Effects of the EatWelLog App on Enhancing Diet Management for Older Adults With Sarcopenic Obesity

Background Sarcopenic obesity (SO), characterized by reduced muscle mass alongside excess body fat, affects 9.95% of Chinese1 and 11% worldwide2, with prevalence exceeding 23% among those 75+1,2.. SO poses greater risks of osteoarthritis, cardio-metabolic diseases, institutionalization, and mortality, than sarcopenia or obesity alone3. Healthcare costs for obese individuals are triple those of individuals with normal BMI (US$16,348 vs US$5,814)4. Sarcopenia alone accounted for an estimated US$18.5 billion in 2000 (1.5% of total healthcare expenditures), with a 10% reduction in prevalence potentially saving US$1.1 billion5. SO's economic burden likely amplifies these costs, highlighting the need for targeted interventions.

Mobile health (m-Health) applications offer a convenient, personalized, and cost-effective alternative to traditional care. Features such as self-monitoring, automated feedback, and interactive messaging enhance treatment adherence, foster peer support, and overcome the barriers of in-person consultations6,7. While evidence shows apps significantly improve nutritional behaviors in chronic disease management, maintaining long-term user engagement remains a challenge8.

Currently, a critical research gap exists: no nutritional app specifically targets SO to support mandatory low-calorie, high-protein diets. The proposed EatWelLog App aims to bridge this gap. By encouraging healthy dietary habits, evaluating long-term usage data, and linking engagement patterns to health outcomes, this digital intervention has the potential to revolutionize SO management and deliver sustainable, cost-effective health outcomes.

Study Objectives \& Hypotheses Objectives: The study aims to evaluate the effects of an mHealth-based intervention using the EatWelLog App, developed by our research team, to empower people's self-management of a healthy diet and thereby improve their sarcopenic obesity status. The expected benefits include reducing body fat and improving muscle health.

Hypotheses: Compared with the control group receiving the same supervised nutrition and exercise programme without the App, the mHealth group using the App during and after the supervised programme will demonstrate sustained improvements in sarcopenic obesity status.

Study Design \& Methodology Study Design: The study will adopt a two-arm, assessor-blinded, parallel-group randomized controlled trial design.

* An m-Health group receiving an 8-week supervised nutrition and exercise programme, and training to incorporate the App for daily dietary management,
* A control group receiving the identical 8-week supervised programme without the App.

Participants:

Sample size: 212 (106 per group) community-dwelling older people with SO

Inclusion criteria:

1. Age 50+;
2. Having SO according to the Asian Working Group for Sarcopenia (AWGS)9 and the WHO's obesity criteria for Asians9:

1. Early-stage sarcopenia refers to the fulfillment both of the following criteria:
2. For participants aged 50-64: low handgrip strength < 34 kg for men and < 20 kg for women, low muscle quality as reflected by low appendicular skeletal muscle mass (ASM) /height squared < 7.6 kg/m2 for men and <5.7 kg/m2 for women. For participants aged 65 or above: handgrip strength <28kg (men) and <18 kg (women); appendicular skeletal muscle mass (ASM)/ height2 <7 kg/m2 (men) and <5.7 kg/m2 (women).
3. Obesity is indicated by BMI ≥25 kg/m2, waist circumference ≥90 cm (men) and ≥80 cm (women)9, or body fat >30%10. fulfil either one criterion to indicate the status of obesity.
3. Smartphone owners with internet access
4. Chinese (Cantonese) literacy and no significant sensory impairments

Exclusion criteria: Individuals who:

1. have diseases that impact digestion or food consumption, including severe cardiac/ pulmonary/ renal diseases, diabetes, cancer, or autoimmune disorders.
2. are on medications that affect eating habits/ digestion/ metabolism, such as weight loss drugs.
3. have alcohol use disorder as defined by the Manual of Mental Disorder (DSM-5), which may hinder dietary behaviour changes.
4. have medical implants like pacemakers that could be disrupted by the low-level electrical currents of the bioelectric impedance analysis (BIA).
5. have a Functional Ambulatory Classification (FAC)11 score of <7, indicating impaired mobility to participate in exercise training

Focus group: Thirty m-Health participants will be divided into 5-8 focus group (4-6 participants per group) for interviewed by a trained research assistant (RA) to understand their App user experiences.

Interventions:

Both groups will separately receive an 8-week supervised programme including a personalized dietary modification programme and group-based exercise. The research team's involvement will conclude after the programme for both groups. However, the m-Health group will continue using the App for daily dietary self-management during and after the programme.

The 8-week Intervention components for both the m-Health and control groups:

* Dietary modification programme: aims to improve the participants' self-efficacy in adopting our previously validated diet regimen*12,13. It includes eight personalized, one-hour, face-to-face sessions.
* *Dietary Regimen: a moderate hypocaloric diet reduces daily energy intake by 12% for steady weight loss while preserving muscle mass9. To address the reduced anabolic response in older people, a protein intake of 1.5 g/kg of body weight per day is recommended, with leucine-rich animal proteins prioritized to enhance muscle development9.
* Exercise Training: involves weekly one-hour group sessions for 8 weeks, with groups of approximately ten. The training combines resistance and aerobic exercises to increase muscle mass and strength while reducing fat in SO individuals7. Each session includes a 10-minute warm-up and cool-down period, 20 minutes of resistance training, and 20 minutes of brisk walking, supervised by an instructor for practice and feedback. Participants will receive a YouTube link and pamphlet detailing exercises to follow 30 minutes daily, five times a week, during and after the programme.

