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People of low socioeconomic position (SEP) are disproportionately affected by type 2 diabetes (T2D), partly due to unhealthy eating patterns that contribute to inadequate disease self-management and prognosis. Digital technologies have the potential to provide a suitable medium to facilitate diabetes education, support self-management, and address some of the barriers to healthy eating, such as lack of nutritional knowledge or shopping or cooking skills, in this target group.
This study aims to test the feasibility, appeal, and potential effectiveness of EatSmart, a 12-week, evidence-based, theoretically grounded, fully automated web-based and mobile-delivered healthy eating behavior change program to help disadvantaged people living with T2D to eat healthily on a budget and improve diabetes self-management.
EatSmart is a mixed methods (quantitative and qualitative) pre-post design pilot study. Sixty socioeconomically disadvantaged people with T2D aged 18 to 75 years will be recruited. Participants will complete self-reported baseline assessments of their basic demographic and clinical data, dietary intake, dietary self-efficacy, and barriers to healthy eating. They will be provided with login access to the EatSmart web program, which includes six progressive skill-based modules covering healthy eating planning; smart food budgeting and shopping; time-saving meal strategies, healthy cooking methods, modifying recipes; and a final reinforcement and summary module. Over the 3-month intervention, participants will also receive 3 text messages weekly, encouraging them to review goals, continue to engage with different components of the EatSmart web program, and eat healthily. Participants will undertake follow-up assessments directly following the intervention 3 months post baseline and again after a 6-month postintervention follow-up period (9 months post baseline). Feasibility will be evaluated using the number of participants recruited and retained and objective indicators of engagement with the website. Program appeal and potential effects on primary and secondary outcomes will be assessed via the same surveys used at baseline, with additional questions asking about experience with and perceptions of the program. In-depth qualitative interviews will also be conducted 6 months post intervention to provide deeper insight into experiences with EatSmart and a more comprehensive description of the program’s appeal.
The EatSmart website has been developed, and all participants have viewed the modules as of May 2020. Results are expected to be submitted for publication in December 2020.
This study will provide data to address the currently limited evidence regarding whether disadvantaged populations with T2D may benefit from digitally delivered behavior change programs that facilitate eating healthily on a budget.
Australian New Zealand Clinical Trials Registry, ACTRN12619001111167; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12619001111167
DERR1-10.2196/19488
Type 2 diabetes (T2D), which is defined by relative insulin deficiency resulting from pancreatic β-cell dysfunction and insulin resistance in target organs [
Individuals of low socioeconomic position (SEP), such as those with lower levels of education, working in low-status occupations, or on a low income, as well as ethnic minority groups, are disproportionately affected by T2D [
Existing initiatives to promote healthy eating among people with T2D include multicomponent face-to-face diabetes self-management classes, community health worker programs, and intensive case-management programs [
Driven by advances in web-based technologies and requests by people with T2D for easily accessible information and ongoing support, digitally delivered programs potentially offer a convenient and efficient platform to facilitate the delivery and increase the reach of the self-management support needed by disadvantaged people with T2D [
Previous reviews suggest that digital-based interventions show promise in increasing knowledge and improving diabetes self-management activities, including medication adherence, engagement in physical activity, and healthy eating behaviors in individuals living with T2D [
While digital interventions continue to be developed and researched, their potential for improving diabetes self-management among people of low SEP remains poorly investigated [
Although these limited studies show promising results in improving dietary behaviors, they were all heterogeneous in scope. For example, they either concentrated on single nutrition-related health outcomes (eg, weight loss or glycemic control), or combined multiple health behaviors (eg, diet, medication adherence, and physical activity), and utilized different modes of intervention delivery (eg, website, text messages). Therefore, study findings are difficult to integrate and interpret, and there is a need for further research into how disadvantaged populations with diabetes may benefit from digital approaches and whether these programs are feasible, appealing, and can produce long-term and sustainable effects. The EatSmart program was developed to address this gap by designing and evaluating a theoretically grounded, evidence-based web- and phone-delivered healthy eating behavior support program to enable disadvantaged people with T2D to strengthen important skills necessary to eat healthily at low cost.
This project is important as it involves a simple and practical approach tailored to the needs of the many people with T2D who struggle to eat healthily in the context of socioeconomic disadvantage. The program may augment existing clinical management by integrating with people’s daily self-management practices of T2D. It also has the potential to reach larger numbers of people with T2D, regardless of geographic location. Moreover, it is designed to be sustainable without intensive ongoing clinical involvement. EatSmart addresses the critical issues of inequities in diabetes-related self-management and associated morbidity.
