# Engagement With a Smartphone-Delivered Dietary Education Intervention and Its Relation to Dietary Intake and Cardiometabolic Risk Markers in People With Type 2 Diabetes: Secondary Analysis of a Randomized Controlled Trial

## TL;DR

A smartphone app for dietary education in people with type 2 diabetes was found to be effective, with higher engagement linked to better dietary habits and health outcomes.

## Contribution

This study demonstrates that user engagement with a smartphone-based dietary intervention is associated with improved diet quality and cardiometabolic markers in type 2 diabetes patients.

## Key findings

- High engagement with the app was associated with increased whole grain intake compared to low engagement.
- Moderate engagement was linked to better dietary changes in fiber, carbohydrates, and sodium over time.
- Higher engagement groups maintained healthier dietary behaviors compared to low engagement groups.

## Abstract

Mobile health (mHealth) interventions offer a promising way to support healthy lifestyle habits, but effectiveness depends on user engagement. Maintaining high user engagement in app-based interventions is important, yet challenging.

We aimed to examine the association between user engagement with an app-based dietary education for people with type 2 diabetes and changes in diet quality, dietary intake, and clinical measures.

In this randomized clinical trial, people with type 2 diabetes were recruited within primary care and randomized 1:1 to a 12-week smartphone-delivered app-based dietary education or control group. Participants were followed up after 3, 6, and 12 months. Dietary intake was assessed using a food frequency questionnaire. The control group received the app at the 3-month follow-up. User engagement was analyzed among all participants. Categories of high (100%), moderate (50%‐99.9%), and low (<50%) user engagement were created based on the percentage of activities completed in the app. We used paired t tests to compare mean changes in diet quality, dietary intake, and clinical markers within user engagement groups, and fitted linear regression models to analyze differences in change between groups.

Data from 119 participants (60.5%, 72/119 men) were analyzed. The mean age at baseline was 63.2 (SD 10.3) years and mean BMI was 30.1 (SD 5.1) kg/m2. User engagement was high with an average of 77.1% of app activities completed. More than half (53.8%, 64/119) of the users showed high user engagement, 21.8% (26/119) moderate, and 24.4% (29/119) low. Directly following the app-based education, a significant difference in change was seen for whole grains (β=20.4, 95%CI 0.57‐40.3) in participants with high user engagement compared to the low user engagement group who decreased their intake (P=.03). At follow-up after 6 to 9 months after completed education, significant differences in change were seen for fiber, wholegrains, carbohydrates, saturated fat, sodium, and total energy in the moderate compared with the low engagement group, and a significant difference in change was seen for carbohydrates in the high, compared with the low, user engagement group.

User engagement was generally high for the smartphone-based dietary education, suggesting that an app targeting dietary habits is feasible to use. Those with higher user engagement seem to maintain healthier dietary behaviours over time, compared to those with low user engagement. Future mHealth interventions should focus on ways to engage those with low interest.