Feasibility and validity of mobile phones to assess dietary intake

Use of digital food records in clinical settings: lessons in translation from a randomised controlled trial

BACKGROUND

Digital food records offer efficiencies in collecting and assessing dietary information remotely; however, research into factors impacting their translation into clinical settings is limited.

METHODS

The study examined factors that may impact the integration of digital food records into clinical dietetic practice by assessing (1) the source and rate of data errors received, (2) the impact of dietitian-adjusted data on dietary variables and (3) the acceptance of use in a complex chronic condition cohort. Adults from specialist clinics enroled in a randomised controlled feasibility trial participated. Participants recorded their dietary intake using a mobile food diary application (Research Food diary, Xyris Software Pty Ltd.); it was analysed via electronic nutrition analysis software (FoodWorks, Xyris Software Pty Ltd.). Records were verified and corrected by a dietitian. Dietary variables assessed before (participant-unadjusted data) and after (dietitian-adjusted data) were compared by the Wilcoxon signed-rank test, Bland-Altman and Passing-Bablok analysis. Surveys and Interviews assessed participants'; acceptance of the mobile application's usability.

RESULTS

Errors appeared in 93% of records. Dietitian-adjusted median data were higher for most variables compared to participant-unadjusted median data (p < 0.05, median changes between 0.0% and 64.7%) of 59 participant records (median age 51 years, interquartile range 38-58). There was poor agreement between participant-unadjusted and dietitian-adjusted data for some dietary variables. Sixty-four percent surveyed (n = 32/50) found the app easy to use, whereas 29 interviews provided insights into facilitators and challenges of use.

CONCLUSIONS

Significant barriers to integrating digital food records into clinical settings exist requiring dietitian adjustment to correct errors which has major implications for estimates of diet quality and intake.

Feasibility of Using an Artificial Intelligence-based Telephone Application for Dietary Assessment and Nudging to Improve the Quality of Food Choices of Female Adolescents in Vietnam: Evidence from a Randomized Pilot Study

Background

Adolescent nutrition has faced a policy neglect, partly owing to the gaps in dietary intake data for this age group. The Food Recognition Assistance and Nudging Insights (FRANI) is a smartphone application validated for dietary assessment and to influence users toward healthy food choices.

Objectives

This study aimed to assess the feasibility (adherence, acceptability, and usability) of FRANI and its effects on food choices and diet quality in female adolescents in Vietnam.

Methods

Adolescents (N = 36) were randomly selected from a public school and allocated into 2 groups. The control group received smartphones with a version of FRANI limited to dietary assessment, whereas the intervention received smartphones with gamified FRANI. After the first 4 wk, both groups used gamified FRANI for further 2 wk. The primary outcome was the feasibility of using FRANI as measured by adherence (the proportion of completed food records), acceptability and usability (the proportion of participants who considered FRANI acceptable and usable according to answers of a Likert questionnaire). Secondary outcomes included the percentage of meals recorded, the Minimum Dietary Diversity for Women (MDDW) and the Eat-Lancet Diet Score (ELDS). Dietary diversity is important for dietary quality, and sustainable healthy diets are important to reduce carbon emissions. Poisson regression models were used to estimate the effect of gamified FRANI on the MDDW and ELDS.

Results

Adherence to the application was 82% and the percentage of meals recorded was 97%. Acceptability and usability were 97%. MDDW in the intervention group was 1.07 points (95% CI: 0.98, 1.18; P = 0.13) greater than that in the control (constant = 4.68); however, the difference was not statistically significant. Moreover, ELDS in the intervention was 1.09 (95% CI: 1.01, 1.18; P = 0.03) points greater than in the control (constant = 3.67).

Conclusions

FRANI was feasible and may be effective to influence users toward healthy food choices. Research is needed for FRANI in different contexts and at scale.The trial was registered at the International Standard Randomized Controlled Trial Number as ISRCTN 10681553.

What Is the Tech Missing? Nutrition Reporting in Type 1 Diabetes

INTRODUCTION

Type 1 Diabetes (T1D) presents self-management challenges, requiring an additional 180 daily decisions to regulate blood glucose (BG) levels. Despite the potential, T1D-focused applications have a 43% attrition rate. This work delves into the willingness of people living with T1D (PwT1D) to use technology.

