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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 Résumé
Nutrition applications for mobile devices (e.g., personal digital Les applications relatives à la nutrition pour les appareils mobiles
assistants, smartphones) are becoming increasingly accessible (p. ex. les assistants numériques et les téléphones intelligents)
and can assist with the difficult task of intake recording for sont de plus en plus accessibles et peuvent faciliter la difficile
dietary assessment and self-monitoring. This review is a tâche des gens qui désirent enregistrer leur apport alimentaire
compilation and discussion of research on this tool for dietary afin de l’évaluer ou d’effectuer de l’autosurveillance. Cette revue
intake documentation in healthy populations and those trying est une compilation et une discussion sur la recherche sur ces
to lose weight. The purpose is to compare this tool with outils pour la documentation de l’apport alimentaire chez les
conventional methods (e.g., 24-hour recall interviews, paper- populations en santé et celles qui tentent de perdre du poids.
based food records). Research databases were searched from L’objectif était de comparer cet outil aux méthodes traditionnelles
January 2000 to April 2011, with the following criteria: healthy (p. ex. les entrevues de rappel alimentaire de 24 heures et les
or weight loss populations, use of a mobile device nutrition journaux alimentaires papier). Des bases de données de recher-
application, and inclusion of at least one of three measures, che ont été consultées afin de trouver des études publiées entre
which were the ability to capture dietary intake in comparison janvier 2000 et avril 2011 et correspondant aux critères suivants :
with conventional methods, dietary self-monitoring adherence, populations en santé ou qui tentent de perdre du poids, utilisation
and changes in anthropometrics and/or dietary intake. Eighteen d’une application relative à la nutrition sur un appareil mobile, et
studies are discussed. Two application categories were inclusion d’au moins l’une de trois mesures, à savoir la capacité
identified: those with which users select food and portion size d’enregistrer l’apport alimentaire comparativement aux méthodes
from databases and those with which users photograph their traditionnelles, l’adhésion à l’autosurveillance de l’alimentation,
food. Overall, positive feedback was reported with applications. et les changements sur le plan des mesures anthropométriques
Both application types had moderate to good correlations for et/ou de l’apport alimentaire. La discussion porte sur 18 études.
assessing energy and nutrient intakes in comparison with Deux catégories d’applications ont été identifiées : celles qui
conventional methods. For self-monitoring, applications versus permettent aux utilisateurs de choisir des aliments et la taille des
conventional techniques (often paper records) frequently portions à partir d’une base de données et celles où les gens
resulted in better self-monitoring adherence, and changes in photographient leurs aliments. Globalement, les applications ont
dietary intake and/or anthropometrics. Nutrition applications généré une rétroaction positive. Les deux types d’applications
for mobile devices have an exciting potential for use in dietetic présentaient des corrélations allant de modérées à bonnes pour
practice. ce qui est de l’évaluation des apports en énergie et en nutri-
ments comparativement aux méthodes traditionnelles. En ce qui
(Can J Diet Pract Res. 2012;73:e253-e260)
concerne l’autosurveillance, les applications, comparativement
(DOI: 10.3148/73.3.2012.e253)
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)

Introduction
Mobile devices (e.g., personal digital assistants [PDAs] and Radio-television and Telecommunications Commission report
smartphones like the Android, BlackBerry, or iPhone) have ex- estimates 14% and 27% of francophone and anglophone Cana-
ploded in capability and popularity. Smartphones are mobile dians, respectively, have smartphones. This is an increase from
phones with computer-like capabilities, including internet/e- 4% to 6% in 2007. Furthermore, the report predicts that by
mail access and the ability to run applications (or apps), which 2014, 50% of mobile phones in Canada will be smartphones (2).
are programs that carry out various tasks (1). A 2011 Canadian Nutrition applications for mobile devices are becoming in-

Canadian Journal of Dietetic Practice and Research – Vol 73 No 3, Fall 2012 e253
Review
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creasingly available. They offer enormous potential for dietetic son with interview- or paper-based approaches, eight evaluated
practice, including use as a tool to support intake recording for dietary self-monitoring outcomes, and one tested both. Partici-
dietary assessment and self-monitoring. Dietary assessment pants were primarily aged 30 to 50, female, overweight/obese,
is typically completed using either 24-hour recall interviews, Caucasian, of higher income, and interested in health/nutrition.
