Background: Mobile health apps are increasingly used as early intervention to support behavior change for diabetes prevention and control, with the overarching goal of lowering the overall disease burden. Objective: This prospective cohort study conducted in Singapore aimed to investigate app engagement features and their association with weight loss and improved glycemic control among adults with diabetes and prediabetes from the intervention arm of the Diabetes Lifestyle Intervention using Technology Empowerment randomized controlled trial. Methods: Diabetes and prediabetes participants (N=171) with a median age of 52 years, BMI of 29.3 kg/m2, and glycated hemoglobin (HbA1c) level of 6.5% and who were being assigned the Nutritionist Buddy Diabetes app were included. Body weight and HbA1c were measured at baseline, 3 months, and 6 months. A total of 476,300 data points on daily app engagement were tracked via the backend dashboard and developer’s report. The app engagement data were analyzed by quartiles and weekly means expressed in days per week. Linear mixed model analysis was used to determine the associations between the app engagements with percentage weight and HbA1c change. Results: The median overall app engagement rate was maintained above 90% at 6 months. Participants who were actively engaged in ≥5 app features were associated with the greatest overall weight reduction of 10.6% from baseline (mean difference −6, 95% CI −8.9 to −3.2; P<.001) at 6 months. Adhering to the carbohydrate limit of >5.9 days per week and choosing healthier food options for >4.3 days per week had the most impact, eliciting weight loss of 9.1% (mean difference −5.2, 95% CI −8.2 to −2.2; P=.001) and 8.8% (mean difference −4.2, 95% CI −7.1 to −1.3; P=.005), respectively. Among the participants with diabetes, those who had a complete meal log for >5.1 days per week or kept within their carbohydrate limit for >5.9 days per week each achieved greater HbA1c reductions of 1.2% (SD 1.3%; SD 1.5%), as compared with 0.2% (SD 1%; SD 0.6%). in the reference groups who used the features <1.1 or ≤2.5 days per week, respectively. Conclusions: Higher app engagement led to greater weight loss and HbA1c reduction among adults with overweight or obesity with type 2 diabetes or prediabetes. Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12617001112358; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12617001112358

Introduction: The ketogenic diet (KD) is widely used for weight management by reducing appetite, enhancing fat oxidation, and facilitating weight loss. However, the high content of total and saturated fats in a conventional KD may elevate low-density lipoprotein (LDL)-cholesterol levels, a known risk factor for cardiovascular diseases, highlighting the need for healthier alternatives. This study aimed to investigate the effect of a newly developed Healthy Ketogenic Diet (HKD) versus an Energy-Restricted Diet (ERD) on weight loss and metabolic outcomes among adults with obesity. Methods: Multi-ethnic Asian adults (n = 80) with body mass index ≥ 27.5 kg/m² were randomized either to HKD (n = 41) or ERD (n = 39) for 6 months. Both groups followed an energy-restricted healthy diet, emphasizing on reducing saturated and trans fats. The HKD group additionally limited net carbohydrate intake to no more than 50 g per day. Dietary adherence was supported via the Nutritionist Buddy app with dietitian coaching. The primary outcome was weight change from baseline at 6 months. Secondary outcomes included weight change at 3 months and 1 year, along with changes in metabolic profiles. Data were analyzed using linear regression with an intention-to-treat approach. Results: The HKD group achieved significantly greater mean weight loss at 6 months than the ERD group (−7.8 ± 5.2 kg vs. −4.2 ± 5.6 kg, p = 0.01). The mean weight loss percentage at 6 months was 9.3 ± 5.9% and 4.9 ± 5.8% for the HKD and ERD groups, respectively (p = 0.004). Improvements in metabolic profiles were also significantly better in the HKD group [glycated hemoglobin (−0.3 ± 0.3% vs. −0.1 ± 0.2%, p = 0.008), systolic blood pressure (−7.7 ± 8.9 mmHg vs. −2.6 ± 12.2 mmHg, p = 0.005), and aspartate transaminase (−7.6 ± 15.5 IU/L vs. 0.6 ± 11.5 IU/L, p = 0.01)], with no increase in LDL-cholesterol (−0.12 ± 0.60 mmol/L vs. −0.04 ± 0.56 mmol/L, p = 0.97) observed in either group. Conclusions: The HKD was more effective than the ERD in promoting weight loss and improving cardiometabolic outcomes without elevation in LDL-cholesterol. It can be recommended for therapeutic intervention in patients with obesity.

Background/Objectives: Conventional ketogenic diets, although effective for weight loss, often contain high total and saturated fat intake, which leads to increased low-density lipoprotein cholesterol (LDL-C). Thus, the Healthy Ketogenic Diet (HKD) was developed to address these concerns. It emphasizes calorie restriction, limiting net carbohydrate intake to 50 g per day, prioritizing unsaturated fats, and reducing saturated fat intake. However, adherence to the HKD remains a challenge in urban, time-constrained environments. Therefore, this pilot randomized controlled trial aimed to investigate the effects of Healthy Ketogenic Diet Ready-To-Eat (HKD-RTE) meals (provided for the first month only) versus HKD alone on weight loss and metabolic parameters among overweight adults. Methods: Multi-ethnic Asian adults (n = 50) with a body mass index (BMI) ≥ 27.5 kg/m² were randomized into the HKD-RTE group (n = 24) and the HKD group (n = 26). Both groups followed the HKD for six months, with the HKD-RTE group receiving HKD-RTE meals during the first month. Five in-person workshops and mobile health coaching through the Nutritionist Buddy Keto app helped to facilitate dietary adherence. The primary outcome was the change in body weight at 6 months. Linear regression was performed on the change from baseline for each continuous outcome, adjusting for demographics and relevant covariates. Logistic regression was performed on binary weight loss ≥ 5%, adjusting for demographics and relevant covariates. Results: In the HKD group, participants’ adherence to the 50 g net carbohydrate target was 15 days, while that in the HKD-RTE group was 19 days over a period of 30 days. Participants’ adherence to calorie targets was 21 days in the HKD group and 23 days in the HKD-RTE. The average compliance with the HKD-RTE meals provided in the HKD-RTE group was 55%. The HKD-RTE group experienced a greater percentage weight loss at 1 month (−4.8 ± 3.0% vs. −1.8 ± 6.2%), although this was not statistically significant. This trend continued up to 6 months, with the HKD-RTE group showing a greater percentage weight reduction (−8.6 ± 6.8% vs. −3.9 ± 8.6%; p = 0.092). At 6 months, the HKD-RTE group had a greater reduction in total cholesterol (−0.54 ± 0.76 mmol/L vs. −0.05 ± 0.56 mmol/L; p = 0.283) and LDL-C (−0.43 ± 0.67 mmol/L vs. −0.03 ± 0.52 mmol/L; p = 0.374) compared to the HKD group. Additionally, the HKD-RTE group exhibited greater reductions in systolic blood pressure (−8.3 ± 9.7 mmHg vs. −5.3 ± 11.0 mmHg), diastolic blood pressure (−7.7 ± 8.8 mmHg vs. −2.0 ± 7.0 mmHg), and HbA1c (−0.3 ± 0.5% vs. −0.1 ± 0.4%) than the HKD group (not statistically significant for any). Conclusions: Both HKD-RTE and HKD led to weight loss and improved metabolic profiles. The HKD-RTE group tended to show more favorable outcomes. Short-term HKD-RTE meal provision may enhance initial weight loss, with sustained long-term effects.