METHOD

An online questionnaire investigated the current practices for carbohydrate estimation, nutritional tracking, and attitudes towards technology engagement, along with hypothetical scenarios and preferences regarding technology use.

RESULTS

Thirty-nine responses were collected from PwT1D (n = 33) and caregivers (n = 6). Nutrition reporting preferences varied, with 50% favoring 'type and scroll' while 30% preferred meal photographing. Concerning the timing of reporting, 33% reported before meals, 55% after, and 12% at a later time. Improved Time in Range (TIR) was a strong motivator for app use, with 78% expressing readiness to adjust insulin doses based on app suggestions for optimizing TIR. Meal descriptions varied; a single word was used in 42% of cases, 23% used a simple description (i.e., "Sunday dinner"), 30% included portion sizes, and 8% provided full recipes.

CONCLUSION

PwT1D shows interest in using technology to reduce the diabetes burden when it leads to an improved TIR. For such technology to be ecologically valid, it needs to strike a balance between requiring minimal user input and providing significant data, such as meal tags, to ensure accurate blood glucose management without overwhelming users with reporting tasks.

Investigating Nutrition and Hydration Knowledge and Practice among a Cohort of Age-Grade Rugby Union Players

Optimal athletic performance relies on meeting specific nutritional requirements, encompassing adequate calorie intake, macronutrient intake, and hydration. Misinformation or misconceptions about these necessities are prevalent among young athletes. This study investigated nutrition and hydration knowledge and practices among 28 male rugby union players aged 16 to 17, participating in Munster Rugby's 2023 Summer Age-Grade Development Programme, specifically the U18's Schools Squad. The Nutrition for Sport Knowledge Questionnaire assessed nutrition knowledge, while the Hydration Assessment Questionnaire evaluated hydration knowledge. Urinalysis for hydration status utilised urine specific gravity measurements pre-exercise on five separate days (1.018 ± 0.008 Usg). Dietary intake was recorded using a 3-day estimated food intake record on the Libro App, analysed with Nutritics software(Version 9.50). Suboptimal nutrition knowledge (49.6 ± 8.2%) and dietary practices were observed, with incongruent nutrient intakes compared to recommendations for adolescent athletes. While superior hydration knowledge (79.0 (77.3, 83.6) %) was evident, pre-exercise urine specific gravity readings indicated significant variation (p < 0.001) and signs of dehydration (USG > 1.020 Usg). No statistically significant correlations were found between knowledge and practices. The study highlights suboptimal nutrition and hydration knowledge and practices in youth athletes, suggesting the need for tailored support and educational interventions to enhance their overall health and performance. Further investigation into barriers and facilitators to dietary adherence is recommended for more effective interventions.

A Smartphone Food Record App Developed for the Dutch National Food Consumption Survey: Relative Validity Study

BACKGROUND

In the Dutch National Food Consumption Survey, dietary intake has been assessed since 2003 through 24-hour dietary recalls using the GloboDiet software. A new self-administered smartphone food record app called DitEetIk! was developed for potential use in future surveys.

OBJECTIVE

This study aims to evaluate the data collected using the DitEetIk! app and its relative validity for food group, energy, and nutrient intake compared with the previous dietary assessment method (GloboDiet 24-hour dietary recalls).

METHODS

A total of 300 participants aged 18 to 79 years were recruited from a consumer panel. Participants were asked to keep a record of their consumption using the DitEetIk! app on 3 nonconsecutive days. Trained dietitians conducted a 24-hour dietary recall interview by telephone using the GloboDiet software (International Agency for Research on Cancer) regarding 1 of 3 DitEetIk! recording days. Nutrient intake was calculated using the NEVO database (version 2021/7.0). Relative validity was studied by comparing data from GloboDiet 24-hour dietary recalls and the DitEetIk app for the same day. Participants with implausible records, defined as days with energy intake of <0.6 or >3.0 basal metabolic rate, were excluded from the analyses. For 19 food groups and 29 nutrients, differences in median intake were assessed using the Wilcoxon signed rank test, and Spearman correlation coefficients were calculated. Bland-Altman plots with mean differences and 95% limits of agreement were created for energy intake and the contribution to energy intake from fat, carbohydrates, and protein.

