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Hietbrink EAG, Oude Nijeweme-d'Hollosy W, Middelweerd A, Konijnendijk AAJ, Schrijver LK, Ten Voorde AS, Fokkema EMS, Laverman GD, Vollenbroek-Hutten MMR. A Digital Coach (E-Supporter 1.0) to Support Physical Activity and a Healthy Diet in People With Type 2 Diabetes: Acceptability and Limited Efficacy Testing. JMIR Form Res 2023; 7:e45294. [PMID: 37505804 PMCID: PMC10422172 DOI: 10.2196/45294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 06/13/2023] [Accepted: 06/20/2023] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND A healthy lifestyle, including regular physical activity and a healthy diet, is increasingly part of type 2 diabetes (T2D) management. As many people with T2D have difficulty living and maintaining a healthy lifestyle, there is a need for effective interventions. eHealth interventions that incorporate behavior change theories and tailoring are considered effective tools for supporting a healthy lifestyle. The E-Supporter 1.0 digital coach contains eHealth content for app-based eHealth interventions and offers tailored coaching regarding physical activity and a healthy diet for people with T2D. OBJECTIVE This study aimed to assess the acceptability of E-Supporter 1.0 and explore its limited efficacy on physical activity, dietary behavior, the phase of behavior change, and self-efficacy levels. METHODS Over a span of 9 weeks, 20 individuals with T2D received daily motivational messages and weekly feedback derived from behavioral change theories and determinants through E-Supporter 1.0. The acceptability of the intervention was assessed using telephone-conducted, semistructured interviews. The interview transcripts were coded using inductive thematic analysis. The limited efficacy of E-Supporter 1.0 was explored using the Fitbit Charge 2 to monitor step count to assess physical activity and questionnaires to assess dietary behavior (using the Dutch Healthy Diet index), phase of behavior change (using the single-question Self-Assessment Scale Stages of Change), and self-efficacy levels (using the Exercise Self-Efficacy Scale). RESULTS In total, 5 main themes emerged from the interviews: perceptions regarding remote coaching, perceptions regarding the content, intervention intensity and duration, perceived effectiveness, and overall appreciation. The participants were predominantly positive about E-Supporter 1.0. Overall, they experienced E-Supporter 1.0 as a useful and easy-to-use intervention to support a better lifestyle. Participants expressed a preference for combining E-Supporter with face-to-face guidance from a health care professional. Many participants found the intensity and duration of the intervention to be acceptable, despite the coaching period appearing relatively short to facilitate long-term behavior maintenance. As expected, the degree of tailoring concerning the individual and external factors that influence a healthy lifestyle was perceived as limited. The limited efficacy testing showed a significant improvement in the daily step count (z=-2.040; P=.04) and self-efficacy levels (z=-1.997; P=.046) between baseline and postintervention. Diet was improved through better adherence to Dutch dietary guidelines. No significant improvement was found in the phase of behavior change (P=.17), as most participants were already in the maintenance phase at baseline. CONCLUSIONS On the basis of this explorative feasibility study, we expect E-Supporter 1.0 to be an acceptable and potentially useful intervention to promote physical activity and a healthy diet in people with T2D. Additional work needs to be done to further tailor the E-Supporter content and evaluate its effects more extensively on lifestyle behaviors.
