Review
Revue
Dietary Assessment and Self-monitoring
With Nutrition Applications for Mobile Devices
JESSICA R. L. LIEFFERS, MSc, RD, and RHONA M. HANNING, PhD, RD, FDC, School of Public Health and Health Systems,
University of Waterloo, Waterloo, ON
ABSTRACT
Nutrition applications for mobile devices (e.g., personal digital
assistants, smartphones) are becoming increasingly accessible
and can assist with the difficult task of intake recording for
dietary assessment and self-monitoring. This review is a
compilation and discussion of research on this tool for dietary
intake documentation in healthy populations and those trying
to lose weight. The purpose is to compare this tool with
conventional methods (e.g., 24-hour recall interviews, paper-
based food records). Research databases were searched from
January 2000 to April 2011, with the following criteria: healthy
or weight loss populations, use of a mobile device nutrition
application, and inclusion of at least one of three measures,
which were the ability to capture dietary intake in comparison
with conventional methods, dietary self-monitoring adherence,
and changes in anthropometrics and/or dietary intake. Eighteen
studies are discussed. Two application categories were
identified: those with which users select food and portion size
from databases and those with which users photograph their
food. Overall, positive feedback was reported with applications.
Both application types had moderate to good correlations for
assessing energy and nutrient intakes in comparison with
conventional methods. For self-monitoring, applications versus
conventional techniques (often paper records) frequently
resulted in better self-monitoring adherence, and changes in
dietary intake and/or anthropometrics. Nutrition applications
for mobile devices have an exciting potential for use in dietetic
practice.
(Can J Diet Pract Res. 2012;73:e253-e260)
(DOI: 10.3148/73.3.2012.e253)
Introduction
Mobile devices (e.g., personal digital assistants [PDAs] and
smartphones like the Android, BlackBerry, or iPhone) have ex-
ploded in capability and popularity. Smartphones are mobile
phones with computer-like capabilities, including internet/e-
mail access and the ability to run applications (or apps), which
are programs that carry out various tasks (1). A 2011 Canadian
Résumé
Les applications relatives à la nutrition pour les appareils mobiles
(p. ex. les assistants numériques et les téléphones intelligents)
sont de plus en plus accessibles et peuvent faciliter la difficile
tâche des gens qui désirent enregistrer leur apport alimentaire
afin de l’évaluer ou d’effectuer de l’autosurveillance. Cette revue
est une compilation et une discussion sur la recherche sur ces
outils pour la documentation de l’apport alimentaire chez les
populations en santé et celles qui tentent de perdre du poids.
L’objectif était de comparer cet outil aux méthodes traditionnelles
(p. ex. les entrevues de rappel alimentaire de 24 heures et les
journaux alimentaires papier). Des bases de données de recher-
che ont été consultées afin de trouver des études publiées entre
janvier 2000 et avril 2011 et correspondant aux critères suivants :
populations en santé ou qui tentent de perdre du poids, utilisation
d’une application relative à la nutrition sur un appareil mobile, et
inclusion d’au moins l’une de trois mesures, à savoir la capacité
d’enregistrer l’apport alimentaire comparativement aux méthodes
traditionnelles, l’adhésion à l’autosurveillance de l’alimentation,
et les changements sur le plan des mesures anthropométriques
et/ou de l’apport alimentaire. La discussion porte sur 18 études.
Deux catégories d’applications ont été identifiées : celles qui
permettent aux utilisateurs de choisir des aliments et la taille des
portions à partir d’une base de données et celles où les gens
photographient leurs aliments. Globalement, les applications ont
généré une rétroaction positive. Les deux types d’applications
présentaient des corrélations allant de modérées à bonnes pour
ce qui est de l’évaluation des apports en énergie et en nutri-
ments comparativement aux méthodes traditionnelles. En ce qui
concerne l’autosurveillance, les applications, comparativement
aux méthodes traditionnelles (souvent un journal papier), engen­
draient fréquemment une meilleure adhésion à l’autosurveillance
et des changements sur le plan de l’apport alimentaire et/ou des
mesures anthropométriques. Les applications relatives à la nutri-
tion pour les appareils mobiles présentent un excellent potentiel
pour une utilisation dans la pratique de la diététique.
