Background
Obesity is a chronic, relapsing disease influenced by environmental, lifestyle, biological, and genetic factors, affecting over 1 billion people globally. Treatment for adults typically involves multicomponent lifestyle interventions-diet, physical activity, and behavior change-for at least 6-12 months. However, adherence is often low, and in-person sessions can be time-consuming and costly. Digital therapeutics (DTx), which enhance patient engagement and support long-term outcomes, have proven effective in managing chronic and mental health conditions. DTx offer scalable, evidence-based solutions with the potential to improve obesity management.
Objective
The Digital Therapy to Promote Weight Loss in Patients With Obesity by Increasing Their Adherence to Treatment (DEMETRA) study is a prospective, multicenter, pragmatic, randomized, double-arm, single-blind, placebo-controlled trial evaluating the 6-month efficacy of an innovative, multicomponent digital intervention for obesity, which combines dietary, physical activity, and behavioral strategies in people with obesity (primary objective). Secondary objectives were assessing changes in BMI, waist circumference, blood pressure, glucose metabolism, lipid profile, adherence, and factors associated with absolute 6-month weight loss.
Methods
The trial was conducted at 2 obesity centers in Italy with 246 participants aged 18-65 years (BMI 30-45 kg/m2), randomly assigned to either the Digital Therapeutics for Obesity (DTxO) app or a placebo app. DTxO offered personalized diet plans, exercise routines, and psycho-behavioral support, while the placebo app only allowed users to log data without feedback. Both groups followed a Mediterranean-style low-calorie diet with an 800 kcal/day deficit. On average, participants used the DTxO app for 42 minutes/day and the placebo app for 35 minutes, primarily for physical activity tracking. Univariable and multivariable generalized linear models were used to assess associations with 6-month absolute weight change (primary end point) and percent weight change (secondary end point).
Results
Overall, 207 participants (84.1%) completed the 6-month visit. Both arms achieved a statistically significant absolute (DtxO: -3.2 kg, IQR -6.0 kg to -0.9 kg; placebo: -4.0 kg, IQR -6.9 kg to -0.5 kg; P<.001) and percent loss in body weight (DtxO: -3.0%, IQR -5.7% to -0.8%; placebo: -4.0%, IQR -8.5% to -0.5%; P<.001) after 6 months, without significant between-group differences (univariable generalized linear models: P=.34 and P=.17, respectively). Univariable regression analyses showed a significant association between adherence to app use and 6-month absolute weight loss (β=-.06, SE 0.02, P=.01) as well as percent weight loss (β=-.05, SE 0.01, P=.01). Adherent participants, defined as those with overall adherence at or above the 75th percentile of daily usage, included 35 individuals in the intervention group and 10 in the placebo group. In this subgroup, the estimated 6-month mean absolute weight change was -7.02 kg (95% CI -9.45 to -4.59) in the DTxO-adherent group and -3.50 kg (95% CI -7.01 to 0.01) in the placebo-adherent group (P=.02). The estimated 6-month mean percent change in weight was -6.31% (95% CI -8.86 to -3.76) in the DTxO-adherent group and -2.78% (95% CI -6.48 to 0.92) in the placebo-adherent group (P=.03). A significantly greater weight loss (P=.01 for study arm, either on absolute or percent change in weight from baseline) among adherent participants randomized to the DTxO app was also confirmed by analyses using mixed linear models for repeated measures.
Conclusions
Although overall weight loss did not differ significantly between the DTxO and placebo groups, participants who used the DTxO app for at least 40% of the expected time achieved significantly greater weight loss. These results suggest that higher engagement with DTx can improve obesity outcomes. Further research should explore combining DTxO with pharmacological treatments or bariatric surgery.
Trial Registration
ClinicalTrials.gov NCT05394779; https://clinicaltrials.gov/ct2/show/NCT05394779. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.3389/fdgth.2023.1159744.