We hypothesize that delivery of the 12-week EatSmart program is feasible, appealing to participants, and effective in improving healthy eating behaviors and related attitudes. Specifically, we hypothesize that EatSmart will lead to high program satisfaction and engagement and improvements in self-reported intakes of vegetables, fruits, and foods aligned with dietary recommendations. It will also reduce self-reported intakes of discretionary noncore foods, increase self-efficacy, and reduce barriers to selecting and preparing a balanced healthy diet.
Ethics approval has been granted by Deakin University’s Human Research Committee and the Western Health Low-Risk Ethics Panel, approval number 49763; version 4, dated 15 March 2019. All participants will be provided with an information sheet explaining the project aim and will be requested to sign a written informed consent form before participating (
EatSmart is a mixed methods (quantitative and qualitative) pre-post design pilot study, which is appropriate for evaluating the feasibility, appeal, and potential effectiveness of a novel intervention. Pilot studies are crucial for examining the acceptability of new interventions and improving their delivery to support the future success of more intensive and larger randomized controlled trials [
EatSmart focuses on people with T2D who attend diabetes clinics in Melbourne’s western suburbs, which, according to the Australian Bureau of Statistics Socioeconomic Index for Areas index of relative advantaged/disadvantaged, comprises a relatively disadvantaged area.
A sample of N=60 (conservatively assuming up to 33% drop-out) has been selected for this pilot study. As this is a pilot study, no formal power calculation was conducted, and this sample size was determined pragmatically to provide adequate data on potential effects on key outcomes, sample variability, recruitment rates, and retention. This number is also adequate for generating rich qualitative and contextual data on intervention engagement, feasibility, and appeal to inform future larger studies.
Sixty people with T2D will be recruited from two outpatient diabetes clinics located at Sunshine Hospital in Melbourne, Australia. Participant recruitment strategies involve (1) distribution of program flyers at diabetes clinics’ waiting rooms and to diabetes nurses and specialist offices in Sunshine Hospital; (2) in-person presentations by diabetes educators or researchers at hospital meetings and diabetes-related events; and (3) face to face recruitment of eligible individuals in diabetes clinic waiting rooms by EatSmart researchers.
For postintervention interviews, patients with T2D who participated in EatSmart and completed the 3-month intervention will be invited by telephone, text message, or email to complete a semistructured interview of up to 40 minutes via telephone or Zoom. Recruitment will be successive until no new themes appear (thematic saturation). Up to ten health care providers from Sunshine Hospital diabetes clinics will also be invited by email to take part in a confidential semistructured telephone or Zoom interview of up to 30 minutes.
Adults aged 18 to 75 years with a diagnosis of T2D, regardless of duration. Participants will be required to own and use a mobile phone, be familiar with receiving and reading text messages, and have mobile data allowance to access the internet or a mobile device (phone/tablet) or computer with internet access. Participants will be socioeconomically disadvantaged, as determined by receiving either a Health Care Card or a pension/benefit as the main source of income, or a stated income up to the cut-off levels used to assess eligibility for the Health Care Card. Annual income thresholds for receipt of a Health Care Card in Australia (as of January 2019) are equal to AU $29,172 (US $20,645) for single adults without children, AU $50,388 (US $35,660) for couples, AU $52,156 (US $36,910) for couples with one child and AU $1768 (US $1251) for each extra dependent child. Due to this study’s focus on people from a lower SEP, assessing eligibility can be a sensitive issue. To be respectful when enquiring as to whether or not an individual receives a Health Care Card or low income (ie, is of a low SEP background), a written document with all relevant questions relating to eligibility will be handed to potential participants. This document allows them to check the questions silently in advance, and if they confirm their willingness to answer, the researcher will approach them to complete the recruitment process.
Participants will be excluded if they cannot read or speak English; cannot use mobile text messaging or internet; are pregnant or breastfeeding; are visually or hearing-impaired; have an eating disorder; have compounding comorbidities (like clinical depression), as diabetes management is typically more complex in these cases; are planning to have surgery; or are planning to travel for an extended time in the next nine months.
EatSmart is a 12-week evidence-based, theoretically grounded, fully automated healthy eating behavior support program delivered via a website (mobile phone compatible) and text messaging. It is a standalone program that could augment standard diabetes management, which typically involves routine visits and consultation with an endocrinologist and diabetes educator, and sometimes a dietitian (depending on clinical circumstances). If demonstrated to be successful, the EatSmart program could become embedded in clinical practice and promoted by clinical staff as an adjunct treatment option.