(Rev can prat rech diétét. 2012;73:e253-e260)
(DOI: 10.3148/73.3.2012.e253)
Radio-television and Telecommunications Commission report
estimates 14% and 27% of francophone and anglophone Cana-
dians, respectively, have smartphones. This is an increase from
4% to 6% in 2007. Furthermore, the report predicts that by
2014, 50% of mobile phones in Canada will be smartphones (2).
Nutrition applications for mobile devices are becoming in-
Canadian Journal of Dietetic Practice and Research – Vol 73 No 3, Fall 2012 e253
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creasingly available. They offer enormous potential for dietetic
practice, including use as a tool to support intake recording for
dietary assessment and self-monitoring. Dietary assessment
is typically completed using either 24-hour recall interviews,
which are interviewer dependent, affected by memory, and asso-
ciated with intake under- and overestimates, or prospective food
intake paper records, which can affect eating behaviour and are
inconvenient (3). Dietary self-monitoring involves document-
ing dietary intake to increase behaviour awareness (4). Increased
self-monitoring adherence is associated with positive outcomes,
including increased weight loss (5); however, many individuals
find self-monitoring difficult with paper records (4,6), and ad-
herence decreases over time (7).
Mobile devices are associated with higher data quality in
comparison with other recording methods (8), perhaps because
the devices are familiar, are always carried, and may not be as-
sociated with stigma. They may also result in better self-moni-
toring outcomes. These may be partly due to instant feedback
at the time of consumption, which allows intake to be adjusted
immediately (9) to meet goals better. They may also provide us-
ers with the feeling someone cares about their progress (10).
PURPOSE
In this review, we compile and discuss research on dietary
intake recording applications for mobile devices in healthy
populations and those trying to lose weight. The goal was to
understand how use of such applications compares with use
of conventional methods, to provide information about ap-
propriate use of this technology in dietetic practice (includ-
ing barriers to and challenges with use), and to identify future
research directions.
METHODS
PubMed, Embase, and Web of Science were searched for Eng-
lish-language articles published from January 2000 to April
2011, using the following keywords: “smartphone,” “mobile
phone,” “mobile electronic device,” “personal digital assis-
tant,” “computers—handheld” AND “nutrition,” “diet,” “food,”
and “weight loss.” Reference lists of relevant articles were also
searched. Articles had to meet the following criteria: inclusion
of a healthy or weight loss population, use of a mobile device
nutrition application to record dietary intake, and inclusion of
at least one of three measures. These measures were the ability to
capture dietary intake in comparison with conventional meth-
ods (e.g., 24-hour recall, paper records), dietary self-monitoring
adherence (i.e., compliance with study self-monitoring criteria),
and changes in anthropometrics and/or dietary intake. When
we were evaluating studies, correlations between methods below
0.3 were considered poor, 0.3 to 0.4 fair, 0.4 to 0.6 moderate, and
above 0.6 good (11). Studies using text messaging, podcasting,
and digital cameras were excluded.
RESULTS
Eighteen studies were included in the review. Nine tested the ap-
plication’s ability to capture dietary intake variables in compari-
e254 Revue canadienne de la pratique et de la recherche en diététique ­– Vol 73 no 3, automne 2012
son with interview- or paper-based approaches, eight evaluated
dietary self-monitoring outcomes, and one tested both. Partici-
pants were primarily aged 30 to 50, female, overweight/obese,
Caucasian, of higher income, and interested in health/nutrition.
All studies up to 2008 used a PDA; however, from 2009 to
2011, three of eight used mobile phones or the iPod touch. Ap-
plications were categorized into two groups: data-based and
photography.
Applications
Eight different data-based applications were tested in 14 stud-
ies (12-25). With these applications, users generally searched or
scrolled through menus to locate the food they ate from a larger
database (e.g., the United States Department of Agriculture
[USDA] National Nutrient Database for Standard Reference)
(26), and then entered the portion size. Database sizes varied
from 300 to more than 45,000 foods (18,23).
Researchers /clinicians received the self-reported food intake
data electronically (e.g., by uploading data to study computers
at research visits, or by modem or e-mail) and did not need to
enter them into other nutrient analysis programs; most applica-
tions did not connect with the internet. Most provided instant
feedback in comparison with food or nutrient intake goals, date/
time stamps, and reminder signals, and some included meal
plans, recipes, exercise monitoring, and health/nutrition games.
User satisfaction with these applications was generally good.
