The Singaporean healthcare system is facing challenges arising from the increase of non-communicable diseases (NCDs) such as type-2 diabetes (T2D), related risk factors, and their associated socio- and health-economic costs. To address this important problem at an early stage of disease onset and because prevention-focused health interventions represent a large unmet need, this project aims to investigate the feasibility and effectiveness of a scalable digital health intervention. Smartphone-delivered and personalised health interventions can prevent T2D on a large scale and at low cost. However, low user engagement has so far limited the usefulness of many mobile health interventions. MobileCoach, an open-source platform that relies on an automated conversational agent (chatbot) to deliver scalable, interactive and engaging mobile health interventions, will be used in this project to address this challenge. The overall goal of this project is therefore to build a scalable, engaging and effective digital lifestyle coach Diane⁺ that supports both low-risk and high-risk populations to prevent T2D.[1] In particular, Diane⁺ has the following distal outcome goals:

1. To reduce T2D risk
2. To increase self-reported quality of life
3. To improve physical capacities and anthropometric measurements

To reach these goals, Diane⁺ aims to build a working alliance with individuals at risk to develop T2D. Diane⁺ will also apply coaching strategies that are personalized according to (1) an individual’s preferences in lifestyle behaviour and (2) the current stage of change. In doing so, Diane⁺ may cover the following lifestyle behaviours in her digital lifestyle coaching sessions:

1. Physical activity, exercise and sedentary behaviour
2. Nutrient-rich (whole food), T2D-preventing diet, intermittent fasting
3. Stress management activities
4. Sleep hygiene

Diane⁺ will be adapted to characteristics of the population and the healthcare ecosystem in Singapore. Diane⁺ will also apply most-effective coaching behaviours that increase adherence to healthy lifestyle behaviours. It will be further explored whether a human lifestyle coach (the “^+” in Diane⁺ stands for additional human health coach support) can help to build a therapeutic bond with users and improve adherence and outcomes.

To carry out this research, the multiphase optimization strategy will be applied. In the preparation phase, we will conduct literature reviews, interviews and discussions with individuals at high/low risk of developing T2D, diabetes experts, health and lifestyle coaches, and (potential) future providers of Diane⁺. We will also develop the conceptual model of the intervention and define the optimization criterion to develop a first MobileCoach-based prototype of Diane⁺. A feasibility trial will be conducted with individuals that are stratified by high/low risk to develop T2D. To identify the most effective intervention components with respect to the distal outcomes, Diane⁺ will then be assessed, as part of the optimization phase of MOST, within an optimization trial with individuals stratified by high/low risk to develop T2D. Based on the results of the trial, final revisions to Diane⁺ will be made, and, as part of the last evaluation phase, an RCT will be employed in the last two years to assess the effectiveness of Diane⁺, again, with individuals stratified by high/low risk to develop T2D.

[1] Please not that Diane⁺ is the current code name of the digital coach and may change in the future.

Project overview by:
Dr. Jacqueline Mair, PhD
M.Sc. Roman Keller
M.Sc. Jiali Yao

Project updates by:
M.Sc. Aishah Alattas
M.Sc. Jiali Yao
M.Sc. Roman Keller

Meeting facilitated by:
Senior Scientist Dr. Jacqueline Mair PhD

Keller, R., Hartmann, S., Teepe, G., Lohse, K.M., Alattas, A., Tudor Car, L., Müller-Riemenschneider, F., von Wangenheim, F., Mair, J., Kowatsch, T., Digital Behavior Change Interventions for the Prevention and Management of Type 2 Diabetes: Systematic Market Analysis, Journal of Medical Internet Research (JMIR) 24(1):e33348, 10.2196/33348.

Keller, R., Yao, J., Teepe, G., Hartmann, S., Lohse, K.M., von Wangenheim, F., Müller-Riemenschneider, F., Mair, J., Kowatsch, T. (2021) Are Conversational Agents Used at Scale by Companies Offering Digital Health Services for the Management and Prevention of Diabetes?, In Proceedings of the 14th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2021) – Volume 5: HEALTHINF, 811-816 ISBN: 978-989-758-490-9 ISSN: 2184-4305. [PDF]