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Affiliation(s)
- Eclaire A G Hietbrink
- Department of Biomedical Signals and Systems, University of Twente, Enschede, Netherlands
- Department of Internal Medicine/Nephrology, Ziekenhuisgroep Twente (ZGT), Almelo, Netherlands
| | | | - Anouk Middelweerd
- Department of Biomedical Signals and Systems, University of Twente, Enschede, Netherlands
| | - Annemieke A J Konijnendijk
- Department of Biomedical Signals and Systems, University of Twente, Enschede, Netherlands
- Office of Research and Innovation, Santeon, Utrecht, Netherlands
| | - Laura K Schrijver
- Department of Biomedical Signals and Systems, University of Twente, Enschede, Netherlands
- Department of Internal Medicine/Nephrology, Ziekenhuisgroep Twente (ZGT), Almelo, Netherlands
| | - Anouk S Ten Voorde
- Department of Biomedical Signals and Systems, University of Twente, Enschede, Netherlands
| | - Elise M S Fokkema
- Department of Biomedical Signals and Systems, University of Twente, Enschede, Netherlands
| | - Gozewijn D Laverman
- Department of Biomedical Signals and Systems, University of Twente, Enschede, Netherlands
- Department of Internal Medicine/Nephrology, Ziekenhuisgroep Twente (ZGT), Almelo, Netherlands
| | - Miriam M R Vollenbroek-Hutten
- Department of Biomedical Signals and Systems, University of Twente, Enschede, Netherlands
- Board of Directors, Medisch Spectrum Twente (MST), Enschede, Netherlands
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Kushniruk A, Middelweerd A, van Empelen P, Preuhs K, Konijnendijk AAJ, Oude Nijeweme-d'Hollosy W, Schrijver LK, Laverman GD, Vollenbroek-Hutten MMR. A Digital Lifestyle Coach (E-Supporter 1.0) to Support People With Type 2 Diabetes: Participatory Development Study. JMIR Hum Factors 2023; 10:e40017. [PMID: 36633898 PMCID: PMC9947918 DOI: 10.2196/40017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 09/29/2022] [Accepted: 11/20/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND A healthy lifestyle, including regular physical activity and a healthy diet, is becoming increasingly important in the treatment of chronic diseases. eHealth interventions that incorporate behavior change techniques (BCTs) and dynamic tailoring strategies could effectively support a healthy lifestyle. E-Supporter 1.0 is an eCoach designed to support physical activity and a healthy diet in people with type 2 diabetes (T2D). OBJECTIVE This paper aimed to describe the systematic development of E-Supporter 1.0. METHODS Our systematic design process consisted of 3 phases. The definition phase included the selection of the target group and formulation of intervention objectives, and the identification of behavioral determinants based on which BCTs were selected to apply in the intervention. In the development phase, intervention content was developed by specifying tailoring variables, intervention options, and decision rules. In the last phase, E-Supporter 1.0 integrated in the Diameter app was evaluated using a usability test in 9 people with T2D to assess intervention usage and acceptability. RESULTS The main intervention objectives were to stimulate light to moderate-vigorous physical activities or adherence to the Dutch dietary guidelines in people with T2D. The selection of behavioral determinants was informed by the health action process approach and theories explaining behavior maintenance. BCTs were included to address relevant behavioral determinants (eg, action control, self-efficacy, and coping planning). Development of the intervention resulted in 3 types of intervention options, consisting of motivational messages, behavioral feedback, and tailor-made supportive exercises. On the basis of IF-THEN rules, intervention options could be tailored to, among others, type of behavioral goal and (barriers to) goal achievement. Data on these variables could be collected using app data, activity tracker data, and daily ecological momentary assessments. Usability testing revealed that user experiences were predominantly positive, despite some problems in the fixed delivery of content. CONCLUSIONS The systematic development approach resulted in a theory-based and dynamically tailored eCoach. Future work should focus on expanding intervention content to other chronic diseases and lifestyle behaviors, enhancing the degree of tailoring and evaluating intervention effects on acceptability, use, and cost-effectiveness.