RESULTS

A total of 227 participants completed a combination of a DitEetIk! app recording day and a 24-hour dietary recall interview for the same day. Of this group, 211 participants (n=104, 49.3% men and n=107, 50.7% women) had plausible recording days. Of all recorded food items, 12.8% (114/894) were entered via food barcode scanning, and 18.9% (169/894) were searched at the brand level. For 31% (5/16) of the food groups, the median intake assessed using the DitEetIk! app was >10% lower than that assessed using 24-hour dietary recalls; this was the case for fruit (P=.005), added fats (P=.001), milk and milk products (P=.02), cereal products (P=.01), and sauces (P<.001). This was also the case for 14% (4/29) of the nutrients (all P<.001). Regarding mean intake, differences were generally smaller. Regarding energy intake, the mean difference and 95% limits of agreement were 14 kcal (-1096 to 1124). Spearman correlation coefficients between intake assessed using the DitEetIk! app and 24-hour dietary recalls ranged from 0.48 to 0.88 (median 0.78) for food groups and from 0.58 to 0.90 (median 0.72) for nutrients.

CONCLUSIONS

Compared with GloboDiet 24-hour dietary recalls, the DitEetIk! app assessed similar mean energy intake levels but somewhat lower median intake levels for several food groups and nutrients.

Are Digital Health Technologies and Models of Nutrition Care the Future of Chronic Kidney Disease Management?

People living with chronic kidney disease (CKD) require long-term support at varying levels of individualization, intensity, and frequency. Mobile and digital models of nutrition care can facilitate long-term behavior change, address nutrition issues proactively, reduce travel burden, and reach people without access to health care more easily. However, while traditional health delivery continues to be digitally disrupted, there are many barriers to address before mobile and digitally supported models of nutrition care can become business as usual in nephrology and nutrition care practice. This paper overviews the current evidence base concerning the past and present mobile and digital health programs to improve nutrition in CKD and highlights the novel future trends in this field. The way nutrition and dietetic care can be feasible, safe, and potentially effective when delivered using various digital and virtual technologies, including consultations, assessments, establishment of diagnoses, formulation of plans, and monitoring/reviewing clinical progress is discussed. Of the available evidence to date, these modalities appear to improve dietary sodium intake and diet quality, self-efficacy, interdialytic weight gain, and body weight. Many barriers exist to sustaining the continued and widespread adoption of digital and mobile health-supported nutrition care in CKD. These include patient-, clinician-, and health system-specific and are discussed in detail. Mobile and digital-supported models of nutrition care present an exciting opportunity to assist kidney dietitians deliver patient-centred nutrition care in CKD.

Reliability of a frequency method for assessing vegetable intake using photos among college students: a smart phone approach

OBJECTIVE

To measure the interrater reliability of assessing the frequency of vegetable intake using mobile photos and descriptions.

DESIGN

Repeated measures design.

SETTING

A Midwestern university.

PARTICIPANTS

Undergraduate students (N = 165).

MEASURABLE OUTCOME/ANALYSIS

Number of times each of these vegetable subgroups were consumed daily: dark green vegetables, beans and peas, starchy vegetables, and other vegetables. Analysis: Two raters independently coded meals using mobile photos and descriptions of meals. Cohen κ was calculated to determine interrater reliability.

RESULTS

A value of κ = 0.9 (p < .001) was obtained, indicating an almost perfect agreement between the two raters. Nearly 92% of participants complied with providing photos along with descriptions of their meals.

CONCLUSIONS AND IMPLICATIONS

A frequency method using mobile photos and descriptions of meals is a reliable strategy to assess vegetable consumption. This frequency method can improve data quality, reduce participant burden, and minimize recall bias in college nutrition programs.