which are interviewer dependent, affected by memory, and asso- All studies up to 2008 used a PDA; however, from 2009 to
ciated with intake under- and overestimates, or prospective food 2011, three of eight used mobile phones or the iPod touch. Ap-
intake paper records, which can affect eating behaviour and are plications were categorized into two groups: data-based and
inconvenient (3). Dietary self-monitoring involves document- photography.
ing dietary intake to increase behaviour awareness (4). Increased
self-monitoring adherence is associated with positive outcomes, Applications
including increased weight loss (5); however, many individuals Eight different data-based applications were tested in 14 stud-
find self-monitoring difficult with paper records (4,6), and ad- ies (12-25). With these applications, users generally searched or
herence decreases over time (7). scrolled through menus to locate the food they ate from a larger
Mobile devices are associated with higher data quality in database (e.g., the United States Department of Agriculture
comparison with other recording methods (8), perhaps because [USDA] National Nutrient Database for Standard Reference)
the devices are familiar, are always carried, and may not be as- (26), and then entered the portion size. Database sizes varied
sociated with stigma. They may also result in better self-moni- from 300 to more than 45,000 foods (18,23).
toring outcomes. These may be partly due to instant feedback Researchers /clinicians received the self-reported food intake
at the time of consumption, which allows intake to be adjusted data electronically (e.g., by uploading data to study computers
immediately (9) to meet goals better. They may also provide us- at research visits, or by modem or e-mail) and did not need to
ers with the feeling someone cares about their progress (10). enter them into other nutrient analysis programs; most applica-
tions did not connect with the internet. Most provided instant
PURPOSE feedback in comparison with food or nutrient intake goals, date/
In this review, we compile and discuss research on dietary time stamps, and reminder signals, and some included meal
intake recording applications for mobile devices in healthy plans, recipes, exercise monitoring, and health/nutrition games.
populations and those trying to lose weight. The goal was to User satisfaction with these applications was generally good.
understand how use of such applications compares with use Participants reported difficulty finding foods in databases
of conventional methods, to provide information about ap- (16,17); however, some apps overcame this by allowing users
propriate use of this technology in dietetic practice (includ- to add foods. Meal entry time was reported in only one study
ing barriers to and challenges with use), and to identify future (eight to 10 minutes per meal) (12); however, some allow meal
research directions. saving for expedient future entry.
Two different photography applications were tested in four
METHODS studies (27-30). They required users to photograph food before
PubMed, Embase, and Web of Science were searched for Eng- consumption and food remaining at the end of the meal, using
lish-language articles published from January 2000 to April specific criteria (e.g., taking pictures at a 45-degree angle, includ-
2011, using the following keywords: “smartphone,” “mobile ing reference objects). Users did not estimate portion sizes, typi-
phone,” “mobile electronic device,” “personal digital assis- cally associated with substantial error (31,32), but were asked to
tant,” “computers—handheld” AND “nutrition,” “diet,” “food,” document details not visible on images (e.g., added fats, mixed
and “weight loss.” Reference lists of relevant articles were also dish ingredients) with a stylus, text documentation, or voice re-
searched. Articles had to meet the following criteria: inclusion cording. The dietitian/researcher obtained photos directly from
of a healthy or weight loss population, use of a mobile device the device at study visits or via mobile phone networks, and then
nutrition application to record dietary intake, and inclusion of compared them with standards; their analysis time has not been
at least one of three measures. These measures were the ability to reported. Inter-rater reliability of energy intake estimation from
capture dietary intake in comparison with conventional meth- such records is high between different dietitians (27,30). Of in-
ods (e.g., 24-hour recall, paper records), dietary self-monitoring terest, these applications had difficulty capturing added fats and
adherence (i.e., compliance with study self-monitoring criteria), seasonings (e.g., salt) (28).
and changes in anthropometrics and/or dietary intake. When User satisfaction was high with photography applications,
we were evaluating studies, correlations between methods below but problems were encountered, such as poor photographic
0.3 were considered poor, 0.3 to 0.4 fair, 0.4 to 0.6 moderate, and technique and lighting (29,30), failure to record additional food
above 0.6 good (11). Studies using text messaging, podcasting, details (29), and user concern about food appearance (28). Re-
and digital cameras were excluded. cording time was approximately three to five minutes per meal
(27,28).
