# Exercise as it relates to Disease/Could using an app a day keep diabetes away?

This is an analysis of the article "A Novel Diabetes Prevention Intervention Using a Mobile App: A Randomized Controlled Trial With Overweight Adults at Risk."

## What is the background to this research?

The World Health Organisation defines diabetes as "a chronic disease that occurs when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces." Diabetes has been described as the "epidemic of the 21st century and the biggest challenge confronting Australia's health system" with the estimated total annual cost of diabetes in Australia being $14.6 billion when considering direct medical costs and lost productivity.
As diabetes is an ever growing issue, the authors of this study set out "to evaluate the feasibility and short-term efficacy of a diabetes prevention intervention enhanced with a mobile phone app among overweight English-speaking adults at risk for developing type 2 diabetes". The main aim of the intervention was to assist in weight loss over a five month period.

## Where is the research from?

This study was conducted amongst a small population (61 participants) with 47 females and an average age of 55.2. The mean Body Mass Index (weight in kilograms/height in meters squared) was 33 and 29 of the participants had an ethnic minority background. Participants were recruited from primary care clinics and through flyers in San Francisco and Berkley, California, United States of America.
The authors have previously investigated obesity and diabetes, publishing several papers investigating their health impacts. Given this, readers can feel safe in knowing that the authors are experienced in this field.
The study was supported by various organisations, however none brought up any conflicts of interest. The main supporters were the University of California, San Francisco (UCSF) Diabetes Family Fund for Innovative Patient Care-education and Scientific Discovery Award and the UCSF Clinical and Translational Science Institute.

## What kind of research was this?

This study was conducted as a randomized controlled trial (RCT). This involves participants being randomly placed in groups and receiving interventions based on their group. Once the study is complete, the different intervention's effects are compared to identify if one is better. They are considered the gold standard for intervention studies and give one of the highest level of evidence with only reviews of RCTs being better.

## What did the research involve?

Table 1. Study groups
| Variable | Control | Intervention |
| Number of participants | 31 | 30 |
| Pedometer (step target) | Yes (no) | Yes (yes) |
| Education | Yes (brochure) | Yes (6 lifestyle intervention sessions) |
| Application use | No | Yes |
The methods used help to discover whether the use of an application can impact diabetes prevention. However, given the numerous variables between groups (see Table 1), it is difficult to isolate the cause of any differences between groups. It would have been better to have the application use as the only difference between groups. Apart from this, the design was suitable given the aim.
This study has several limitations which are acknowledged. Firstly, the study is relatively small with only english-speaking people and predominantly females meaning generalisability is reduced. Also, the results relied on participants using the pedometer and application daily. Consequently, if they forgot to wear it or the batteries were flat, the results would be impacted. As the measures stopped at five months, the sustainability of the results are also unknown. Also, the participant recruitment may not reveal the true effect of the intervention as those recruited were from primary-care institutions and flyers. It could be argued they are more proactive regarding their health and may make the interventions seem more effective than they are.

## What were the basic results?

Table 2. Study results
| Variable | Control | Intervention | Statically significant? |
| Weight change (%) | +0.3±3.0 | -6.8±5.4 | Yes |
| BMI change (%) | +0.3±3.0 | -6.6±5.7 | Yes |
| Hip circumference (cm) | 115.9±14.4 | 108.8±10.9 | Yes |
| Mean resting blood pressure (mmHg) | 129.5±12.1/80.2±8.1 | 121.1±11.1/73.7±7.9 | Yes |
The results (see Table 2) were interpreted by the authors to show that their interventions lead to increased weight loss and lower blood pressure over a five month period. They determined that increased activity levels and decreased saturated fat intake mediated this effect. Whilst they acknowledge that their interventions produce statistically significant results, they do not over-emphasise them as researchers sometimes do.

## What conclusions should be taken away from this research?

There are many conclusions that can be drawn from this study however the main message is that by being proactive, participating in physical activity and eating a diet low in saturated fat, people may lose weight and lower blood pressure, decreasing the likelihood of diabetes. This effect may be enhanced by attending lifestyle education sessions, having a daily step target and using an application encouraging physical activity.
Research in this field has yielded mixed results with some studies indicating positive results and others showing no effect. This research fits in with the area that supports use of applications, however, the authors note that it is an area that requires more research to gain a better insight into the effectiveness.

## Practical implications

This research shows that, even though technology is condemned as being bad for health, applications can increase healthy behaviours. It is also shows that if we are proactive in addressing diabetes, we can prevent those who are at risk of diabetes from developing it. However, it is important to know that before undertaking any lifestyle modification, medical professionals should be consulted to ensure that the intervention is suitable.

## Further reading

The following links have further information regarding diabetes:
* Diabetes Australia website - https://www.diabetesaustralia.com.au/
* Australian Diabetes Society website - https://diabetessociety.com.au

## References

* 1 2 3 4 5 6 7 8 9 10 Fukuoka, Y., Gay, C. L., Joiner, K. L., Vittinghoff, E. (2015). A Novel Diabetes Prevention Intervention Using a Mobile App: A Randomized Controlled Trial With Overweight Adults at Risk. American Journal of Preventive Medicine. 49(2), 223-237.
* ↑ World Health Organization. (2016). Diabetes. Retrieved from World Health Organization website: http://www.who.int/mediacentre/factsheets/fs312/en/
* ↑ Diabetes Australia. (2015). About Diabetes. Retrieved from Diabetes Australia website: https://www.diabetesaustralia.com.au/about-diabetes
* ↑ Diabetes Australia. (2015). Diabetes in Australia. Retrieved from Diabetes Australia website: https://www.diabetesaustralia.com.au/diabetes-in-australia
* ↑ Hoffman, T., Bennett, S., & Del Mar, C. (2013). Evidence-Based Practice Across The Health Professions. Sydney, Australia: Churchill Livingstone.