The intervention development was informed by Social Cognitive Theory [
EatSmart draws on empirical evidence of the key determinants of eating behaviors in people of low SEP, including previous studies suggesting the importance of addressing perceived cost barriers, food planning, budgeting, preparation skills, and nutrition knowledge [
Intervention mapping was conducted [
The research team has developed a set of modules, all of which focus on the specific needs of people of low SEP, particularly affordability and nutrition-related skills. The materials target the proposed theoretical mediators of nutrition self-efficacy, perceived affordability, and other perceived barriers to vegetable and fruit consumption. The intervention components share similarities with those used in the ShopSmart study [
The skill-based modules of the EatSmart website address the following topics:
Importance of vegetables, fruits, and whole foods for health
Strategies to buy healthy foods on a budget (highlighting the range of low-cost vegetables and fruits available and their uses, and also the value of more affordable options such as tinned and frozen vegetables and fruits)
Planning for smart shopping and how to choose healthy foods, with supermarket shopping tours and advice on label reading
Trying and incorporating new vegetables, fruits, and whole foods
Building cooking confidence and skills by including recipes of healthy and inexpensive meals from various countries and cultures featuring vegetables and fruits; meal planning; simple and convenient meal and snack ideas; and how to modify recipes to be healthier
Storing, preparing, and cooking fresh produce, reducing food waste, and “eating out Smart.”
The website also offers a range of practical activities, including calculating current and ideal spending on different food groups, videos (eg, virtual shopping tours), and links to other resources (eg, government or not-for-profit health information websites).
EatSmart involves delivering key behavior change techniques, including setting goals for purchasing and consuming key food groups, self-monitoring consumption, engaging social support from family and friends, and problem-solving key barriers to healthy eating. A behavior change taxonomy was used to describe the active ingredients of the intervention [
As part of EatSmart, participants receive three unidirectional text messages/week (36 in total), at a time they indicate is convenient, to encourage them to maintain healthy eating, review their goals, and continue to engage with different components of the website (
After consenting to the study, participants complete baseline assessments immediately in person or at a more convenient time by telephone or through a secure weblink. The baseline evaluation requests information on basic demographic and clinical data, dietary intake, dietary self-efficacy, and barriers to healthy eating. Upon completing baseline assessments, participants are shown how to log on to the website using their username and password. Once logged in, participants can access the six intervention modules offered to them consecutively on a biweekly basis. Each module can be completed in around 15 minutes, but no recommendation or limitation regarding timing and usage will be given. Therefore, they can read the materials and engage with the website in a suitable and convenient timeframe.
Following intervention completion at three months, participants undertake the same baseline evaluation (except for demographic details). During the 6-month follow-up period (3 to 9 months post baseline), participants will have free access to all website materials; however, they will not receive text messages. After the 3-month data collection period, all participants who complete the postintervention assessments (regardless of their level of engagement) will receive an AU $50 (US $35) shopping voucher as compensation for their time. Those who complete the online follow-up survey will receive an AU $20 (US $14) shopping voucher, and those who agree to be interviewed will receive an extra AU $20 (US $14) shopping voucher.
Summary of intervention components, targeted determinants, and behavior change techniques.
Intervention component | Primary message/resources |
Targeted determinant | Behavior change techniques |
Module 1 |
Importance of a balanced diet for health in diabetes Addressing cost and time barriers to healthy eating Resources for setting healthy eating goals |
Knowledge Health values Perceived affordability Perceived barriers: time |
Action planning Discrepancy between current behavior and goal Goal setting on core food group intake (behaviors) Information about health consequences Information about social consequences (cost) Instructions on how to perform behaviours Problem-solving Self-incentives Self-monitoring behaviour Self-rewards for goals |
Module 2 |
Planning for healthy eating on a budget |
Knowledge and skills (budgeting, planning) Self-efficacy Perceived affordability |
Action planning Demonstration of the behavior Discrepancy between current behavior and goal Information about social consequences (cost) Instructions on how to perform behaviors Problem-solving Reviewing behavior goals Self-incentives Self-monitoring behavior Self-rewards Social rewards for goals |
Module 3 |
Planning and shopping smart Label reading Affordability: focus on tinned/frozen options (eg, fruit, vegetables, fish, legumes) Saving money and time Food safety (to reduce waste) |
Knowledge and skills Perceived affordability Self-efficacy Perceived barriers: social (family preferences), time |
Action planning Conserving mental resources (wallet label reading cards) Demonstration of the behavior Discrepancy between current behavior and goal Goal setting (behaviors) Identification of self as a role model Information about health consequences Information about social consequences (cost) Instructions on how to perform behaviors Practical social support Prompts/cues Self-incentive Self-reward Social reward for goals |
Module 4 |
Confidence in the kitchen Storing and cooking fruit and vegetables Reducing waste Cooking confidence and skills Recipe modification Healthy entertaining |
Knowledge and skills Self-efficacy Perceived affordability |
Action planning Behavior substitution (recipes, takeaway food) Demonstration of the behavior Discrepancy between current behavior and goal Goal setting (behaviors) Information about social consequences (cost) Instruction on how to perform behaviors Practical social support Problem-solving Reviewing behavior goals Self-incentive Self-reward Social reward for goals |
Module 5 |
Eating out Trying new fruits & vegetables |
Skills Self-efficacy Perceived affordability Perceived barriers: taste |
Action planning Behavior substitution (eating out) Demonstration of the behavior Discrepancy between current behavior and goal Goal setting (behaviors) Instruction on how to perform behaviors Problem-solving Self-incentive Self-reward Social reward for goals |
Module 6 |
Message reinforcement |
Knowledge Skills Self-efficacy Perceived affordability |
Conserving mental resources Discrepancy between current behavior and goal Instruction on how to perform behaviors Problem-solving Reviewing behavior goals Self-monitoring behavior |
The website structure has specific design characteristics to address barriers to electronic literacy (e-literacy) [
Screenshots of EatSmart website.