Design and Development of 'Diet DQ Tracker': A Smartphone Application for Augmenting Dietary Assessment

The purpose of the current study was to describe the design, development, and validation of the 'Diet DQ Tracker'. The 'Diet DQ Tracker' is the first self-administered smartphone app designed to collect dietary data for diet diversity indicators. The main objective of the app was to replace the traditional methods of dietary data collection, such as in-person or telephone 24 h recall via pen and paper questionnaire or tablets. The real-time meal recording, extensive food database, and automatic score calculations and visualizations for MDD-W, IYCF-MDD, and HDDS have the potential to overcome the drawbacks of 24 h recalls. Recall depends on respondent memory, food expertise, and time consumption and demands skilled interviewers. Further, SAIN, LIM recommendations in the app prompt users to diversify diets with healthy foods. The pilot study determined the acceptability, feasibility, and relative validity of the 'Diet DQ Tracker' with a 24 h dietary recall. The results demonstrated minimal differences in dietary scores by both methodologies. The app, being convenient, easy to use, less time-consuming, and enjoyable, was preferred by the entire study sample over 24 h recall. The app will be continually updated with foods from different cultures for validating in large-scale studies. The future studies will help to improve the subsequent versions of the app.

Validation of the smartphone-based dietary assessment tool 'Traqq' for assessing actual dietary intake by repeated 2-hour recalls in adults: comparison with 24h recalls and urinary biomarkers

BACKGROUND

Conventional dietary assessment methods are affected by measurement error. We developed a smartphone-based 2-hour recall (2hR) methodology to reduce participant burden and memory-related bias.

OBJECTIVE

Assessing the validity of the 2hR method against traditional 24-hour recalls (24hRs) and objective biomarkers.

METHODS

Dietary intake was assessed in 215 Dutch adults on six randomly selected non-consecutive days (i.e., three 2hR-days and three 24hRs) during a four-week period. Sixty-three participants provided four 24-hour urine samples, to assess urinary nitrogen and potassium concentrations.

RESULTS

Intake estimates of energy (2,052±503 kcal vs. 1,976±483 kcal) and nutrients (e.g., protein: 78±23 g vs. 71±19 g; fat: 84±30 g vs. 79±26 g; carbohydrates: 220±60 g vs. 216±60 g) were slightly higher with 2hR-days than 24hRs. Comparing self-reported protein and potassium intakes to urinary nitrogen and potassium concentrations indicated a slightly higher accuracy of 2hR-days than 24hRs (protein: -14% vs. -18%; potassium: -11% vs. -16%). Correlation coefficients between methods ranged from 0.41 to 0.75 for energy and macronutrients and from 0.41 to 0.62 for micronutrients. Generally regularly consumed food groups showed small differences in intake (<10%) and good correlations (>0.60). Intakes of and energy, nutrients and food groups showed similar reproducibility (ICC) for 2hR-days and 24hRs.

CONCLUSIONS

Comparing 2hR-days with 24hRs showed relatively similar group-level bias for energy, most nutrients, and food groups. Differences were mostly due to higher intake estimates by 2hR-days. Biomarker comparisons showed less underestimation by 2hR-days as compared to 24hRs, suggesting that 2hR-days are a valid approach to assess intake of energy, nutrients and food groups.

TRIAL REGISTRATION

This trial was registered at the Dutch Central Committee on Research Involving Human Subjects (CCMO) registry as ABR. No. NL69065.081.19.

Relative Validity and Reliability of the Remind App as an Image-Based Method to Assess Dietary Intake and Meal Timing in Young Adults