Intervention components for the m-Health group:

• The EatWelLog App: designed for older people with SO, incorporates Klasnja and Pratt's m-health development framework to facilitate health behavioural change7 by integrating BCT14 to support ongoing adherence to dietary regimens.

The control condition:

• After the 8-week programme (identical to the mHealth group but conducted separately), the control group will be encouraged to follow dietary and exercise guidelines independently, with no further formal interactions or training. To ensure they are not deprived of the App's benefits, they will receive a training session on using the App and full access to it after completing the 12-month follow up.

• Dietary Modification programme (Behavioral): • This programme aims to improve the participants' self-efficacy in adopting our previously validated diet regimen*. It includes 3 personalized, one-hour, face-to-face sessions in weeks 1, 3 and 7 conducted by a dietitian plus 5 dietary related health talks in the remaining weeks (i.e. Week 2, 4-6, 8) * Dietary Regimen: a moderate hypocaloric diet reduces daily energy intake by 12% for steady weight loss while preserving muscle mass9. To address the reduced anabolic response in older people, a protein intake of 1.5 g/kg of body weight per day is recommended, with leucine-rich animal proteins prioritized to enhance muscle development9
• Exercise Training (Behavioral): Participants will receive an 8-week exercise training during the programme. The training combines resistance and aerobic exercises to increase muscle mass and strength while reducing fat in individual with SO. Participants will receive a YouTube link and pamphlet detailing exercises to follow 30 minutes daily, five times a week, during and after the programme.
• The EatWelLog App (Behavioral): Participants in the M-health group will be instructed to use the EatWelLog App for daily diet self-management. This App supports participants with SO by providing a structured approach to managing a diet that encourages steady weight loss while maintaining muscle mass. Nutritional recommendations will be also be provided according to individuals' demographic information.

Primary outcomes

• Muscle Strength [From baseline (T0) to 8 weeks (T1), 3 months (T2), 6 months (T3), 9 months (T4), and 12 months (T5) after completing the program]: Handgrip strength (kg) will be measured by using a Takei TKK5401 digital hand dynamometer.
• Muscle Quantity [From baseline (T0) to 8 weeks (T1), 3 months (T2), 6 months (T3), 9 months (T4), and 12 months (T5) after completing the program.]: Muscle mass (kg) will be measured by using bioelectrical impedance analysis (InBody S10, Korea).
• Body Mass Index (BMI) [From baseline (T0) to 8 weeks (T1), 3 months (T2), 6 months (T3), 9 months (T4), and 12 months (T5) after completing the program.]: The weight and height will be combined to report BMI in kg/m\^2.
• Waist Circumference [From baseline (T0) to 8 weeks (T1), 3 months (T2), 6 months (T3), 9 months (T4), and 12 months (T5) after completing the program.]: Waist circumference was taken as the minimum circumference between the umbilicus and xiphoid process and measured to the nearest 0.5 cm.
• Fat Mass [From baseline (T0) to 8 weeks (T1), 3 months (T2), 6 months (T3), 9 months (T4), and 12 months (T5) after completing the program.]: Fat mass (kg) will be measured by using bioelectrical impedance analysis (S10, Korea).
• The Short Physical Performance Battery (SPPB) scale [From baseline (T0) to 8 weeks (T1), 3 months (T2), 6 months (T3), 9 months (T4), and 12 months (T5) after completing the program.]: The Short Physical Performance Battery (SPPB) scale will be used to measure physical function, which is a well-established tool for monitoring function in older people, which contains three kinds of assessments: stand for 10 seconds with feet in 3 different positions, 3-meter or 4-meter walking speed test, and time to rise from a chair for five times. The scores of SPPB range from 0 (worst performance) to 12 (best performance). The minimum and maximum values are 0 and 10 respectively. Higher scores mean a better performance.

