funding from the European Union's Horizon 2020 programme.

Non-pharmaceutical interventions to optimize cancer immunotherapy

The traditional picture of cancer patients as weak individuals requiring maximum rest and protection is beginning to dissolve. Too much focus on the medical side and one's own vulnerability and mortality might be counterproductive and not doing justice to the complexity of human nature. Unlike cytotoxic and lympho-depleting treatments, immune-engaging therapies strengthen the immune system and are typically less harmful for patients. Thus, cancer patients receiving checkpoint inhibitors are not viewed as being vulnerable per se, at least not in immunological and physical terms. This perspective article advocates a holistic approach to cancer immunotherapy, with an empowered patient in the center, focusing on personal resources and receiving domain-specific support from healthcare professionals. It summarizes recent evidence on non-pharmaceutical interventions to enhance the efficacy of immune checkpoint blockade and improve quality of life. These interventions target behavioral factors such as diet, physical activity, stress management, circadian timing of checkpoint inhibitor infusion, and waiving unnecessary co-medication curtailing immunotherapy efficacy. Non-pharmaceutical interventions are universally accessible, broadly applicable, instantly actionable, scalable, and economically sustainable, creating value for all stakeholders involved. Most importantly, this holistic framework re-emphasizes the patient as a whole and harnesses the full potential of anticancer immunity and checkpoint blockade, potentially leading to survival benefits. Digital therapeutics are proposed to accompany the patients on their mission toward change in lifestyle-related behaviors for creating optimal conditions for treatment efficacy and personal growth.

Effective Behavior Change Techniques in Digital Health Interventions for the Prevention or Management of Noncommunicable Diseases: An Umbrella Review

BACKGROUND

Despite an abundance of digital health interventions (DHIs) targeting the prevention and management of noncommunicable diseases (NCDs), it is unclear what specific components make a DHI effective.

PURPOSE

This narrative umbrella review aimed to identify the most effective behavior change techniques (BCTs) in DHIs that address the prevention or management of NCDs.

METHODS

Five electronic databases were searched for articles published in English between January 2007 and December 2022. Studies were included if they were systematic reviews or meta-analyses of DHIs targeting the modification of one or more NCD-related risk factors in adults. BCTs were coded using the Behavior Change Technique Taxonomy v1. Study quality was assessed using AMSTAR 2.

RESULTS

Eighty-five articles, spanning 12 health domains and comprising over 865,000 individual participants, were included in the review. We found evidence that DHIs are effective in improving health outcomes for patients with cardiovascular disease, cancer, type 2 diabetes, and asthma, and health-related behaviors including physical activity, sedentary behavior, diet, weight management, medication adherence, and abstinence from substance use. There was strong evidence to suggest that credible source, social support, prompts and cues, graded tasks, goals and planning, feedback and monitoring, human coaching and personalization components increase the effectiveness of DHIs targeting the prevention and management of NCDs.

CONCLUSIONS

This review identifies the most common and effective BCTs used in DHIs, which warrant prioritization for integration into future interventions. These findings are critical for the future development and upscaling of DHIs and should inform best practice guidelines.

Perspective: A Conceptual Framework for Adaptive Personalized Nutrition Advice Systems (APNASs)

Nearly all approaches to personalized nutrition (PN) use information such as the gene variants of individuals to deliver advice that is more beneficial than a generic "1-size-fits-all" recommendation. Despite great enthusiasm and the increased availability of commercial services, thus far, scientific studies have only revealed small to negligible effects on the efficacy and effectiveness of personalized dietary recommendations, even when using genetic or other individual information. In addition, from a public health perspective, scholars are critical of PN because it primarily targets socially privileged groups rather than the general population, thereby potentially widening health inequality. Therefore, in this perspective, we propose to extend current PN approaches by creating adaptive personalized nutrition advice systems (APNASs) that are tailored to the type and timing of personalized advice for individual needs, capacities, and receptivity in real-life food environments. These systems encompass a broadening of current PN goals (i.e., what should be achieved) to incorporate "individual goal preferences" beyond currently advocated biomedical targets (e.g., making sustainable food choices). Moreover, they cover the "personalization processes of behavior change" by providing in situ, "just-in-time" information in real-life environments (how and when to change), which accounts for individual capacities and constraints (e.g., economic resources). Finally, they are concerned with a "participatory dialog between individuals and experts" (e.g., actual or virtual dieticians, nutritionists, and advisors) when setting goals and deriving measures of adaption. Within this framework, emerging digital nutrition ecosystems enable continuous, real-time monitoring, advice, and support in food environments from exposure to consumption. We present this vision of a novel PN framework along with scenarios and arguments that describe its potential to efficiently address individual and population needs and target groups that would benefit most from its implementation.