Image-based dietary records have been validated as tools to evaluate dietary intake. However, to determine meal timing, previous studies have relied primarily on image-based smartphone applications without validation. Noteworthy, the validation process is necessary to determine how accurately a test method measures meal timing compared with a reference method over the same time period. Thus, we aimed to assess the relative validity and reliability of the Remind^® app as an image-based method to assess dietary intake and meal timing. For this purpose, 71 young adults (aged 20-33 years, 81.7% women) were recruited for a 3-day cross-sectional study, where they completed a 3-day image-based record using the Remind app (test method) and a 3-day handwritten food record (reference method). The relative validity of the test method versus the reference method was assessed using multiple tests including Bland-Altman, % difference, paired t-test/Wilcoxon signed-rank test, Pearson/Spearman correlation coefficients, and cross-classification. We also evaluated the reliability of the test method using an intra-class correlation (ICC) coefficient. The results showed that, compared to the reference method, the relative validity of the test method was good for assessing energy and macronutrient intake, as well as meal timing. Meanwhile, the relative validity of the test method to assess micronutrient intake was poor (p < 0.05) for some micronutrients (iron, phosphorus, potassium, zinc, vitamins B1, B2, B3, B6, C, and E, and folates) and some food groups (cereals and grains, legumes, tubers, oils, and fats). Regarding the reliability of an image-based method to assess dietary intake and meal timing, results ranged from moderate to excellent (ICC 95% confidence interval [95% CI]: 0.50-1.00) for all nutrients, food groups (except oils and fats, which had low to moderate reliability), and meal timings. Thus, the results obtained in this study provide evidence of the relative validity and reliability of image-based methods to assess dietary intake (energy, macronutrients, and most food groups) and meal timing. These results open up a new framework for chrononutrition, as these methods improve the quality of the data collected and also reduce the burden on users to accurately estimate portion size and the timing of meals.

Validation of Dietary Intake Estimated by Web-Based Dietary Assessment Methods and Usability Using Dietary Records or 24-h Dietary Recalls: A Scoping Review

The goal was to summarize studies comparing the accuracy of web-based dietary assessments with those of conventional face-to-face or paper-based assessments using 24-h dietary recall or dietary record methods in the general population. Using two databases, mean differences and correlation coefficients (CCs) for intakes of energy, macronutrients, sodium, vegetables, and fruits were extracted from each study independently by the authors. We also collected information regarding usability from articles reporting this. From 17 articles included in this review, the mean dietary intake differences in the web-based dietary assessment compared to conventional methods, were -11.5-16.1% for energy, -12.1-14.9% for protein, -16.7-17.6% for fat, -10.8-8.0% for carbohydrates, -11.2-9.6% for sodium, -27.4-3.9% for vegetables, and -5.1-47.6% for fruits. The CC was 0.17-0.88 for energy, protein, fat, carbohydrates, and sodium, and 0.23-0.85 for vegetables and fruits. In three out of four studies reporting usability, more than half of the participants preferred the web-based dietary assessment. In conclusion, % difference and CC of dietary intake were acceptable in both web-based dietary records and 24-h dietary recalls. The findings from this review highlight the possibility of wide-spread application of the web-based dietary assessment in the future.

Is the uptake, engagement, and effectiveness of exclusively mobile interventions for the promotion of weight-related behaviors equal for all? A systematic review

Mobile health interventions are promising behavior change tools. However, there is a concern that they may benefit some populations less than others and thus widen inequalities in health. This systematic review investigated differences in uptake of, engagement with, and effectiveness of mobile interventions for weight-related behaviors (i.e., diet, physical activity, and sedentary behavior) based on a range of inequality indicators including age, gender, race/ethnicity, and socioeconomic status. The protocol was registered on PROSPERO (CRD42020192473). Six databases (CINAHL, EMBASE, ProQuest, PsycINFO, Pubmed, and Web of Science) were searched from inception to July 2021. Publications were eligible for inclusion if they reported the results of an exclusively mobile intervention and examined outcomes by at least one inequality indicator. Sixteen publications reporting on 13 studies were included with most reporting on multiple behaviors and inequality indicators. Uptake was investigated in one study with no differences reported by the inequality indicators studied. Studies investigating engagement (n = 7) reported differences by age (n = 1), gender (n = 3), ethnicity (n = 2), and education (n = 2), while those investigating effectiveness (n = 9) reported differences by age (n = 3), gender (n = 5), education (n = 2), occupation (n = 1), and geographical location (n = 1). Given the limited number of studies and their inconsistent findings, evidence of the presence of a digital divide in mobile interventions targeting weight-related behaviors is inconclusive. Therefore, we recommend that inequality indicators are specifically addressed, analyzed, and reported when evaluating mobile interventions.

Self-completed online dietary recalls as an alternative method of dietary assessment for dietetic outpatient appointments: A feasibility study

BACKGROUND

Integrating digital dietary assessment within dietetic care could save time and reduce costs, at the same time as increasing patient engagement. The present study explores the feasibility of implementing a web-based dietary assessment tool, myfood24 (https://www.myfood24.org), into routine healthcare.