Participants reported difficulty finding foods in databases
(16,17); however, some apps overcame this by allowing users
to add foods. Meal entry time was reported in only one study
(eight to 10 minutes per meal) (12); however, some allow meal
saving for expedient future entry.
Two different photography applications were tested in four
studies (27-30). They required users to photograph food before
consumption and food remaining at the end of the meal, using
specific criteria (e.g., taking pictures at a 45-degree angle, includ-
ing reference objects). Users did not estimate portion sizes, typi-
cally associated with substantial error (31,32), but were asked to
document details not visible on images (e.g., added fats, mixed
dish ingredients) with a stylus, text documentation, or voice re-
cording. The dietitian/researcher obtained photos directly from
the device at study visits or via mobile phone networks, and then
compared them with standards; their analysis time has not been
reported. Inter-rater reliability of energy intake estimation from
such records is high between different dietitians (27,30). Of in-
terest, these applications had difficulty capturing added fats and
seasonings (e.g., salt) (28).
User satisfaction was high with photography applications,
but problems were encountered, such as poor photographic
technique and lighting (29,30), failure to record additional food
details (29), and user concern about food appearance (28). Re-
cording time was approximately three to five minutes per meal
(27,28).
Dietary assessment studies
Table 1 summarizes studies that compare dietary assessment us-
 Table 1
Studies of dietary intake assessment with mobile devices
Mean Device/
Population age application
type/sample (years)/ Device/ recording Comparison Control
Study size BMI application time (days) measure group Key findings
Data-based applications
Beasley et 39 healthy Age: 53 PDA/ 3 24-hour recall No No significant mean differences were observed for energy/macronutrients and all
al., 2005 participants; BMI: 28 DietMatePro at end of day Pearson correlations were significant between the 24-hour recall and the 3-day PDA
(12) 54% female 3, weighed record for energy/macronutrients/SF/cholesterol (r range: 0.505-0.797). All Pearson
lab lunch correlations between a laboratory-weighed lunch and the PDA-entered lunch for energy/
macronutrients/SF/cholesterol were significant (r range: 0.419-0.786).
Yon et al., 61 from WL study; Age: 48 PDA/Calorie 7 Equation No 41% and 57% were considered low and valid energy reporters, respectively, using
2006 (16) 92% female BMI: 32 King estimated TEE Goldberg’s cutoff. Energy was underreported on average by 217 + _ 908 kcal/day.
Beasley et 174 from Age: PDA/ 7 24-hour recall Yes—PR Median energy differences between the 24-hour recall and the paper record and 24-hour
al., 2008 WL study; 52 PDA DietMatePro after day 7 of group recall and PDA were 5 and 137 kcal, respectively (NS). Compared with the 24-hour recall,
(13) 80% female 54 PR recording Spearman correlations (energy, macronutrients, cholesterol, fibre, vitamins A and C, calcium,
BMI: iron) all were significant between the PDA (r range: 0.377-0.705) and the paper record (r
30 PDA range: 0.580-0.831). Correlations with the 24-hour recall interview were significantly lower
32 PR in the PDA group compared with the paper record group for 6 of 11 variables.
Fowles et 10 pregnant Age: 23 PDA/ 2 24-hour recall No No significant differences were seen in mean Healthy Eating Index scores between the
al., 2008 females from the BMI: NA BalanceLog before day 1 PDA and 24-hour recall.
(19) WIC program of recording
Fukuo et 44 healthy Age: 23 PDA/custom 7 (compared 24-hour recall No No significant differences were seen between energy/macronutrients measured using
al., 2009 participants; BMI: 21 (with only day 7 for day 7 of the last PDA recording day and 24-hour recall for the same day. Significant Pearson
(25) 55% female photographs) with 24-hour PDA recording (0.715-0.854) and intraclass (0.697-0.854) correlations were seen between the two
recall) methods for energy/macronutrients.
McClung et 26 WS military Age: 23 PDA/ 7 TEE DLW Yes—PR The PDA had 8% fewer and the paper record had 3% more kcal compared with measured
al., 2009 personnel; BMI: 24 BalanceLog group TEE (NS). Pearson correlations were significant between the PDA reported energy intake
(20) 8% female and TEE (r=0.60), but not for the PR reported energy intake and TEE (r=0.45).