Digital Behavior Change Interventions to Reduce Sedentary Behavior and Promote Physical Activity in Adults with Diabetes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Technological advancements and ease of Internet access have increased the number of digital behavior change interventions (DBCIs). This systematic review and meta-analysis aimed to assess the effectiveness of DBCIs in reducing sedentary behavior (SB) and promoting physical activity (PA) in adults with diabetes.

METHODS

A comprehensive search of seven databases-PubMed, Embase, PsycINFO, Cochrane Library, CINAHL, Web of Science, and Sedentary Behavior Research Database-was performed. Two reviewers independently carried out the study selection, data extraction, risk of bias assessment, and quality of evidence evaluation. Meta-analyses were performed where feasible; otherwise, narrative summaries were performed.

RESULTS

A total of 13 randomized controlled trials with 980 participants met the inclusion criteria. Overall, DBCIs could significantly increase steps and the number of breaks in sedentary time. The subgroup analyses exhibited significant effects in DBCIs with over 10 behavior change techniques (BCTs) in improving steps, the time spent in light physical activity (LPA), and moderate-to-vigorous physical activity (MVPA). The subgroup analyses showed a significant step increment in DBCIs of moderate and long durations, with over 4 BCT clusters, or in conjunction with a face-to-face component. The subgroup analyses also indicated significant effects in studies with ≥ 2 DBCI components in improving steps, the time spent in LPA and MVPA, and reducing sedentary time.

CONCLUSION

There is some evidence that DBCI may increase PA and reduce SB in adults with type 2 diabetes. However, more high-quality studies are required. Future studies are needed to examine the potential of DBCIs in adults with type 1 diabetes.

Development of "LvL UP 1.0": a smartphone-based, conversational agent-delivered holistic lifestyle intervention for the prevention of non-communicable diseases and common mental disorders

Background

Non-communicable diseases (NCDs) and common mental disorders (CMDs) are the leading causes of death and disability worldwide. Lifestyle interventions via mobile apps and conversational agents present themselves as low-cost, scalable solutions to prevent these conditions. This paper describes the rationale for, and development of, "LvL UP 1.0″, a smartphone-based lifestyle intervention aimed at preventing NCDs and CMDs.

Materials and Methods

A multidisciplinary team led the intervention design process of LvL UP 1.0, involving four phases: (i) preliminary research (stakeholder consultations, systematic market reviews), (ii) selecting intervention components and developing the conceptual model, (iii) whiteboarding and prototype design, and (iv) testing and refinement. The Multiphase Optimization Strategy and the UK Medical Research Council framework for developing and evaluating complex interventions were used to guide the intervention development.

Results

Preliminary research highlighted the importance of targeting holistic wellbeing (i.e., both physical and mental health). Accordingly, the first version of LvL UP features a scalable, smartphone-based, and conversational agent-delivered holistic lifestyle intervention built around three pillars: Move More (physical activity), Eat Well (nutrition and healthy eating), and Stress Less (emotional regulation and wellbeing). Intervention components include health literacy and psychoeducational coaching sessions, daily "Life Hacks" (healthy activity suggestions), breathing exercises, and journaling. In addition to the intervention components, formative research also stressed the need to introduce engagement-specific components to maximise uptake and long-term use. LvL UP includes a motivational interviewing and storytelling approach to deliver the coaching sessions, as well as progress feedback and gamification. Offline materials are also offered to allow users access to essential intervention content without needing a mobile device.

Conclusions

The development process of LvL UP 1.0 led to an evidence-based and user-informed smartphone-based intervention aimed at preventing NCDs and CMDs. LvL UP is designed to be a scalable, engaging, prevention-oriented, holistic intervention for adults at risk of NCDs and CMDs. A feasibility study, and subsequent optimisation and randomised-controlled trials are planned to further refine the intervention and establish effectiveness. The development process described here may prove helpful to other intervention developers.

Assessing the Quality and Impact of eHealth Tools: Systematic Literature Review and Narrative Synthesis

BACKGROUND

Technological advancements have opened the path for many technology providers to easily develop and introduce eHealth tools to the public. The use of these tools is increasingly recognized as a critical quality driver in health care; however, choosing a quality tool from the myriad of tools available for a specific health need does not come without challenges.