RESULTS
Eighteen studies were included in the review. Nine tested the ap- Dietary assessment studies
plication’s ability to capture dietary intake variables in compari- Table 1 summarizes studies that compare dietary assessment us-

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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 tographs of standard portion sizes (34). Fukuo
methods. Six studies tested data-based and Tools are et al. (25) compared the final day of seven days
four tested photography applications. The of dietary recording with a PDA application,
number of studied nutrients ranged from one available to which incorporated food photographs to assist
to 11 for data-based applications, which largely
encompassed energy and macronutrients, and help estimate with portion size estimation, with a 24-hour
recall interview for the same day. Energy and
one to 35 for photography applications, which
encompassed energy, macronutrients, and mi-
portion size. macronutrient Pearson correlations were gen-
erally higher (range: 0.715 to 0.854) than in the
cronutrients. Beasley et al. study (12) (range: 0.505 to 797),
which suggests a possible benefit; however, different participants
Data-based applications and study conditions preclude direct comparison.
Yon et al. (16) found that PDA diet recording resulted in In conclusion, data-based applications appear to be as effec-
similar rates of energy under-reporting in comparison with tive as paper records or 24-hour recall interviews for capturing
conventional methods (41% versus 27% to 46%) based on dietary intake. Because of less data entry for dietitians/research-
total energy expenditure (TEE) and Goldberg’s cut-off (33) in ers, high overall participant satisfaction, and more individuals
overweight/obese participants, most of whom were female. carrying mobile devices, this method offers exciting promise.
McClung et al. (20) also found that energy intakes recorded by
PDA or paper were not significantly different from a criterion Photography applications
standard measure (doubly labelled water-measured TEE) in Martin et al. (30) compared healthy adults’ energy intakes, cap-
military personnel with stable weights. However, the Pearson tured using a photography-based application, with the same
correlation was significant between TEE and the PDA energy laboratory-weighed meals. Pearson correlations for energy
intake (r=0.60), but not between TEE and the energy intake were highly significant between the two methods (range: 0.93
recorded on paper. to 0.95); however, the application significantly underestimated
Beasley et al. (12) found that energy and macronutrient in- energy intake by 4.7% to 6.6%. Although these small differences
takes had moderate to good agreement when captured using a were significant, they are marginal compared with self-report
PDA versus a 24-hour recall interview in healthy adults (Pearson methods (30). In addition, participants were comfortable with
correlation range: 0.505 to 0.797, p<0.05). Fowles and Gentry the application and more than 90% indicated they would prefer
(19) noted similar results in pregnant women with low incomes. it to a paper record.
Moreover, participants preferred the PDA to a 24-hour recall in- Wang et al. (27,28) studied a group of female nutrition stu-
terview, and 50% felt it was more accurate. dents in free-living conditions, comparing energy and macro-
A second trial by Beasley et al. (13) was the only one in which nutrient intakes estimated for one day from a photography ap-
participants were randomized to either paper or PDA food dia- plication with weighed food records for the same day. Results
ries and compared nutrient intake results with those obtained were not significantly different, and Spearman correlations were
with a 24-hour recall interview (which occurred at the end significant (r range: 0.50 to 0.88). Moreover, fair to good Spear-
of the recording week). Study participants were overweight/ man correlations were observed for several micronutrients, dif-
obese and participating in a behavioural weight loss interven- ferent fats, and fibre. However, in the general population dur-
tion. Spearman correlations between a 24-hour recall interview ing a five-day study (29), this same application had significantly
and the equivalent period from the PDA or paper record were lower mean values for 19 of 28 variables, including energy and
significant for all measured variables (energy, macronutrients, macronutrients, in comparison with weighed food records. Nev-
cholesterol, fibre, vitamins A and C, calcium, and iron). How- ertheless, most Spearman correlations were significant (energy
ever, when the PDA and 24-hour recall interview correlations and macronutrient range: 0.557 to 0.692). Improper device use
were compared with those from the paper record and 24-hour leading to poor picture quality was common, and may explain
recall interview, all correlations were lower (PDA versus 24-hour the poorer results in comparison with nutrition students (29).