Screenshots of different parts of modules.
The site’s navigation, overall look, and feel are consistent across all pages by using the same color schemes, typefaces, backgrounds, and tone of the text messages. All six modules comprise four parts. The first part includes healthy eating and nutritional information, followed by goals, quizzes, and resources, which are color-coded to distinguish them from other features. This approach was adopted to enhance the usability of the website [
During website development (before the main project begins), the first four modules were pilot tested with 12 people approached in diabetes clinics at Sunshine Hospital who fell into the project demographic. These participants were asked to complete, with the researchers, a brief survey asking questions about how appealing and understandable they found the website and its modules. No identifying data were collected, although the researchers noted the sex and approximate age of participants in case these factors influenced their views on the modules and/or website design and content. Based on this pilot test, specific suggestions from the participants about content and design of the website (for example, introducing more budget-saving strategies, the inclusion of more simple ethnic recipes, more colorful pictures and visual messages, bigger font size, and easier browsing) have been incorporated to improve interest, readability, tone, and layout in the final development of the intervention for end users.
This study’s primary outcome is pre-post intervention (baseline versus 3 months) changes in the consumption of vegetables and fruits.
Secondary outcomes are:
Six-month follow-up changes in consumption of vegetables and fruits (baseline versus 9-month),
Pre-post intervention and 6-month follow-up changes in other dietary indicators aligned with dietary guidelines (wholemeal/whole grain bread, milk, water, and some discretionary items),
Pre-post intervention and 6-month follow-up changes in dietary self-efficacy (including perceived skills and confidence),
Pre-post intervention and 6-month follow-up changes in perceived barriers to healthy eating (including budget/perceived unaffordability, family preferences, taste, and skills),
Feasibility and engagement,
Appeal, satisfaction, usability, and longer term acceptability of the program.
Study measures across time points are presented in
Feasibility and engagement will be evaluated by the number of participants recruited/retained, numbers accessing the website, logins and duration of website use, pages engaged with, and numbers receiving/reading the text messages [
Participants will complete all self-report surveys, either web-based or telephone-assisted, at baseline and again at 3 and 9 months. The data capture and management tool REDCap (Research Electronic Data Capture) [
Data on program appeal, usability, and participant satisfaction will be supplemented by semistructured interviews at 6 months post intervention to explore longer term maintenance of any behavioral or attitudinal changes.
At 9 months post baseline, participants will be invited by telephone, text message, or email to complete a one-on-one semistructured interview of up to 40 minutes via telephone. Recruitment for interviews will be successive until no new themes appear (thematic saturation). However, based on other qualitative reports in the same area [
These interviews will add to the program feedback from the surveys and create a base for understanding the characteristics of patients for whom these healthy changes occur and last. These data will provide us with insight into contextual factors that promote engagement.
At the end of the intervention, we will also conduct one-on-one interviews with up to ten health care providers involved with diabetes care (including endocrinologists, diabetes nurses, and diabetes nurse educators) at Western Health diabetes clinics. These interviews aim to understand providers’ views about successful or unsuccessful elements of EatSmart as a technology-delivered intervention, concerns or barriers regarding using these kinds of interventions, and feedback from their interactions with patients about the intervention’s content, impact, or observed benefits. The providers will be invited by email or face-to-face invitations to participate in a confidential semistructured interview of up to 30 min length. Interviews will be conducted at the health care practice or via telephone, as convenient for the provider. The interviews will begin by reviewing the website’s modules and text messages to guide the discussion. An open-ended discussion guide, audio recording, and note-taking of every session will be used to capture data. These data will complement the participant interviews to refine and develop the program for future studies.