Photography applications
Wang et al., 20 female food Age: NA PDA/ 1 Weighed food No Median values for 24 of 35 variables were not significantly different between the two
2002 (27) and nutrition BMI: NA Wellnavi record for the methods. All Spearman correlations between both methods were significant except for
students same day retinol (significant r range: 0.46-0.93).
Wang et al., 28 female food Age: 19 PDA/ 1, at 2 Weighed food No (but Median values for 27 of 33 variables were not significantly different between the PDA and
2006 (28) and nutrition BMI: 21 Wellnavi different time record for the compared food record. Spearman correlations for 27 of 33 variables were significant at both time points
students points same days WFR with (significant r range: 0.39-0.86). No differences were found and all Spearman correlations were
24-hour significant between the 24-hour recall and the food record. Most correlations between the food
recall) record and the 24-hour recall were higher than those between the food record and the PDA.
Kikunaga 75 healthy Age: 49 PDA/ 5 Weighed food No For 19 of 28 variables, the PDA had significantly lower means compared with the food
et al., 2007 general BMI: 24 Wellnavi record for the record. Overall, 25 of 28 Spearman correlations were significant (significant r range:
(29) population adults; same days 0.304-0.776). Obesity was associated with Wellnavi under-reporting in men, but not
64% female women.
Martin et 50 healthy adult Age: 32 Mobile 3 non- Laboratory- No (but Results were similar between the dine-in (ate lunch and dinner in the laboratory) and
al., 2009 volunteers; BMI: 27 phone/ consecutive weighed food divided take-out (ate lunch in the laboratory and dinner was brought home in a cooler and
(30) 54% female remote food for the same into a leftover food was returned) groups. All Pearson energy correlations between laboratory-
photography days as RFPM dine-in weighed food and RFPM were significant (range: 0.93-0.95). Compared with laboratory-
method recording and take- weighed food, the RFPM significantly underestimated energy by 4.7%-6.6%. Age and
(RFPM) out group) body weight did not affect RFPM error.
BMI = body mass index; DLW = doubly labelled water; NA = not available; NS = not significant; PDA = personal digital assistant; PR = paper record; SF = saturated fat; TEE = total energy expenditure; WFR = weighed food record;

Canadian Journal of Dietetic Practice and Research – Vol 73 No 3, Fall 2012

WIC = Women, Infants and Children; WL = weight loss; WS = weight stable
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ing nutrition applications with conventional
methods. Six studies tested data-based and Tools are
four tested photography applications. The
number of studied nutrients ranged from one available to
to 11 for data-based applications, which largely
encompassed energy and macronutrients, and help estimate
one to 35 for photography applications, which
encompassed energy, macronutrients, and mi-
portion size.
cronutrients.
Data-based applications
Yon et al. (16) found that PDA diet recording resulted in
similar rates of energy under-reporting in comparison with
conventional methods (41% versus 27% to 46%) based on
total energy expenditure (TEE) and Goldberg’s cut-off (33) in
overweight/obese participants, most of whom were female.
McClung et al. (20) also found that energy intakes recorded by
PDA or paper were not significantly different from a criterion
standard measure (doubly labelled water-measured TEE) in
military personnel with stable weights. However, the Pearson
correlation was significant between TEE and the PDA energy
intake (r=0.60), but not between TEE and the energy intake
recorded on paper.
Beasley et al. (12) found that energy and macronutrient in-
takes had moderate to good agreement when captured using a
PDA versus a 24-hour recall interview in healthy adults (Pearson
correlation range: 0.505 to 0.797, p<0.05). Fowles and Gentry
(19) noted similar results in pregnant women with low incomes.
Moreover, participants preferred the PDA to a 24-hour recall in-
terview, and 50% felt it was more accurate.
A second trial by Beasley et al. (13) was the only one in which
participants were randomized to either paper or PDA food dia-
ries and compared nutrient intake results with those obtained
with a 24-hour recall interview (which occurred at the end
of the recording week). Study participants were overweight/
obese and participating in a behavioural weight loss interven-
tion. Spearman correlations between a 24-hour recall interview
and the equivalent period from the PDA or paper record were
significant for all measured variables (energy, macronutrients,
cholesterol, fibre, vitamins A and C, calcium, and iron). How-
ever, when the PDA and 24-hour recall interview correlations
were compared with those from the paper record and 24-hour
recall interview, all correlations were lower (PDA versus 24-hour
recall r range: 0.377 to 0.705; paper record versus 24-hour recall
r range: 0.580 to 0.831), and they were significantly lower for
six of 11 variables. Because no gold standard dietary assessment
method exists, determining which method is best remains dif-
ficult. Possibly the PDA information was closer to the truth than
either the paper record or the 24-hour recall information.