recall r range: 0.377 to 0.705; paper record versus 24-hour recall These results suggest that photography applications approxi-
r range: 0.580 to 0.831), and they were significantly lower for mate but do not replicate the intakes achieved with the most
six of 11 variables. Because no gold standard dietary assessment rigorous (weighed) food records.
method exists, determining which method is best remains dif-
ficult. Possibly the PDA information was closer to the truth than Dietary self-monitoring studies
either the paper record or the 24-hour recall information. Table 2 summarizes nine studies that tested whether dietary self-
Beasley et al. (12) investigated error types associated with monitoring using mobile devices improved dietary intake, an-
intakes entered on PDAs in comparison with a laboratory- thropometrics, and/or self-monitoring adherence, and/or tested
weighed lunch. Overall, 49% of error was from improper por- whether these outcomes improved more with mobile devices
tion size estimation, even with portion size training, which is than with traditional methods (usually paper records). Most
also problematic with conventional methods (31,32). Numerous were weight loss studies and all used data-based applications.
tools are available to help estimate portion size, including pho- Study designs, measured outcomes, and durations were hetero-

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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 toring adherence (measured by the percentage
self-monitoring and weekly group sessions in Age and of weeks a diary was submitted), or treatment
both intervention and control groups, which goal adherence. However, those who self-mon-
makes the studies difficult to compare. Overall, duration did itored more frequently lost more weight. An
positive outcomes were reported in seven of
the nine studies. not ... have important finding was that the PDA was not
well liked by participants. However, after six
Glanz et al. (23) used a pre/post design to
study four weeks of diet self-monitoring with
an effect. months into a two-year weight loss trial, Burke
et al. (14) observed a 5% weight loss in more
a PDA in women aged 54 to 82. The investi- participants self-monitoring using a PDA with
gators found significant decreases in fat intake, a trend toward feedback messages than in the group using a PDA without feed-
decreased calorie intake, and no significant changes in fruit, back messages and a group using a paper record. In both PDA
vegetable, grain, and fibre intakes. Participants developed more groups, self-monitoring adherence (more than 50% of weekly
positive feelings about self-monitoring after using the PDA ver- energy goal recorded) also was significantly better than in the
sus self-monitoring before the study. Cushing et al. (21) report- paper record group (more than 50% versus 31%). Both PDA
ed similar results in their 10- to 12-week crossover study in three groups combined decreased energy and saturated fat intakes
overweight teenagers. Although they did not measure changes significantly more than did the paper record group. In the same
in dietary intake, adherence to personalized self-monitoring fre- population, Acharya et al. (15) found those self-monitoring with
quency goals increased from 3% to 4% with a paper record to a PDA had greater increases in vegetable and fruit intakes and
55% to 100% with the application. Two of the three participants greater decreases in refined grain intakes than did the paper re-
indicated they would continue self-monitoring with the device cord group. Moreover, favourable decreases in total and trans-
following the study. fat levels did not require the PDA group’s self-monitoring ad-
In Beasley et al.’s (13) four-week randomized, controlled herence to be as good as that of the paper record group. This was
trial (RCT), 174 weight loss study participants were asked to thought to be due to immediate feedback and less effort needed
follow the Ornish diet (a low-fat diet) (35). The authors found to self-monitor with a PDA.
