By Susan Gallagher
Dori Steinberg, a registered dietitian with a PhD in public health nutrition, knows what it takes to help people maintain their weight, lose weight or just make healthier food choices. She also knows that the “gold standard” approach—an individualized program with coaching and monitoring—is often out of reach for people in low-resource communities who are most at risk for obesity and related health problems.
Steinberg, an associate professor of nursing and global health, learned early on in her research career that digital health and mobile health (mHealth) tools can help increase access to these kinds of programs. Under the mentorship of Gary Bennett, the founding director of the Duke Global Digital Health Science Center at the Duke Global Health Institute, she’s been working to translate best practices from conventional healthcare settings to digital and mobile platforms.
“Changing behaviors around eating is very difficult, even more so for people who have limited resources to access healthy food,” says Steinberg, the associate director of the Duke Global Digital Health Science Center. “I’m interested in how we can develop digital tools to emulate an individualized treatment model in a way that’s scalable and accessible to many more people.”
Steinberg’s research at the Center focuses not just on weight management, but also on helping people manage chronic obesity-related diseases such as diabetes and hypertension. And next month, she’ll step up her leadership responsibilities when she replaces Bennett—now the vice provost for undergraduate education at Duke’s Trinity College—as the Center director.
We recently talked with Steinberg to learn more about the Center, the potential of digital health and mHealth technologies, and where she sees the digital health field going in the future. Here are some excerpts from our conversation.
DGHI: Tell us about the Duke Global Digital Health Science Center.
Steinberg: The Center’s mission is to conduct research on digital health technologies, to develop a better understanding of what kinds of programs work and why, and to explore potential policy implications of how we leverage mobile technologies or digital technologies, particularly to improve behavior change among more socioeconomically disadvantaged populations. Reducing health disparities in North Carolina is a core part of our mission.
We focus primarily on obesity prevention and obesity-related diseases like hypertension and diabetes. We’re trying to figure out how to best use technologies that people have in their pocket to improve the health of those who are disproportionately affected by these diseases.
Many of the people we work with have limited or no access to health clinics that offer a “gold standard” of care in person. We’re trying to use digital health tools to deliver something that's comparable to that standard, but still accessible, where people can be coached and monitored remotely using bots and other technology. Our goal is to help people feel connected and accountable, which can lead to positive effects beyond just losing weight or exercising more.
Another part of our mission is to collaborate with others at Duke and outside of Duke to help them advance their research programs—for example, they might be exploring a research question that we’re also interested in, or they may want to leverage one of our digital health tools. Our team can share our expertise in areas like software engineering or the science of digital health.
DGHI: What are the unique advantages of digital health, compared to more conventional healthcare models, for people in low-resource settings?
Steinberg: First and foremost, digital health technologies allow us to reach people in remote areas that otherwise we wouldn’t be able to reach—people who face major barriers to visiting a clinic in person, whether those barriers are geographic, financial or logistical.
Traditional obesity programs rely on people having a face-to-face encounter with a provider to receive coaching, engaging in highly cognitive, high-literacy activities like monitoring everything you do, recording what you’re eating and tracking every minute of physical activity. With digital health tools, we can communicate with them from afar, monitor their progress through data that’s sent to us remotely and provide them with a highly effective program to help them address their health issues.
Many of these tools are very affordable, and they take advantage of something they’re already using in their everyday lives: their phones. We’re not saying, “Go and purchase something new.” We’re saying, “Here’s something you’re already using; now let’s help you use it for your health.”
It’s a common misconception that poor people don’t have access to these technologies. They do. In fact, more of them are dependent on cell phones than people who have more resources. For example, if they don’t have broadband in their house, they use their smartphone to access the internet.
We’ve also found that people who are socioeconomically disadvantaged will use mobile tools and will use them for a long time. We get a really high level of engagement in our programs from people who are experiencing huge barriers to health and health care. We’ve been very thoughtful about using digital technologies effectively for individuals with lower literacy and people with limited resources and a lot of health burdens.
DGHI: How do you envision the future of digital health and the future of the Center in the next five years?
Steinberg: There’s a need to apply more data science to digital health technology, and I think we’re going to get better at it. Digital health tools offer a tremendous amount of data to the individual, and in some cases, to their provider. So how do we help them use this data best? For example, I collected some diet data from our study participants every day. I’m trying to figure out ways to summarize it and make it easy for them to understand and use. But that’s where I think the field is going: learning better methods for data science and including more data scientists in the development and implementation process.
There will always be new technology and tools, but we’re at a point where we already have a lot of amazing tools, and we don’t necessarily know how to best use the data within them or integrate them effectively into broader systems like electronic health records. I’m sure we’ll soon have a new sensor that can be implanted into your arm that can measure everything about you—but that will only lead to more data. (laughs)
As for the Center, our plan is to maintain a high level of research productivity and continue to grow our collaborations so people at Duke and beyond really understand the resources our center can offer.
A lot of people are getting into the digital health space, but our unique expertise is creating, and helping others create, digital health programs that really support behavior change. For example, one important insight from our research is that the people who engage with these technologies in the first two weeks—no matter what change they're trying to make—are the ones who do the best long term. That’s a really interesting finding across multiple studies that we need to continue to highlight, so when we create new programs, we think, “What can we do to draw people in during this critical time period?”
This is our niche, and we hope to grow this aspect of our work while creating synergy across other digital health initiatives across Duke, like the Mobile App Gateway. I’d love to see us all come together and be connected instead of working in our silos.
We’re trying to figure out how to best use technologies that people have in their pocket to improve the health of those who are disproportionately affected by these diseases.Dori Steinberg, associate professor, nursing and global health