Beasley et al. (12) investigated error types associated with
intakes entered on PDAs in comparison with a laboratory-
weighed lunch. Overall, 49% of error was from improper por-
tion size estimation, even with portion size training, which is
also problematic with conventional methods (31,32). Numerous
tools are available to help estimate portion size, including pho-
e256 Revue canadienne de la pratique et de la recherche en diététique ­– Vol 73 no 3, automne 2012
tographs of standard portion sizes (34). Fukuo
et al. (25) compared the final day of seven days
of dietary recording with a PDA application,
which incorporated food photographs to assist
with portion size estimation, with a 24-hour
recall interview for the same day. Energy and
macronutrient Pearson correlations were gen-
erally higher (range: 0.715 to 0.854) than in the
Beasley et al. study (12) (range: 0.505 to 797),
which suggests a possible benefit; however, different participants
and study conditions preclude direct comparison.
In conclusion, data-based applications appear to be as effec-
tive as paper records or 24-hour recall interviews for capturing
dietary intake. Because of less data entry for dietitians/research-
ers, high overall participant satisfaction, and more individuals
carrying mobile devices, this method offers exciting promise.
Photography applications
Martin et al. (30) compared healthy adults’ energy intakes, cap-
tured using a photography-based application, with the same
laboratory-weighed meals. Pearson correlations for energy
were highly significant between the two methods (range: 0.93
to 0.95); however, the application significantly underestimated
energy intake by 4.7% to 6.6%. Although these small differences
were significant, they are marginal compared with self-report
methods (30). In addition, participants were comfortable with
the application and more than 90% indicated they would prefer
it to a paper record.
Wang et al. (27,28) studied a group of female nutrition stu-
dents in free-living conditions, comparing energy and macro-
nutrient intakes estimated for one day from a photography ap-
plication with weighed food records for the same day. Results
were not significantly different, and Spearman correlations were
significant (r range: 0.50 to 0.88). Moreover, fair to good Spear-
man correlations were observed for several micronutrients, dif-
ferent fats, and fibre. However, in the general population dur-
ing a five-day study (29), this same application had significantly
lower mean values for 19 of 28 variables, including energy and
macronutrients, in comparison with weighed food records. Nev-
ertheless, most Spearman correlations were significant (energy
and macronutrient range: 0.557 to 0.692). Improper device use
leading to poor picture quality was common, and may explain
the poorer results in comparison with nutrition students (29).
These results suggest that photography applications approxi-
mate but do not replicate the intakes achieved with the most
rigorous (weighed) food records.
Dietary self-monitoring studies
Table 2 summarizes nine studies that tested whether dietary self-
monitoring using mobile devices improved dietary intake, an-
thropometrics, and/or self-monitoring adherence, and/or tested
whether these outcomes improved more with mobile devices
than with traditional methods (usually paper records). Most
were weight loss studies and all used data-based applications.
Study designs, measured outcomes, and durations were hetero-
 Table 2
Studies of dietary self-monitoring with mobile devices
Population
type/sample Mean age (years)/ Device/ Study Study
Study size BMI application design length Key findings
Glanz et 33 women from Age: 64 PDA/custom Pre/post 1 month With FFQs before and after the study, total and percentage of energy from fat decreased
al., 2006 the Women’s BMI: NA (developed with significantly; a trend toward decreased calorie intake. No change occurred in fruit, vegetable,
(23) Health Initiative focus groups) grain, and fibre intakes. Participants found self-monitoring less of a burden, easier, and more
study convenient after using the PDA compared with self-monitoring before the study.
Yon et al., 176 behavioural Age: 48 PDA, 46 PDA/ Controlled 6 No differences were seen in fat or energy intake decreases measured by FFQ, weight loss,
2007 (17) WL study control Calorie King clinical trial months self-monitoring adherence (measured using percentage of weeks a diary was submitted), or
participants; BMI: 32 PDA, 31 adherence to treatment goals between groups. Increased self-monitoring adherence and
86% female control compliance with treatment goals were associated with more weight loss in both groups. The
PDA was not well liked by participants.