OBJECTIVE

This review aimed to systematically investigate the literature to understand the different approaches and criteria used to assess the quality and impact of eHealth tools by considering sociotechnical factors (from technical, social, and organizational perspectives).

METHODS

A structured search was completed following the participants, intervention, comparators, and outcomes framework. We searched the PubMed, Cochrane, Web of Science, Scopus, and ProQuest databases for studies published between January 2012 and January 2022 in English, which yielded 675 results, of which 40 (5.9%) studies met the inclusion criteria. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and the Cochrane Handbook for Systematic Reviews of Interventions were followed to ensure a systematic process. Extracted data were analyzed using NVivo (QSR International), with a thematic analysis and narrative synthesis of emergent themes.

RESULTS

Similar measures from the different papers, frameworks, and initiatives were aggregated into 36 unique criteria grouped into 13 clusters. Using the sociotechnical approach, we classified the relevant criteria into technical, social, and organizational assessment criteria. Technical assessment criteria were grouped into 5 clusters: technical aspects, functionality, content, data management, and design. Social assessment criteria were grouped into 4 clusters: human centricity, health outcomes, visible popularity metrics, and social aspects. Organizational assessment criteria were grouped into 4 clusters: sustainability and scalability, health care organization, health care context, and developer.

CONCLUSIONS

This review builds on the growing body of research that investigates the criteria used to assess the quality and impact of eHealth tools and highlights the complexity and challenges facing these initiatives. It demonstrates that there is no single framework that is used uniformly to assess the quality and impact of eHealth tools. It also highlights the need for a more comprehensive approach that balances the social, organizational, and technical assessment criteria in a way that reflects the complexity and interdependence of the health care ecosystem and is aligned with the factors affecting users' adoption to ensure uptake and adherence in the long term.

The Clinical Impact of Flash Glucose Monitoring-a Digital Health App and Smartwatch Technology in Patients With Type 2 Diabetes: Scoping Review

BACKGROUND

Type 2 diabetes has a growing prevalence and confers significant cost burden to the health care system, raising the urgent need for cost-effective and easily accessible solutions. The management of type 2 diabetes requires significant commitment from the patient, caregivers, and the treating team to optimize clinical outcomes and prevent complications. Technology and its implications for the management of type 2 diabetes is a nascent area of research. The impact of some of the more recent technological innovations in this space, such as continuous glucose monitoring, flash glucose monitoring, web-based applications, as well as smartphone- and smart watch-based interactive apps has received limited attention in the research literature.

OBJECTIVE

This scoping review aims to explore the literature available on type 2 diabetes, flash glucose monitoring, and digital health technology to improve diabetic clinical outcomes and inform future research in this area.

METHODS

A scoping review was undertaken by searching Ovid MEDLINE and CINAHL databases. A second search using all identified keywords and index terms was performed on Ovid MEDLINE (January 1966 to July 2021), EMBASE (January 1980 to July 2021), Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library, latest issue), CINAHL (from 1982), IEEE Xplore, ACM Digital Libraries, and Web of Science databases.

RESULTS

There were very few studies that have explored the use of mobile health and flash glucose monitoring in type 2 diabetes. These studies have explored somewhat disparate and limited areas of research, and there is a distinct lack of methodological rigor in this area of research. The 3 studies that met the inclusion criteria have addressed aspects of the proposed research question.

CONCLUSIONS

This scoping review has highlighted the lack of research in this area, raising the opportunity for further research in this area, focusing on the clinical impact and feasibility of the use of multiple technologies, including flash glucose monitoring in the management of patients with type 2 diabetes.

Feasibility of Implementation and the Impact of a Digital Prehabilitation Service in Patients Undergoing Treatment for Oesophago-Gastric Cancer

BACKGROUND

Home-based and supervised prehabilitation programmes are shown to have a positive impact on outcomes in patients with oesophago-gastric (OG) cancer. The primary aim of this study was to establish the feasibility of delivering a digital prehabilitation service.

METHODS

Patients undergoing treatment for OG cancer with curative intent were recruited into the study. During the COVID-19 pandemic, patients were offered a digital prehabilitation service. Following the lifting of COVID-19 restrictions, patients were also offered both a hybrid clinic-based in-person service and a digital service. Implementation and clinical metrics from the two prehabilitation models were compared.