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Affiliation(s)
| | - Anouk Middelweerd
- Department of Biomedical Signals and Systems, University of Twente, Enschede, Netherlands
| | - Pepijn van Empelen
- Department of Child Health, TNO (Netherlands Organization for Applied Scientific Research), Leiden, Netherlands
| | - Katharina Preuhs
- Department of Child Health, TNO (Netherlands Organization for Applied Scientific Research), Leiden, Netherlands
| | | | | | - Laura K Schrijver
- Department of Biomedical Signals and Systems, University of Twente, Enschede, Netherlands
| | - Gozewijn D Laverman
- Department of Biomedical Signals and Systems, University of Twente, Enschede, Netherlands.,Department of Internal Medicine/Nephrology, Ziekenhuisgroep Twente, Almelo, Netherlands
| | - Miriam M R Vollenbroek-Hutten
- Department of Biomedical Signals and Systems, University of Twente, Enschede, Netherlands.,Board of Directors, Medisch Spectrum Twente, Enschede, Netherlands
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Oosterwijk MM, den Braber N, Bakker SJL, Laverman GD. Urinary creatinine excretion is an indicator of physical performance and function. J Cachexia Sarcopenia Muscle 2022; 13:1431-1433. [PMID: 35224882 PMCID: PMC8978018 DOI: 10.1002/jcsm.12965] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Milou M Oosterwijk
- Department of Internal Medicine/Nephrology, Ziekenhuis Groep Twente, Almelo, The Netherlands
| | - Niala den Braber
- Faculty of Electrical Engineering, Mathematics and Computer Science (EEMCS) and Biomedical Signals and Systems (BSS), University of Twente, Enschede, The Netherlands
| | - Stephan J L Bakker
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gozewijn D Laverman
- Department of Internal Medicine/Nephrology, Ziekenhuis Groep Twente, Almelo, The Netherlands.,Faculty of Electrical Engineering, Mathematics and Computer Science (EEMCS) and Biomedical Signals and Systems (BSS), University of Twente, Enschede, The Netherlands
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Clinical and Dietary Determinants of Muscle Mass in Patients with Type 2 Diabetes: Data from the Diabetes and Lifestyle Cohort Twente. J Clin Med 2021; 10:jcm10225227. [PMID: 34830509 PMCID: PMC8623198 DOI: 10.3390/jcm10225227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 10/29/2021] [Accepted: 11/06/2021] [Indexed: 12/25/2022] Open
Abstract
Low muscle mass in patients with type 2 diabetes is associated with a progressively higher risk of morbidity and mortality. The aim of this study was to identify modifiable targets for intervention of muscle mass in type 2 diabetes. Cross-sectional analyses were performed in 375 patients of the Diabetes and Lifestyle Cohort Twente-1 study. Muscle mass was estimated by 24 h urinary creatinine excretion rate (CER, mmol/24 h). Patients were divided in sex-stratified tertiles of CER. To study determinants of CER, multivariable linear regression analyses were performed. Protein intake was determined by Maroni formula and by a semi-quantitative Food Frequency Questionnaire. The mean CER was 16.1 ± 4.8 mmol/24 h and 10.9 ± 2.9 mmol/24 h in men and women, respectively. Lower CER was significantly associated with older age (p < 0.001) as a non-modifiable risk factor, whereas higher BMI (p = 0.015) and lower dietary protein intake (both methods p < 0.001) were identified as modifiable risk factors for lower CER. Overall body mass index (BMI) was high, even in the lowest CER tertile the mean BMI was 30.9 kg/m2, mainly driven by someone’s body weight (p = 0.004) instead of someone’s height (p = 0.58). In the total population, 28% did not achieve adequate protein intake of >0.8 g/kg/day, with the highest percentage in the lowest CER tertile (52%, p < 0.001). Among patients with type 2 diabetes treated in secondary care, higher BMI and low dietary protein intake are modifiable risk factors for lower muscle mass. Considering the risk associated with low muscle mass, intervention may be useful. To that purpose, dietary protein intake and BMI are potential targets for intervention.