Atienza et 27 healthy Age: 63 PDA, 58 PDA/custom (43 RCT with normal 8 weeks With FFQs before and after the study, the PDA group had a significantly higher vegetable
al., 2008 adults control questions about care (written intake increase/1000 kcal and a trend toward increased dietary fibre from grains/1000
(24) >50 years; BMI: 27 PDA, 30 dietary intake materials) kcal compared with controls. On average, 51% of PDA entries were completed. Average
70% female control and behaviours) control adherence dropped throughout the study (week 1 = 75%, week 8 = 40%).
Beasley et 174 WL study Age: 52 PDA, 54 PR PDA/ RCT with paper 4 weeks Ornish diet adherence using the diary data in week 4 was significantly higher in the PDA
al., 2008 participants; BMI: 30 PDA, 32 PR DietMatePro record control group than in controls (43% vs. 28%). Fat and energy intakes measured using 24-hour recalls
(13) 80% female before and after intervention and WC decreased significantly more in the PDA group than in
the paper record group. No difference in body weight changes was seen between groups.
Shay et 39 from military Age: 35 PDA/ RCT with paper 12 No difference was seen in WC, percentage of body fat, and BMI losses and self-monitoring
al., 2009 WL program BMI: 33 Calorie King or web record weeks adherence (measured using proportion of days 2 entries were recorded totalling ≥800 kcal)
(18) (ShipShape); control between groups. Participants self-monitoring using their preferred method had significantly
41% female higher self-monitoring adherence throughout the study (64% vs. 43%) in comparison with
those who did not use their preferred method.
Lee et al., 36 from an Age: 28 phone, 30 Mobile phone/ Case control 6 weeks Significant decreases were seen in fat mass (-1.2 kg), body weight (-2.0 kg), and BMI
2010 (22) obesity clinic; control SmartDiet (-0.75 kg/m2) in the SmartDiet group but not in the control group. Only 8% used the device
% female NA BMI: 22 (both groups) daily as instructed; 75% used it weekly.
Cushing et 3 female Age: 16 iPod Touch/ Crossover with 10-12 Paper record self-monitoring adherence (measured using percentage of adherence to personalized
al., 2011 overweight BMI: 96th percentile Livestrong paper record weeks self-monitoring frequency goals each week) was on average approximately 0 for 2 participants,
(21) teens and steadily dropped in the third participant (62.5% at week 1 to 10% by week 4). With the iPod
Touch, self-monitoring adherence averages were approximately 75%-100% for 2 participants and
approximately 55% for the other.
Burke et 210 WL study Age: 47 PDA/ RCT with paper 6 More participants in the PDA-F group (63%) lost 5% weight than in the paper record group
al., 2011 participants; BMI: 34 DietMatePro record control months (46%) (p=0.04) and PDA group (49%) (p=0.09). Self-monitoring adherence was measured
(14) 85% female with (PDA-F) weekly and participants were considered adherent if they recorded >50% of their weekly
and without energy goal. The PDA groups had significantly better median self-monitoring adherence
feedback (PDA) than did the paper record group (PDA-F: 90%; PDA: 80%; paper record: 55%). At 6 months,
messages self-monitoring adherence dropped to 53% in the PDA group, 60% in the PDA-F group,
and 31% in the paper record group. Both PDA groups combined had significantly larger
decreases in energy and saturated fat intakes measured with pre/post 24-hour recalls and
percentage of WC in comparison with the paper record group.
Acharya et 192 WL study Age: 49 PDA/ RCT with paper 6 The PDA group had significantly greater increases in fruit and vegetable intakes and
al., 2011 participants; BMI: 34 DietMatePro record control months significantly greater decreases in refined grain intakes than did the paper record group,
(15) 84% female measured by pre/post 24-hour recalls. The PDA group still was able to have a substantial
reduction in total fat and trans-fat intakes with lower self-monitoring adherence levels in
comparison with the paper record group.