RESULTS

31 of 41 patients accepted the digital service (75%). Of the people who started the digital programme, 3 dropped out (10%). Compliance with the weekly touchpoints was 86%, and the median length of programme was 12 weeks. Twenty-six patients enrolled in the in-person service. Two patients dropped out (10%). Average compliance to weekly touchpoints was 71%, and the median length of programme was 10 weeks. In the digital group, sit to stand (STS) increased from 14.5 (IQR 10.5-15.5) to 16 (IQR 16-22); p = 0.02. Median heart rate recovery (HRR) increased from 10.5 (IQR 7.5-14) to 15.5 (IQR 11-20) bpm; p = 0.24. There was a significant drop in distress (median 3 (IQR 0-5) to 1 (IQR 0-2); p = 0.04) and a small drop in anxiety (median 3 (0-5) to 2 (0-3); p = 0.22). There was no difference in the postoperative complication rate and length of hospital stay between the two groups.

DISCUSSION

This study has shown that digital prehabilitation can be delivered effectively to patients with OG cancer, with high engagement and retention rates. We observed improvements in some physical and psychological parameters with the digital service, with comparable clinical outcomes to the in-person service.

Broadened assessments, health education and cognitive aids in the remote memory clinic

The prevalence of dementia is increasing and poses a health challenge for individuals and society. Despite the desire to know their risks and the importance of initiating early therapeutic options, large parts of the population do not get access to memory clinic-based assessments. Remote memory clinics facilitate low-level access to cognitive assessments by eschewing the need for face-to-face meetings. At the same time, patients with detected impairment or increased risk can receive non-pharmacological treatment remotely. Sensor technology can evaluate the efficiency of this remote treatment and identify cognitive decline. With remote and (partly) automatized technology the process of cognitive decline can be monitored but more importantly also modified by guiding early interventions and a dementia preventative lifestyle. We highlight how sensor technology aids the expansion of assessments beyond cognition and to other domains, e.g., depression. We also illustrate applications for aiding remote treatment and describe how remote tools can facilitate health education which is the cornerstone for long-lasting lifestyle changes. Tools such as transcranial electric stimulation or sleep-based interventions have currently mostly been used in a face-to-face context but have the potential of remote deployment-a step already taken with memory training apps. Many of the presented methods are readily scalable and of low costs and there is a range of target populations, from the worried well to late-stage dementia.

Promoting Physical Activity in Older Adults With Type 2 Diabetes via an Anthropomorphic Conversational Agent: Development of an Evidence and Theory-Based Multi-Behavior Intervention

Introduction

Anthropomorphic conversational agents (ACA) are a promising digital tool to support self-management of type 2 diabetes (T2D), albeit little explored. There is a dearth of literature on the detailed content of these interventions, which may limit effectiveness and replication. Our aim is to describe the development of an evidence and theory-based intervention to improve physical activity in older adults with T2D, subsumed in a multi-behavior intervention via a mobile application with an ACA.

Methods

Overall decisions on the multi-behavior intervention design, such as the use of standardized behavior change techniques (BCTTv1), guided the development of the physical activity component. Firstly, recommendations on ambulatory activity were used to select the target behavior (walking). Meta-research on effective behavior change techniques (BCTs) was then identified. One meta-analysis linked effective BCTs with the three basic psychological needs of the self-determination theory (SDT). This meta-analysis, taken together with additional evidence on SDT, led to the selection of this theory to inform the design. BCTs were extracted from meta-research; we selected the most appropriate to be operationalized via the conversational agent through multidisciplinary discussions. Rules governing the dialogue flow and BCTs tailoring, taking the form "if some conditions hold then execute some action," were derived based on the Basic Psychological in Exercise Scale (competence, autonomy, and relatedness scores), in conjunction with published evidence and multidisciplinary discussions.

Results

Thirteen BCTs were implemented in the prototype via the ACA (e.g., goal setting behavior 1.1). Six if-then rules were derived and depicted in the dialogue steps through process flow diagrams, which map how the system functions. An example of a rule is "If competence score ≤ 10 then, apply BCT 1.1 with 500 steps increments as options for the daily walking goal; If competence score > 10 then, apply BCT 1.1 with 1,000 steps increments as options for the daily walking goal."

Conclusion

Evidence and SDT were translated into a mobile application prototype using an ACA to promote physical activity in older adults with T2D. This approach, which includes 13 BCTs and six if-then rules for their tailoring, may leverage the efforts of others in developing similar interventions.