METHODS

This mixed methods feasibility study recruited dietitians and patients from a National Health Service (NHS) hospital outpatient setting. Patients completed and shared three online 24-h dietary recalls in advance, which were used as a dietary assessment by dietitians. Recruitment data were collected and questionnaires on technology, usability, and acceptability were completed. Patient interviews and focus groups with dietitians were conducted.

RESULTS

Eleven dietitians working in allergy, bariatrics, diabetes, oncology, general, renal, infectious diseases, and coeliac services took part with 39 patients. Recruitment rates were highest in bariatrics and lowest in renal and oncology. Compared to other studies, completion rates were good, with 29 (74.4%) completing three recalls despite lower technology readiness and software usability scores than in similar studies. Illness and difficulty with technology were reasons for non-completion. Opportunity to receive nutritional feedback from the tool and share this with a dietitian motivated patients to complete the record accurately. Consultation times were shortened in approximately one-third of appointments and a higher proportion of time was spent on nutritional education compared to usual practice. However, mean preparation time increased by 13 min per appointment because dietitians found nutritional analysis reports difficult to interpret.

CONCLUSIONS

It is feasible to introduce a digital dietary assessment tool into NHS dietetic practice. However, further development is needed to ensure that the tool is suitable for healthcare.

MyDietCam: Development and usability study of a food recognition integrated dietary monitoring smartphone application

Background

Diet monitoring has been linked with improved eating habits and positive health outcomes such as prevention of obesity. However, this is often unsustainable as traditional methods place a high burden on both participants and researchers through pen and paper recordings and manual nutrient coding respectively. The digitisation of dietary monitoring has greatly reduced these barriers. This paper proposes a diet application with a novel food recognition feature with a usability study conducted in the real world.

Methods

This study describes the development of a mobile diet application (MyDietCam) targeted at healthy Malaysian adults. Focus group discussions (FGD) were carried out among dietitians and potential users to determine ideal features in a diet application. Thirty participants were recruited from a local university to log their meals through MyDietCam for six days and submit the Malay mHealth Application Usability Questionnaire (M-MAUQ) at the end of the study.

Results

The findings from the FGD led to the implementation of the main features: individualised recommendations, food logging through food recognition to reduce steps for data entry and provide detailed nutrient analyses through visuals. An average overall usability score of 5.13 out of a maximum of seven was reported from the M-MAUQ which is considered acceptable.

Conclusion

The development of a local (Malaysian) mobile diet application with acceptable usability may be helpful in sustaining the diet monitoring habit to improve health outcomes. Future work should focus on improving the issues raised before testing the effectiveness of the application for improving health outcomes.

Linking dietary intake, circadian biomarkers, and clock genes on obesity: A study protocol

Background

The prevalence of obesity continues to rise, and although this is a complex disease, the screening is made simply with the value of the Body Mass Index. This index only considers weight and height, being limited in portraying the multiple existing obesity phenotypes. The characterization of the chronotype and circadian system as an innovative phenotype of a patient's form of obesity is gaining increasing importance for the development of novel and pinpointed nutritional interventions.

Objective

The present study is a prospective observational controlled study conducted in Portugal, aiming to characterize the chronotype and determine its relation to the phenotype and dietary patterns of patients with obesity and healthy participants.

Methods

Adults with obesity (study group) and healthy adults (control group), aged between 18 and 75, will be enrolled in this study. Data will be collected to characterize the chronotype, dietary intake, and sleep quality through validated questionnaires. Body composition will also be assessed, and blood samples will be collected to quantify circadian and metabolic biomarkers.

Discussion

This study is expected to contribute to a better understanding of the impact of obesity and dietary intake on circadian biomarkers and, therefore, increase scientific evidence to help future therapeutic interventions based on chronobiology, with a particular focus on nutritional interventions.

Personal Devices to Monitor Physical Activity and Nutritional Intake After Colorectal Cancer Surgery: Feasibility Study

BACKGROUND

The use of self-monitoring devices is promising for improving perioperative physical activity and nutritional intake.