Video Abstract by:
M.Sc. Roman Keller

1. Stieger, M., Flückiger, C., Rüegger, D., Kowatsch, T., Roberts, B.W., Allemand, M. (in press) Changing Personality Traits with the Help of a Digital Personality Change Intervention, Proceedings of the National Academy of Sciences of the United States of America (PNAS).
2. Stanger, C., Kowatsch, T., Xie, H., Nahum-Shani, I., Lim Liberty, F., Anderson, M., Santhanam, P., Kaden, S., Rosenberg, B. (2021), SweetGoals, a Digital Health Intervention for Young Adults with Type 1 Diabetes: Protocol for a Factorial Randomized Trial, JMIR Research Protocols 10.2196/27109 (forthcoming).
3. Maritsch, M., Föll, S., Lehmann, V., Bérubé, C., Kraus, M., Feuerriegel, S., Kowatsch, T., Züger, T., Stettler, C., Fleisch, E., Wortmann, F., Towards Wearable-based Hypoglycemia Detection and Warning in Diabetes, CHI 2020 Late Breaking Work, April 25-30, Honolulu, Hawai’i, USA. [PDF]
4. Lüscher, J., Kowatsch, T., Boateng, G., Santhanam, P., Bodemann, G., Scholz, U., Social Support and Common Dyadic Coping in Couples’ Dyadic Management of Type II Diabetes: Protocol for an Ambulatory Assessment Application, JMIR Res Protoc 2019;8(10):e13685 DOI: 10.2196/13685. [PDF]
5. Züger, T., Lehmann, V., Kraus, M., Feuerriegel, S., Kowatsch, T., Wortmann, F., Laimer, M., Fleisch, E., Stettler, C., HEADWIND: Design and Evaluation of a Vehicle Hypoglycemia Warning System in Diabetes – A Proof of Principle Study, Poster presented at the Swiss Society of Endocrinology and Diabetology Annual Meeting 2019 (SGED 2019). Nov 14-15, Bern, Switzerland. [PDF]
6. Boateng, G., Santhanam, P., Lüscher, J., Scholz, U., Kowatsch, T., Multimodal Affect Detection among Couples for Diabetes Management, Poster presented at the Black in AI Workshop at the 32nd Annual Conference on Neural Information Processing Systems (NeurIPS), December 7, 2018, Montreal, Canada. [PDF]
7. Shih, I., Tomita, N., Lukic, Y., Hernández, Á., Fleisch, E., Kowatsch, T. (2018), Breeze: Smartphone-based Acoustic Real-time Detection of Breathing Phases for a Gamified Biofeedback Breathing Training, Proceedings of the ACM on Interactive, Mobile, Wearable and Ubiquitous Technologies (IMWUT) 3(4): Paper 152 10.1145/3369835
8. Stieger, M., Nißen, M.K., Rüegger, D., Kowatsch, T., Flückiger, C., Allemand, M. (2018) PEACH, a smartphone- and conversational agent-based coaching intervention for intentional personality change: study protocol of a randomized, wait-list controlled trial, BMC Psychology 6(43) 10.1186/s40359-018-0257-9
9. Kowatsch, T., Volland, D., Shih, I., Rüegger, D., Künzler, F., Barata, F., Filler, A., Büchter, D., Brogle, B., Heldt, K., Gindrat, P., Farpour-Lambert, N., l’Allemand, D. (2017) Design and Evaluation of a Mobile Chat App for the Open Source Behavioral Health Intervention Platform MobileCoach, In: Maedche A., vom Brocke J., Hevner A. (eds) Designing the Digital Transformation. DESRIST 2017. Lecture Notes in Computer Science, vol 10243. Springer: Berlin; Germany, 485-489. (Paper-PDF | Poster-PDF | Slide-PDF | Screencast)
10. Filler, A., Kowatsch, T., Haug, S., Wahle, F., Staake, T. & Fleisch, E. (2015) MobileCoach: A Novel Open Source Platform for the Design of Evidence-based, Scalable and Low-Cost Behavioral Health Interventions – Overview and Preliminary Evaluation in the Public Health Context. Wireless Telecommunications Symposium 2015 (WTS 2015), New York, USA. ***Outstanding Paper Award & Best Graduate Student Paper Award*** PDF

M.Sc. Roman Keller, B.Sc. Chang Siang Lim, Dr. Alicia Salamanca-Sanabria, Dr. Jacqueline Mair, Prof. Dr. Elgar Fleisch, Prof. Dr. Florian von Wangenheim & Prof. Dr. Tobias Kowatsch

March 2020 – February 2025

Prof. Falk Müller-Riemenschneider, MD
Prof. Dr. Rob Van Dam
Prof. Dr. E Shyong Tai

Dr. Jacqueline Mair, PhD