Trustworthy AI in Digital Health: A Comprehensive Review of Robustness and Explainability

Ensuring trust in AI systems is essential for the safe and ethical integration of machine learning systems into high-stakes domains such as digital health. Key dimensions, including robustness, explainability, fairness, accountability, and privacy, need to be addressed throughout the AI lifecycle, from problem formulation and data collection to model deployment and human interaction. While various contributions address different aspects of trustworthy AI, a focused synthesis on robustness and explainability, especially tailored to the healthcare context, remains limited. This review addresses that need by organizing recent advancements into an accessible framework, highlighting both technical and practical considerations. We present a structured overview of methods, challenges, and solutions, aiming to support researchers and practitioners in developing reliable and explainable AI solutions for digital health. This review article is organized into three main parts. First, we introduce the pillars of trustworthy AI and discuss the technical and ethical challenges, particularly in the context of digital health. Second, we explore application-specific trust considerations across domains such as intensive care, neonatal health, and metabolic health, highlighting how robustness and explainability support trust. Lastly, we present recent advancements in techniques aimed at improving robustness under data scarcity and distributional shifts, as well as explainable AI methods ranging from feature attribution to gradient-based interpretations and counterfactual explanations. This paper is further enriched with detailed discussions of the contributions toward robustness and explainability in digital health, the development of trustworthy AI systems in the era of LLMs, and various evaluation metrics for measuring trust and related parameters such as validity, fidelity, and diversity.

Latent-LoRA: Compact Latent-Space Adapters with Gradient-Free Routing for Continual Learning

Large language models generalize well to individual tasks but lack an inherent mechanism for learning them sequentially, leading to catastrophic forgetting. To mitigate this, LoRA-based continual learning methods allocate a separate low-rank adapter per task, yet existing approaches either require task identity at inference or sum all adapters indiscriminately, letting irrelevant branches distort the output. Recent gating-based solutions route inputs to the correct adapter but introduce trainable parameters that themselves need protection against forgetting. In this work, we observe that pooled token embeddings from a frozen LLM embedding layer already separate task distributions throughout the learning sequence. A Gaussian mixture model fitted on these embeddings, without any gradient-based training, is sufficient for task-agnostic adapter selection at test time. This eliminates the need for a learned gating module. On the adapter side, constraining each task's parameters to the principal subspace of the pretrained weights via SVD yields a compact latent-space parameterization. Within this subspace, orthogonal regularization directly controls inter-task interference. The resulting system, Latent-LoRA, is replay-free, requires no trainable routing component, and uses substantially fewer parameters per task. Experiments across five model scales and two established continual learning benchmarks show state-of-the-art performance with near-zero forgetting.

MetaPlate: Counterfactual-Guided RAG-LLM Tool for Personalized Food Recommendation and Hyperglycemia Prevention

Postprandial hyperglycemia is a key risk factor for metabolic disorders; however, existing dietary guidance is often static, impractical, and insufficiently personalized, providing recommendations that are difficult to follow or not impactful. While recent advances leverage continuous glucose monitoring (CGM) and machine learning to predict glycemic responses, these approaches are largely predictive and lack actionable guidance. Moreover, recommendation systems are often misaligned with user goals and require extensive input. We present MetaPlate, a counterfactual explanation (CF) guided, context-aware decision-support framework that generates personalized meal recommendations to mitigate postprandial glucose excursions in healthy adults. MetaPlate integrates multimodal data, including CGM readings, wearable-derived physiological signals, and user-provided meal inputs from $25$ individuals to model pre-meal context. A machine learning model predicts glucose response, while a CF optimization module adjusts meal composition modifying macronutrient amounts to maintain glucose levels within a target range ($\leq 140$ mg/dL). An LLM-based retrieval-augmented generation (RAG) layer enhances interpretability by producing human-readable recommendations using constrained search of the USDA food database. We evaluate MetaPlate via a structured expert-in-the-loop assessment with registered dietitians (RDs), comparing performance before and after prompt refinement. Results show improvements in meal realism, portion suitability, and recommendation likelihood, with expert feedback indicating a shift from clinically implausible outputs to actionable, contextually appropriate recommendations. Our findings emphasize the importance of domain knowledge and structured constraints in LLM-driven systems and highlight the potential of MetaPlate as a real-time personalized dietary decision-support tool.