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Hagedoorn IJM, den Braber N, Oosterwijk MM, Gant CM, Navis G, Vollenbroek-Hutten MMR, van Beijnum BJF, Bakker SJL, Laverman GD. Low Physical Activity in Patients with Complicated Type 2 Diabetes Mellitus Is Associated with Low Muscle Mass and Low Protein Intake. J Clin Med 2020; 9:jcm9103104. [PMID: 32992990 PMCID: PMC7601707 DOI: 10.3390/jcm9103104] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/20/2020] [Accepted: 09/23/2020] [Indexed: 12/13/2022] Open
Abstract
Objective: In order to promote physical activity (PA) in patients with complicated type 2 diabetes, a better understanding of daily movement is required. We (1) objectively assessed PA in patients with type 2 diabetes, and (2) studied the association between muscle mass, dietary protein intake, and PA. Methods: We performed cross-sectional analyses in all patients included in the Diabetes and Lifestyle Cohort Twente (DIALECT) between November 2016 and November 2018. Patients were divided into four groups: <5000, 5000–6999, 7000–9999, ≥ 10,000 steps/day. We studied the association between muscle mass (24 h urinary creatinine excretion rate, CER) and protein intake (by Maroni formula), and the main outcome variable PA (steps/day, Fitbit Flex device) using multivariate linear regression analyses. Results: In the 217 included patients, the median steps/day were 6118 (4115–8638). Of these patients, 48 patients (22%) took 7000–9999 steps/day, 37 patients (17%) took ≥ 10,000 steps/day, and 78 patients (36%) took <5000 steps/day. Patients with <5000 steps/day had, in comparison to patients who took ≥10,000 steps/day, a higher body mass index (BMI) (33 ± 6 vs. 30 ± 5 kg/m2, p = 0.009), lower CER (11.7 ± 4.8 vs. 14.8 ± 3.8 mmol/24 h, p = 0.001), and lower protein intake (0.84 ± 0.29 vs. 1.08 ± 0.22 g/kg/day, p < 0.001). Both creatinine excretion (β = 0.26, p < 0.001) and dietary protein intake (β = 0.31, p < 0.001) were strongly associated with PA, which remained unchanged after adjustment for potential confounders. Conclusions: Prevalent insufficient protein intake and low muscle mass co-exist in obese patients with low physical activity. Dedicated intervention studies are needed to study the role of sufficient protein intake and physical activity in increasing or maintaining muscle mass in patients with type 2 diabetes.
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Affiliation(s)
- Ilse J. M. Hagedoorn
- Division of Nephrology, Department of Internal Medicine, Ziekenhuisgroep Twente, 7609 PP Almelo, The Netherlands; (N.d.B); (M.M.O.); (M.M.R.V.-H.); (G.D.L.)
- Correspondence: ; Tel.: +31-6-44-019-033
| | - Niala den Braber
- Division of Nephrology, Department of Internal Medicine, Ziekenhuisgroep Twente, 7609 PP Almelo, The Netherlands; (N.d.B); (M.M.O.); (M.M.R.V.-H.); (G.D.L.)
- Faculty of Electrical Engineering, Mathematics and Computer Science, University of Twente, 7522 NB Enschede, The Netherlands;
| | - Milou M. Oosterwijk
- Division of Nephrology, Department of Internal Medicine, Ziekenhuisgroep Twente, 7609 PP Almelo, The Netherlands; (N.d.B); (M.M.O.); (M.M.R.V.-H.); (G.D.L.)
| | - Christina M. Gant
- Division of Nephrology, Department of Internal Medicine, University of Groningen, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (C.M.G.); (G.N); (S.J.L.B.)
- Department of Internal Medicine, Meander Medisch Centrum, 3813 TZ Amersfoort, The Netherlands
| | - Gerjan Navis
- Division of Nephrology, Department of Internal Medicine, University of Groningen, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (C.M.G.); (G.N); (S.J.L.B.)
| | - Miriam M. R. Vollenbroek-Hutten
- Division of Nephrology, Department of Internal Medicine, Ziekenhuisgroep Twente, 7609 PP Almelo, The Netherlands; (N.d.B); (M.M.O.); (M.M.R.V.-H.); (G.D.L.)