significantly better diet adherence and greater decreases in fat
and energy intakes and waist circumference (but not weight) in DISCUSSION
those who self-monitored their diet with a PDA versus those us- To our knowledge, this is the first review to exclusively examine
ing a paper record. In a six-week case control study, Lee et al. nutrition applications for mobile devices for healthy popula-
(22) found those who self-monitored using a mobile phone ap- tions and those trying to lose weight; in a previous review, mo-
plication, which included a nutrition education game, lost sig- bile applications for diabetes were examined (36). All research
nificantly more weight and fat mass than did a control group, was peer reviewed and all studies except Lee et al.’s (22) provided
although only 8% of the mobile phone group used the applica- the application and devices free of charge for only the duration
tion daily throughout the study. In an RCT, Atienza et al. (24) of the study. This heterogeneous group of studies suggests that
examined individuals who self-monitored diet with a PDA ap- applications can be effective for dietary assessment and self-
plication that asked questions about their diet and factors sur- monitoring in comparison with conventional methods. An im-
rounding eating habits, and used self-regulatory behavioural portant finding is that users generally reported satisfaction with
approaches to encourage dietary change. These individuals had mobile devices, even though many of them had limited experi-
a significantly higher increase in vegetable intake and a trend to- ence with these devices before the study. Many study participants
ward increased dietary fibre intakes from grains in comparison felt they could or wanted to continue using the devices after the
with controls using standard written nutrition education mate- study. These devices may also be useful for individuals located
rials. The investigators also found PDA usage decreased as the far from dietitians or researchers (30). However, such devices are
eight-week study progressed. not suitable for everyone, and are not exempt from all the issues
In a 12-week study, Shay et al. (18) found no significant dif- associated with conventional methods (12), including a failure
ferences in self-monitoring adherence (measured using the per- to use the diary, a failure to record all foods or the correct foods
centage of days in which two entries were recorded and totalled eaten, improper portion size estimation for data-based applica-
at least 800 kcal), weight loss, body composition, and waist cir- tions (12), and decreased use over time (14,24).
cumference changes in overweight/obese military participants Both application types appear comparable with traditional
who were randomized to self-monitor using either a PDA, the dietary assessment methods for capturing dietary intakes for up
internet, or a paper record. Of interest is the finding that those to one week; correlations were largely moderate to good (11).
using their preferred method had significantly higher self-mon- With dietary self-monitoring, most investigators reported posi-
itoring adherence in comparison with those who did not. tive outcomes with the application in studies ranging from one
In a behavioural weight loss study, Yon et al. (17) compared to six months. Participant age and study duration did not ap-
participants completing PDA dietary self-monitoring with a pear to have an effect. In studies where the mobile device did not
control group keeping a paper record. The authors found no dif- result in better self-monitoring outcomes in comparison with
ferences in weight loss, fat or energy intake changes, self-moni- paper record diaries, the results were explained by application/

e258 Revue canadienne de la pratique et de la recherche en diététique ­– Vol 73 no 3, automne 2012


Review
Revue
device dissatisfaction, and preferences for other self-monitoring couragement is needed for high-quality data and good outcomes.
tools (17,18). Social support mechanisms and personalized feedback also have
Several research gaps warrant future study. First, little re- been identified as important with mobile phone applications in
search has been done in disadvantaged populations and chil- weight loss interventions (46,47). Human resources for data entry
dren. However, applications have been used to help vulnerable should be considered; however, the requirement for human analy-
hemodialysis patients self-monitor their diet better (37-40), sis for photographic applications may be decreased in the future
and have been found feasible for use with children (41). Sec- with new image segmentation techniques (41,48-50).
ond, photography applications have not been tested as a dietary Although new nutrition applications in app stores offer po-
self-monitoring tool; still unclear is whether they can improve tential benefits, their quality remains largely unknown and cau-
self-monitoring adherence, anthropometrics, or dietary intake tion is needed when they are used. Dietitians should consider
in comparison with traditional approaches. Furthermore, the collaborating with nutrition application developers to provide
ability of data-based applications to capture micronutrient in- input into future applications. Dietitians also will undoubtedly
take is largely unknown; however, because many applications have an important role in ensuring that future nutrition applica-
use databases with micronutrient information (e.g., the USDA tions are safe and effective.
nutrient database), this could be studied. In addition, for dietary
assessment, the intent of applications is to monitor individual Acknowledgements
intake over time; some authors have suggested that, for this Jessica Lieffers is supported by a Canadian Institutes of Health
purpose, mobile devices may be easier to use than traditional Research Doctoral Award.
methods (29). Bias seems unlikely to change over time, but this
has not been studied. Longer studies are needed, and, moreover, References
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