GUIDE: Reinforcement Learning for Behavioral Action Support in Type 1 Diabetes

Type 1 Diabetes (T1D) management requires continuous adjustment of insulin and lifestyle behaviors to maintain blood glucose within a safe target range. Although automated insulin delivery (AID) systems have improved glycemic outcomes, many patients still fail to achieve recommended clinical targets, warranting new approaches to improve glucose control in patients with T1D. While reinforcement learning (RL) has been utilized as a promising approach, current RL-based methods focus primarily on insulin-only treatment and do not provide behavioral recommendations for glucose control. To address this gap, we propose GUIDE, an RL-based decision-support framework designed to complement AID technologies by providing behavioral recommendations to prevent abnormal glucose events. GUIDE generates structured actions defined by intervention type, magnitude, and timing, including bolus insulin administration and carbohydrate intake events. GUIDE integrates a patient-specific glucose level predictor trained on real-world continuous glucose monitoring data and supports both offline and online RL algorithms within a unified environment. We evaluate both off-policy and on-policy methods across 25 individuals with T1D using standardized glycemic metrics. Among the evaluated approaches, the CQL-BC algorithm demonstrates the highest average time-in-range, reaching 85.49% while maintaining low hypoglycemia exposures. Behavioral similarity analysis further indicates that the learned CQL-BC policy preserves key structural characteristics of patient action patterns, achieving a mean cosine similarity of 0.87 $\pm$ 0.09 across subjects. These findings suggest that conservative offline RL with a structured behavioral action space can provide clinically meaningful and behaviorally plausible decision support for personalized diabetes management.

Gated Adaptation for Continual Learning in Human Activity Recognition

Wearable sensors in Internet of Things (IoT) ecosystems increasingly support applications such as remote health monitoring, elderly care, and smart home automation, all of which rely on robust human activity recognition (HAR). Continual learning systems must balance plasticity (learning new tasks) with stability (retaining prior knowledge), yet AI models often exhibit catastrophic forgetting, where learning new tasks degrades performance on earlier ones. This challenge is especially acute in domain-incremental HAR, where on-device models must adapt to new subjects with distinct movement patterns while maintaining accuracy on prior subjects without transmitting sensitive data to the cloud. We propose a parameter-efficient continual learning framework based on channel-wise gated modulation of frozen pretrained representations. Our key insight is that adaptation should operate through feature selection rather than feature generation: by restricting learned transformations to diagonal scaling of existing features, we preserve the geometry of pretrained representations while enabling subject-specific modulation. We provide a theoretical analysis showing that gating implements a bounded diagonal operator that limits representational drift compared to unconstrained linear transformations. Empirically, freezing the backbone substantially reduces forgetting, and lightweight gates restore lost adaptation capacity, achieving stability and plasticity simultaneously. On PAMAP2 with 8 sequential subjects, our approach reduces forgetting from 39.7% to 16.2% and improves final accuracy from 56.7% to 77.7%, while training less than 2% of parameters. Our method matches or exceeds standard continual learning baselines without replay buffers or task-specific regularization, confirming that structured diagonal operators are effective and efficient under distribution shift.

Counterfactual Modeling with Fine-Tuned LLMs for Health Intervention Design and Sensor Data Augmentation

Counterfactual explanations (CFEs) provide human-centric interpretability by identifying the minimal, actionable changes required to alter a machine learning model's prediction. Therefore, CFs can be used as (i) interventions for abnormality prevention and (ii) augmented data for training robust models. We conduct a comprehensive evaluation of CF generation using large language models (LLMs), including GPT-4 (zero-shot and few-shot) and two open-source models-BioMistral-7B and LLaMA-3.1-8B, in both pretrained and fine-tuned configurations. Using the multimodal AI-READI clinical dataset, we assess CFs across three dimensions: intervention quality, feature diversity, and augmentation effectiveness. Fine-tuned LLMs, particularly LLaMA-3.1-8B, produce CFs with high plausibility (up to 99%), strong validity (up to 0.99), and realistic, behaviorally modifiable feature adjustments. When used for data augmentation under controlled label-scarcity settings, LLM-generated CFs substantially restore classifier performance, yielding an average 20% F1 recovery across three scarcity scenarios. Compared with optimization-based baselines such as DiCE, CFNOW, and NICE, LLMs offer a flexible, model-agnostic approach that generates more clinically actionable and semantically coherent counterfactuals. Overall, this work demonstrates the promise of LLM-driven counterfactuals for both interpretable intervention design and data-efficient model training in sensor-based digital health. Impact: SenseCF fine-tunes an LLM to generate valid, representative counterfactual explanations and supplement minority class in an imbalanced dataset for improving model training and boosting model robustness and predictive performance

Guiding Diffusion with Deep Geometric Moments: Balancing Fidelity and Variation

Text-to-image generation models have achieved remarkable capabilities in synthesizing images, but often struggle to provide fine-grained control over the output. Existing guidance approaches, such as segmentation maps and depth maps, introduce spatial rigidity that restricts the inherent diversity of diffusion models. In this work, we introduce Deep Geometric Moments (DGM) as a novel form of guidance that encapsulates the subject's visual features and nuances through a learned geometric prior. DGMs focus specifically on the subject itself compared to DINO or CLIP features, which suffer from overemphasis on global image features or semantics. Unlike ResNets, which are sensitive to pixel-wise perturbations, DGMs rely on robust geometric moments. Our experiments demonstrate that DGM effectively balance control and diversity in diffusion-based image generation, allowing a flexible control mechanism for steering the diffusion process.