- Faculty of Electrical Engineering, Mathematics and Computer Science, University of Twente, 7522 NB Enschede, The Netherlands;
| | - Bert-Jan F. van Beijnum
- Faculty of Electrical Engineering, Mathematics and Computer Science, University of Twente, 7522 NB Enschede, The Netherlands;
| | - Stephan J. L. Bakker
- Division of Nephrology, Department of Internal Medicine, University of Groningen, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands; (C.M.G.); (G.N); (S.J.L.B.)
| | - Gozewijn D. Laverman
- Division of Nephrology, Department of Internal Medicine, Ziekenhuisgroep Twente, 7609 PP Almelo, The Netherlands; (N.d.B); (M.M.O.); (M.M.R.V.-H.); (G.D.L.)
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den Braber N, Vollenbroek-Hutten MMR, Oosterwijk MM, Gant CM, Hagedoorn IJM, van Beijnum BJF, Hermens HJ, Laverman GD. Requirements of an Application to Monitor Diet, Physical Activity and Glucose Values in Patients with Type 2 Diabetes: The Diameter. Nutrients 2019; 11:nu11020409. [PMID: 30781348 PMCID: PMC6413029 DOI: 10.3390/nu11020409] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 02/06/2019] [Accepted: 02/11/2019] [Indexed: 11/22/2022] Open
Abstract
Adherence to a healthy diet and regular physical activity are two important factors in sufficient type 2 diabetes mellitus management. It is recognized that the traditional treatment of outpatients does not meet the requirements for sufficient lifestyle management. It is hypothesised that a personalized diabetes management mHealth application can help. Such an application ideally measures food intake, physical activity, glucose values, and medication use, and then integrates this to provide patients and healthcare professionals insight in these factors, as well as the effect of lifestyle on glucose values in daily life. The lifestyle data can be used to give tailored coaching to improve adherence to lifestyle recommendations and medication use. This study describes the requirements for such an application: the Diameter. An iterative mixed method design approach is used that consists of a cohort study, pilot studies, literature search, and expert meetings. The requirements are defined according to the Function and events, Interactions and usability, Content and structure and Style and aesthetics (FICS) framework. This resulted in 81 requirements for the dietary (n = 37), activity and sedentary (n = 15), glycaemic (n = 12), and general (n = 17) parts. Although many applications are currently available, many of these requirements are not implemented. This stresses the need for the Diameter as a new personalized diabetes application.
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Affiliation(s)
- Niala den Braber
- Department of Internal Medicine/Nephrology, Ziekenhuisgroep Twente (ZGT), 7609 PP Almelo, The Netherlands.
- Biomedical Signals and Systems (BSS), University of Twente, 7522 NB Enschede, The Netherlands.
| | - Miriam M R Vollenbroek-Hutten
- Department of Internal Medicine/Nephrology, Ziekenhuisgroep Twente (ZGT), 7609 PP Almelo, The Netherlands.
- Biomedical Signals and Systems (BSS), University of Twente, 7522 NB Enschede, The Netherlands.
| | - Milou M Oosterwijk
- Department of Internal Medicine/Nephrology, Ziekenhuisgroep Twente (ZGT), 7609 PP Almelo, The Netherlands.
| | - Christina M Gant
- Department of Internal Medicine/Nephrology, Ziekenhuisgroep Twente (ZGT), 7609 PP Almelo, The Netherlands.
| | - Ilse J M Hagedoorn
- Department of Internal Medicine/Nephrology, Ziekenhuisgroep Twente (ZGT), 7609 PP Almelo, The Netherlands.
| | - Bert-Jan F van Beijnum
- Biomedical Signals and Systems (BSS), University of Twente, 7522 NB Enschede, The Netherlands.
| | - Hermie J Hermens
- Biomedical Signals and Systems (BSS), University of Twente, 7522 NB Enschede, The Netherlands.
- Roessingh Research and Development (RRD), 7522 AH Enschede, The Netherlands.
| | - Gozewijn D Laverman
- Department of Internal Medicine/Nephrology, Ziekenhuisgroep Twente (ZGT), 7609 PP Almelo, The Netherlands.
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