OBJECTIVE

This study aimed to assess the feasibility, usability, and acceptability of a physical activity tracker and digital food record in persons scheduled for colorectal cancer (CRC) surgery.

METHODS

This observational cohort study was conducted at a large training hospital between November 2019 and November 2020. The study population consisted of persons with CRC between 18- and 75 years of age who were able to use a smartphone or tablet and scheduled for elective surgery with curative intent. Excluded were persons not proficient in Dutch or following a protein-restricted diet. Participants used an activity tracker (Fitbit Charge 3) from 4 weeks before until 6 weeks after surgery. In the week before surgery (preoperative) and the fifth week after surgery (postoperative), participants also used a food record for 1 week. They shared their experience regarding usability (system usability scale, range 0-100) and acceptability (net promoter score, range -100 to +100).

RESULTS

In total, 28 persons were included (n=16, 57% male, mean age 61, SD 8 years), and 27 shared their experiences. Scores regarding the activity tracker were as follows: preoperative median system usability score, 85 (IQR 73-90); net promoter score, +65; postoperative median system usability score, 78 (IQR 68-85); net promotor score, +67. The net promoter scores regarding the food record were +37 (preoperative) and-7 (postoperative).

CONCLUSIONS

The perioperative use of a physical activity tracker is considered feasible, usable, and acceptable by persons with CRC in this study. Preoperatively, the use of a digital food record was acceptable, and postoperatively, the acceptability decreased.

Characteristics of smartphone-based dietary assessment tools: a systematic review

Smartphones have become popular in assessing eating behaviour in real-life and real-time. This systematic review provides a comprehensive overview of smartphone-based dietary assessment tools, focusing on how dietary data is assessed and its completeness ensured. Seven databases from behavioural, social and computer science were searched in March 2020. All observational, experimental or intervention studies and study protocols using a smartphone-based assessment tool for dietary intake were included if they reported data collected by adults and were published in English. Out of 21,722 records initially screened, 117 publications using 129 tools were included. Five core assessment features were identified: photo-based assessment (48.8% of tools), assessed serving/ portion sizes (48.8%), free-text descriptions of food intake (42.6%), food databases (30.2%), and classification systems (27.9%). On average, a tool used two features. The majority of studies did not implement any features to improve completeness of the records. This review provides a comprehensive overview and framework of smartphone-based dietary assessment tools to help researchers identify suitable assessment tools for their studies. Future research needs to address the potential impact of specific dietary assessment methods on data quality and participants' willingness to record their behaviour to ultimately improve the quality of smartphone-based dietary assessment for health research.

Development and Validation of a Smartphone Application for Telenutrition in Patients with Inflammatory Bowel Disease

The use of smartphone-based applications as a telenutrition tool could redefine the nutritional management of IBD. We developed and validated a digital health platform in the form of a smartphone application for the nutritional assessment of IBD patients. Our team of gastroenterologists and dieticians at the All-India Institute of Medical Sciences, New Delhi developed a smartphone application titled IBD NutriCare, which was made available in both Android and iOS interfaces in English and seven other Indian languages. The application includes >650 Indian recipes and provides subjective global assessment and IBD clinical activity scores in a patient-friendly manner. The utility of the smartphone app was validated in comparison with the traditional 24-h dietary recall method. A total of 49 IBD patients were enrolled in the study. The mean difference in energy intake between the two dietary assessment methods was −4.776 kJ (95% LOA, range −417.916−408.365 kJ). A total of 94% of patients found the smartphone application convenient and acceptable in comparison to the recall method for dietary assessment. Bland−Altman plots showed a good level of agreement for nutrients and food groups between the two methods. Telenutrition in the form of a smartphone application helps in real-time tracking of dietary details of IBD patients, thus making appropriate interventions and large-scale data acquisition feasible.