GlyTwin: Digital Twin for Glucose Control in Type 1 Diabetes Through Optimal Behavioral Modifications Using Patient-Centric Counterfactuals

Frequent and long-term exposure to hyperglycemia (i.e., high blood glucose) increases the risk of chronic complications such as neuropathy, nephropathy, and cardiovascular disease. Current technologies like continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM) primarily model specific aspects of glycemic control-like hypoglycemia prediction or insulin delivery. Similarly, most digital twin approaches in diabetes management simulate only physiological processes. These systems lack the ability to offer alternative treatment scenarios that support proactive behavioral interventions. To address this, we propose GlyTwin, a novel digital twin framework that uses counterfactual explanations to simulate optimal treatments for glucose regulation. Our approach helps patients and caregivers modify behaviors like carbohydrate intake and insulin dosing to avoid abnormal glucose events. GlyTwin generates behavioral treatment suggestions that proactively prevent hyperglycemia by recommending small adjustments to daily choices, reducing both frequency and duration of these events. Additionally, it incorporates stakeholder preferences into the intervention design, making recommendations patient-centric and tailored. We evaluate GlyTwin on AZT1D, a newly constructed dataset with longitudinal data from 21 type 1 diabetes (T1D) patients on automated insulin delivery systems over 26 days. Results show GlyTwin outperforms state-of-the-art counterfactual methods, generating 76.6% valid and 86% effective interventions. These findings demonstrate the promise of counterfactual-driven digital twins in delivering personalized healthcare.

Enhancing Metabolic Syndrome Prediction with Hybrid Data Balancing and Counterfactuals

Metabolic Syndrome (MetS) is a cluster of interrelated risk factors that significantly increases the risk of cardiovascular diseases and type 2 diabetes. Despite its global prevalence, accurate prediction of MetS remains challenging due to issues such as class imbalance, data scarcity, and methodological inconsistencies in existing studies. In this paper, we address these challenges by systematically evaluating and optimizing machine learning (ML) models for MetS prediction, leveraging advanced data balancing techniques and counterfactual analysis. Multiple ML models, including XGBoost, Random Forest, TabNet, etc., were trained and compared under various data balancing techniques such as random oversampling (ROS), SMOTE, ADASYN, and CTGAN. Additionally, we introduce MetaBoost, a novel hybrid framework that integrates SMOTE, ADASYN, and CTGAN, optimizing synthetic data generation through weighted averaging and iterative weight tuning to enhance the model's performance (achieving a 1.14% accuracy improvement over individual balancing techniques). A comprehensive counterfactual analysis is conducted to quantify feature-level changes required to shift individuals from high-risk to low-risk categories. The results indicate that blood glucose (50.3%) and triglycerides (46.7%) were the most frequently modified features, highlighting their clinical significance in MetS risk reduction. Additionally, probabilistic analysis shows elevated blood glucose (85.5% likelihood) and triglycerides (74.9% posterior probability) as the strongest predictors. This study not only advances the methodological rigor of MetS prediction but also provides actionable insights for clinicians and researchers, highlighting the potential of ML in mitigating the public health burden of metabolic syndrome.

AIMI: Leveraging Future Knowledge and Personalization in Sparse Event Forecasting for Treatment Adherence

Adherence to prescribed treatments is crucial for individuals with chronic conditions to avoid costly or adverse health outcomes. For certain patient groups, intensive lifestyle interventions are vital for enhancing medication adherence. Accurate forecasting of treatment adherence can open pathways to developing an on-demand intervention tool, enabling timely and personalized support. With the increasing popularity of smartphones and wearables, it is now easier than ever to develop and deploy smart activity monitoring systems. However, effective forecasting systems for treatment adherence based on wearable sensors are still not widely available. We close this gap by proposing Adherence Forecasting and Intervention with Machine Intelligence (AIMI). AIMI is a knowledge-guided adherence forecasting system that leverages smartphone sensors and previous medication history to estimate the likelihood of forgetting to take a prescribed medication. A user study was conducted with 27 participants who took daily medications to manage their cardiovascular diseases. We designed and developed CNN and LSTM-based forecasting models with various combinations of input features and found that LSTM models can forecast medication adherence with an accuracy of 0.932 and an F-1 score of 0.936. Moreover, through a series of ablation studies involving convolutional and recurrent neural network architectures, we demonstrate that leveraging known knowledge about future and personalized training enhances the accuracy of medication adherence forecasting. Code available: https://github.com/ab9mamun/AIMI.