Secondary outcomes

• Mini Nutritional Assessment (MNA) Short-form [From baseline (T0) to 8 weeks (T1), 3 months (T2), 6 months (T3), 9 months (T4), and 12 months (T5) after completing the program.]: Participants' nutritional status will be assessed through the Mini Nutritional Assessment (MNA). It is a simple and quick tool for assessing older people who are malnourished or at risk of malnutrition. The MNA Short-form contains 6 items. Questions are weighted, 2-3 points per item. Scores are categorised as 0-7 (malnourished), 8-11 (at risk of malnutrition), 12-14 (normal nutritional status). The minimum and maximum values are 0 and 14 respectively. Higher scores mean a better nutritional status.
• Health Action Process Approach (HAPA) Nutrition Self-efficacy Scale [From baseline (T0) to 8 weeks (T1), 3 months (T2), 6 months (T3), 9 months (T4), and 12 months (T5) after completing the program.]: The nutrition self-efficacy scale is one part of the Health-Specific Self-efficacy Scale. The nutritional self-efficacy scale is a 5-item scale, and each item is rated on 4-point likert scale from 1= very uncertain, 2=rather uncertain, 3=rather certain, 4=very certain. Higher score means higher self-efficacy. The minimum and maximum values are 0 and 20 respectively. Higher scores mean a higher self-efficacy.
• Dietary Quality Index-International (DQI-I) [From baseline (T0) to 8 weeks (T1), 3 months (T2), 6 months (T3), 9 months (T4), and 12 months (T5) after completing the program.]: The DQI-I will be used to estimate the dietary quality of participants. It is a well-used questionnaire without being affected by culture. The total scores range from 0 to 100, with a higher score representing better diet quality. The minimum and maximum values are 0 and 100 respectively. Higher scores mean a better diet quality.
• EuroQoL 5D-5L (EQ-5D-5L) [From baseline (T0) to 8 weeks (T1), 3 months (T2), 6 months (T3), 9 months (T4), and 12 months (T5) after completing the program.]: The EQ-5D-5L comprises five dimensions of health: mobility, self-care, usual activities, pain / discomfort, and anxiety/depression. Each of them has five severity levels: no problems, slight problems, moderate problems, severe problems, or extreme problems, and a 0-100 points visual analogue scale (EQ VAS). The ratings from the five categories can be transformed into a utility index score by utilizing the scores derived from the preference weights of the general population in Hong Kong. The utility score generally ranges from less than 0 to 1. A higher score indicates higher health utility. The EQ VAS ranges from 0 to 100, with higher scores indicate better imaginable health.
• Diet Adherence [From baseline (T0) to 8 weeks (T1), 3 months (T2), 6 months (T3), 9 months (T4), and 12 months (T5) after completing the program.]: The adherence of total caloric and other nutrient intakes will be analyzed by a software program "Food Processor®". If any participant forgets to keep the dietary record, the dietitian will employ the 3-day food recall method to check their food intake, a standard approach in nutritional studies. Participants' consultation session attendance rates will also be monitored.
• Exercise Adherence [From baseline (T0) to 8 weeks (T1), 3 months (T2), 6 months (T3), 9 months (T4), and 12 months (T5) after completing the program.]: Assessed based on attendance in the weekly exercise training sessions and self-reported adherence to the exercise regimen on an 11-point Likert scale with 0 = poorest compliance; 10 = highest compliance.
• Mobile Application Rating Scale (uMARS) [From 8 weeks (T1), 3 months (T2), 6 months (T3), 9 months (T4), and 12 months (T5) after completing the program.]: The uMARS is used to assess the app usage experience among participants in M-health group. Participants will also be invited in focus groups at the 3- and 12-month follow-ups to explore the participants' perceptions of the usefulness, ease of use, attitude toward using, and intention to use the App.
• Health service utilization [From baseline (T0) to 8 weeks (T1), 3 months (T2), 6 months (T3), 9 months (T4), and 12 months (T5) after completing the program.]: Health service utilization will be collected using a self-reported questionnaire, capturing the number, frequency, reasons, and duration of hospital stays, emergency room and clinical visits at each measurement point.

Sex: All, ages: 50 Years to any

Inclusion Criteria:

* Community-dwelling older people aged > 50 years;
* Meeting the diagnostic criteria of sarcopenia according to the Asian Sarcopenia Working Group (ASWG) which include:
* Sarcopenia refers to the fulfillment both of the following criteria: For participants aged 50-64: low handgrip strength < 34 kg for men and < 20 kg for women, low muscle quality as reflected by low appendicular skeletal muscle mass (ASM) /height squared < 7.6 kg/m2 for men and <5.7 kg/m2 for women. For participants aged 65 or above: handgrip strength <28kg (men) and <18 kg (women); appendicular skeletal muscle mass (ASM)/ height2 <7 kg/m2 (men) and <5.7 kg/m2 (women).
* Obesity refers to the fulfillment of one of the following criteria: Body Mass Index (BMI) ≥ 25kg/m2 or waist circumference ≥ 90 cm in men and ≥ 80 cm in women, or percentage of body fat > 30%.
* Able to communicate, read, and write in Chinese without significant hearing and vision problems to ensure that our instructions are understood; and • Own a smartphone, and able to access the internet at home or elsewhere.

Exclusion Criteria:

* With any form of disease or condition that might affect food intake and digestion (such as severe heart or lung diseases, renal diseases, diabetes, cancer, or autoimmune diseases);
* Taking medications that may influence eating behaviour, digestion, or metabolism (such as weight loss medication);
* With alcohol use disorder as defined by DSM-5, potentially hindering dietary behaviour changes; and
* Having any medical implant device such as a pacemaker, because low-level currents will flow through the body when doing the bioelectric impedance analysis (BIA by InBody S10, Korea), which may cause the device to malfunction.
* Have a Functional Ambulatory Classification (FAC) score of <7, indicating impaired mobility to participate in exercise training.

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• Justina Liu, PhD, Principal investigator, The Hong Kong Polytechnic University