Statistical analyses of quantitative and qualitative data will be conducted using Stata version 16 [
Participants’ baseline and sociodemographic characteristics will be summarized using descriptive statistics. To understand the potential limitations of this intervention’s generalizability, characteristics of participants who prematurely exit the program will be compared with those who complete the program [
Furthermore, a thematic analysis will be employed for open-ended surveys to identify key program likes and dislikes. For qualitative measures from interviews, audiotapes of the interviews will be transcribed verbatim and de-identified. Transcripts will be imported to NVivo software to enable coding of the interview data and expedite the organization of codes into themes and subthemes. Two researchers will do line-by-line coding on three initial transcripts and then meet to discuss the development of preliminary conceptual themes and subthemes. These initial conceptual themes will then be applied to subsequent transcripts. Open discussions within the research team will resolve discrepancies in data interpretation. The coding process will continue until saturation, such that no further codes or categories can be found in the data. Thematic analysis will be used to describe why and among whom the program works best [
The EatSmart website has been developed, tailored to the needs of people of lower SEP with T2D, and all the modules viewed by participants. Recruitment began in October 2019 and finished in February 2020. Data collection will continue through October 2020. Data analysis and cleaning will be conducted after data collection is complete. We anticipate reporting results in December 2020 by submitting professional publications in peer-reviewed journals and conference presentations.
As with many chronic diseases, a disproportionately high burden of diabetes and its associated complications is shouldered by those who are socioeconomically disadvantaged. This target group is often neglected in research trials as they are generally considered too hard to reach and impact [
Several approaches have been employed to increase the efficacy of EatSmart. Firstly, in all stages of the website’s design, development, and content, the end users’ particular needs and perspectives have been evaluated and considered. Secondly, a behavioral support reminder system in the form of regular text messages helps promote continued engagement and address the problem of high attrition rates, a problem common to eHealth studies [
EatSmart targets nutritional knowledge gaps and misinformation, promotes positive mindsets toward healthy eating (ie, self-efficacy), and facilitates changes in eating behaviors to increase self-efficacy and behavior change. Active learning, guided practice, reinforcement, and modeling are key features of Social Cognitive Theory contained within EatSmart. Some of the strategies incorporated into the design of EatSmart included goal setting and problem solving for building self-management skills, providing hands-on skill-building activities (eg, cooking activities utilizing healthy ingredients and cooking methods), and direct instruction and modeling by the intervention nutritionist (in videos). Modeling is an important influence, providing individuals with skills and strategies to adopt and maintain behaviors in different situations. The video components of the EatSmart website incorporate modeling, with actors (research team members) providing support in real-world environments such as the supermarket and the kitchen at home. The intervention also draws on empirical evidence of the key determinants of eating behaviors, including our past work suggesting the significance of addressing nutrition knowledge, food planning and budgeting and preparation skills, perceived and actual food costs, and other barriers [
The results of this pilot study will be interpreted with consideration of the following limitations. The study relies on self-reported measures, which may be subject to recall and social desirability bias. The lack of a control group is another limitation, although this is an appropriate design for a pilot study in a relatively new area, with feasibility and exploratory focus. Furthermore, while clinicians and 12 randomly selected patients with T2D were involved in reviewing and providing input to a draft website, there could have been greater involvement from these groups throughout the development of the intervention. However, as it is a pilot study, the feedback survey and interviews will be used to further inform the development of future interventions. Finally, EatSmart is currently only presented in English, which is essential to evaluate the feasibility of this initial pilot trial. Translation to other languages can be a future priority to reach other underserved communities at higher risk of health disparities.
The EatSmart intervention study results will make a valuable contribution to the evidence base on diabetes self-management in a high-risk population. This project will inform scalable public health programs to promote healthy eating and diabetes self-management as an inexpensive adjunct to clinical care among vulnerable populations and contribute new knowledge to digitally delivered health research in Australia and internationally.
Participant Information and Consent Form.
Participant Information and Consent Form (Follow up interview).
HCP Information and Consent Form.
Text messages provided in the EatSmart program.
Study measures and assessment tools across time points.
socioeconomic position
type 2 diabetes
We are grateful to Diabetes Australia for the Diabetes Australia Research Program grant to support this work and the Institute for Physical Activity and Nutrition (IPAN) at Deakin University. Each named author has contributed to conducting the underlying research and drafting this manuscript.
None declared.