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BMI = body mass index; FFQ = food frequency questionnaire; NA = not available; PDA = personal digital assistant; RCT = randomized, controlled trial; WC = waist circumference; WL = weight loss
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geneous. Some studies also included exercise
self-monitoring and weekly group sessions in Age and
both intervention and control groups, which
makes the studies difficult to compare. Overall, duration did
positive outcomes were reported in seven of
the nine studies. not ... have
Glanz et al. (23) used a pre/post design to
study four weeks of diet self-monitoring with
an effect.
a PDA in women aged 54 to 82. The investi-
gators found significant decreases in fat intake, a trend toward
decreased calorie intake, and no significant changes in fruit,
vegetable, grain, and fibre intakes. Participants developed more
positive feelings about self-monitoring after using the PDA ver-
sus self-monitoring before the study. Cushing et al. (21) report-
ed similar results in their 10- to 12-week crossover study in three
overweight teenagers. Although they did not measure changes
in dietary intake, adherence to personalized self-monitoring fre-
quency goals increased from 3% to 4% with a paper record to
55% to 100% with the application. Two of the three participants
indicated they would continue self-monitoring with the device
following the study.
In Beasley et al.’s (13) four-week randomized, controlled
trial (RCT), 174 weight loss study participants were asked to
follow the Ornish diet (a low-fat diet) (35). The authors found
significantly better diet adherence and greater decreases in fat
and energy intakes and waist circumference (but not weight) in
those who self-monitored their diet with a PDA versus those us-
ing a paper record. In a six-week case control study, Lee et al.
(22) found those who self-monitored using a mobile phone ap-
plication, which included a nutrition education game, lost sig-
nificantly more weight and fat mass than did a control group,
although only 8% of the mobile phone group used the applica-
tion daily throughout the study. In an RCT, Atienza et al. (24)
examined individuals who self-monitored diet with a PDA ap-
plication that asked questions about their diet and factors sur-
rounding eating habits, and used self-regulatory behavioural
approaches to encourage dietary change. These individuals had
a significantly higher increase in vegetable intake and a trend to-
ward increased dietary fibre intakes from grains in comparison
with controls using standard written nutrition education mate-
rials. The investigators also found PDA usage decreased as the
eight-week study progressed.
In a 12-week study, Shay et al. (18) found no significant dif-
ferences in self-monitoring adherence (measured using the per-
centage of days in which two entries were recorded and totalled
at least 800 kcal), weight loss, body composition, and waist cir-
cumference changes in overweight/obese military participants
who were randomized to self-monitor using either a PDA, the
internet, or a paper record. Of interest is the finding that those
using their preferred method had significantly higher self-mon-
itoring adherence in comparison with those who did not.
In a behavioural weight loss study, Yon et al. (17) compared
participants completing PDA dietary self-monitoring with a
control group keeping a paper record. The authors found no dif-
ferences in weight loss, fat or energy intake changes, self-moni-
e258 Revue canadienne de la pratique et de la recherche en diététique ­– Vol 73 no 3, automne 2012
toring adherence (measured by the percentage
of weeks a diary was submitted), or treatment
goal adherence. However, those who self-mon-
itored more frequently lost more weight. An
important finding was that the PDA was not
well liked by participants. However, after six
months into a two-year weight loss trial, Burke
et al. (14) observed a 5% weight loss in more
participants self-monitoring using a PDA with
feedback messages than in the group using a PDA without feed-
back messages and a group using a paper record. In both PDA
groups, self-monitoring adherence (more than 50% of weekly
energy goal recorded) also was significantly better than in the
paper record group (more than 50% versus 31%). Both PDA
groups combined decreased energy and saturated fat intakes
significantly more than did the paper record group. In the same
population, Acharya et al. (15) found those self-monitoring with
a PDA had greater increases in vegetable and fruit intakes and
greater decreases in refined grain intakes than did the paper re-
cord group. Moreover, favourable decreases in total and trans-
fat levels did not require the PDA group’s self-monitoring ad-
herence to be as good as that of the paper record group. This was
thought to be due to immediate feedback and less effort needed
to self-monitor with a PDA.
DISCUSSION
To our knowledge, this is the first review to exclusively examine
nutrition applications for mobile devices for healthy popula-
tions and those trying to lose weight; in a previous review, mo-
bile applications for diabetes were examined (36). All research
was peer reviewed and all studies except Lee et al.’s (22) provided
the application and devices free of charge for only the duration
of the study. This heterogeneous group of studies suggests that
applications can be effective for dietary assessment and self-
monitoring in comparison with conventional methods. An im-
portant finding is that users generally reported satisfaction with
mobile devices, even though many of them had limited experi-
ence with these devices before the study. Many study participants
felt they could or wanted to continue using the devices after the
study. These devices may also be useful for individuals located
far from dietitians or researchers (30). However, such devices are
not suitable for everyone, and are not exempt from all the issues
associated with conventional methods (12), including a failure
to use the diary, a failure to record all foods or the correct foods
eaten, improper portion size estimation for data-based applica-
tions (12), and decreased use over time (14,24).
Both application types appear comparable with traditional
dietary assessment methods for capturing dietary intakes for up
to one week; correlations were largely moderate to good (11).
With dietary self-monitoring, most investigators reported posi-
tive outcomes with the application in studies ranging from one
to six months. Participant age and study duration did not ap-
pear to have an effect. In studies where the mobile device did not
result in better self-monitoring outcomes in comparison with
paper record diaries, the results were explained by application/

device dissatisfaction, and preferences for other self-monitoring
tools (17,18).
Several research gaps warrant future study. First, little re-
search has been done in disadvantaged populations and chil-
dren. However, applications have been used to help vulnerable
hemodialysis patients self-monitor their diet better (37-40),
and have been found feasible for use with children (41). Sec-
ond, photography applications have not been tested as a dietary
self-monitoring tool; still unclear is whether they can improve
self-monitoring adherence, anthropometrics, or dietary intake
in comparison with traditional approaches. Furthermore, the
ability of data-based applications to capture micronutrient in-
take is largely unknown; however, because many applications
use databases with micronutrient information (e.g., the USDA
nutrient database), this could be studied. In addition, for dietary
assessment, the intent of applications is to monitor individual
intake over time; some authors have suggested that, for this
purpose, mobile devices may be easier to use than traditional
methods (29). Bias seems unlikely to change over time, but this
has not been studied. Longer studies are needed, and, moreover,
no studies have compared different application types; until dif-
ferent applications are compared with RCTs, the advantage of
different types and features (e.g., portion size photographs) re-
mains unknown. Similarly, little research has been conducted on
nutrition applications easily accessible in commercial applica-
tion stores (e.g., the Apple App Store). Poor quality and/or lim-
ited involvement of health care professionals have been found
for smoking cessation (42), pain (43), and obesity management
applications (44) from these stores. Further investigation is still
needed for dietary recording applications.
RELEVANCE TO PRACTICE
Mobile devices and their applications are escalating in popular-
ity and capability (e.g., the improved ability to connect to the
internet for updates, messages, and feedback). Convenient new
tools to monitor diet and support improved nutritional status
therefore probably will flourish. Such monitoring likely will be-
come a preferred method for dietary tracking. Thus, dietitians
should develop an understanding of application capabilities,
and when their use is appropriate. Factors to consider include
training requirements, ease of update, cost, application/device
quality and capabilities (e.g., reminder alarms, exercise monitor-
ing), database quality, Canadian content, security, confidential-
ity, and patient preferences. For example, populations with low
literacy may prefer photography-based applications, those with
food pictures or barcode scanners (40). Similarly, photography
applications may be more suitable for populations with diffi-
culties estimating portion sizes (e.g., children) (45). In contrast,
users desiring immediate feedback or wanting a tool to look up
foods quickly may prefer data-based applications.
Also important is determining when traditional approaches
may be more appropriate and age may or may not have an effect.
Potential challenges, including difficulty finding foods in data-
bases, improper use, and equipment issues, could be encoun-
tered. Proper training and ongoing entry feedback (24,30) and en-
Review
Revue
couragement is needed for high-quality data and good outcomes.
Social support mechanisms and personalized feedback also have
been identified as important with mobile phone applications in
weight loss interventions (46,47). Human resources for data entry
should be considered; however, the requirement for human analy-
sis for photographic applications may be decreased in the future
with new image segmentation techniques (41,48-50).
Although new nutrition applications in app stores offer po-
tential benefits, their quality remains largely unknown and cau-
tion is needed when they are used. Dietitians should consider
collaborating with nutrition application developers to provide
input into future applications. Dietitians also will undoubtedly
have an important role in ensuring that future nutrition applica-
tions are safe and effective.
Acknowledgements
Jessica Lieffers is supported by a Canadian Institutes of Health
Research Doctoral Award.
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