Development and validation of a smartphone image-based app for dietary intake assessment among Palestinian undergraduates

Accurate dietary assessment is required in a variety of research fields and clinical settings. Image-based dietary assessment using smartphones applications offer the opportunity to reduce both researcher and participant burden compared to traditional dietary assessment methods. The current study, conducted in Palestine, aimed to design an image-based dietary assessment application, to assess the relative validity of the application as a dietary assessment tool for energy and macronutrient intake using the 3-Day Food Record (3-DFR) as a reference method, and to test its usability among a sample of Palestinian university students. The development of a smartphone application (Ghithaona) designed to assess energy and macronutrient intake is reported. The application validity was tested among a sample of Palestinian undergraduates from An-Najah National University. Participants recorded their dietary intake using the Ghithaona application over 2 consecutive days and 1 weekend day. Intake from the Ghithaona application were compared to intake collected from 3-DFR, taken on 2 consecutive weekdays and 1 weekend day, in the second week following the Ghithaona application. At the end of the study, participants completed an exit survey to test assess application usability and to identify barriers to its use. Mean differences in energy, and macronutrients intake were evaluated between the methods using paired t-tests or Wilcoxon signed-rank tests. Agreement between methods was ascertained using Pearson correlations and Bland–Altman plots. The Ghithaona application took 6 months to develop. The validation test was completed by 70 participants with a mean age of 21.0 ± 2.1 years. No significant differences were found between the two methods for mean intakes of energy or macronutrients (p > 0.05). Significant correlations between the two methods were observed for energy, and all macronutrients (r = 0.261–0.58, p ≤ 0.05). Bland–Altman plots confirmed wide limits of agreement between the methods with no systematic bias. According to the exit survey, it was found that majority of participants strongly agreed and agreed that the application saves time (94.2%), helps the participant to pay attention to their dietary habits (87.2%), and is easy to use (78.6%). The Ghithaona application showed relative validity for assessment of nutrient intake of Palestinian undergraduates.

Validation of a Smartphone Application for the Assessment of Dietary Compliance in an Intermittent Fasting Trial

Accurate dietary analysis of energy, nutrient intake, and meal timing in human studies using traditional dietary assessment methods (e.g., food records) is challenging and time-consuming. The widespread use of smartphones, tablets, and nutrition applications (apps) can overcome some of these problems. The objective of this study was to evaluate the validity of an FDDB smartphone app and food database compared with PRODI®—a professional platform for nutritional counselling using the German Nutrient Database. Dietary records were collected from 10 subjects participating in the crossover intermittent fasting trial for 2 weeks at baseline and during the eating timeframe of 8 h (early or late in the course of the day). The FDDB app and database enabled a quicker and less sophisticated analysis of food composition and timing than the PRODI® software. Good agreement between the methods was found for energy and macronutrient intakes, while the FDDB data on most micronutrients and saturated/unsaturated fat intake were unreliable. In contrast to PRODI®, FDDB provided effective assessment of timely compliance, making it a promising tool for chrononutritional studies. Thus, the FDDB app is comparable to the traditional PRODI® dietary assessment method, and can be effectively used in human dietary trials and medical practice for specific goals.

Improvement of Methodology for Manual Energy Intake Estimation From Passive Capture Devices

Objective

To describe best practices for manual nutritional analyses of data from passive capture wearable devices in free-living conditions.

Method

18 participants (10 female) with a mean age of 45 ± 10 years and mean BMI of 34.2 ± 4.6 kg/m² consumed usual diet for 3 days in a free-living environment while wearing an automated passive capture device. This wearable device facilitates capture of images without manual input from the user. Data from the first nine participants were used by two trained nutritionists to identify sources contributing to inter-nutritionist variance in nutritional analyses. The nutritionists implemented best practices to mitigate these sources of variance in the next nine participants. The three best practices to reduce variance in analysis of energy intake (EI) estimation were: (1) a priori standardized food selection, (2) standardized nutrient database selection, and (3) increased number of images captured around eating episodes.

Results

Inter-rater repeatability for EI, using intraclass correlation coefficient (ICC), improved by 0.39 from pre-best practices to post-best practices (0.14 vs 0.85, 95% CI, respectively), Bland–Altman analysis indicated strongly improved agreement between nutritionists for limits of agreement (LOA) post-best practices.

Conclusion

Significant improvement of ICC and LOA for estimation of EI following implementation of best practices demonstrates that these practices improve the reproducibility of dietary analysis from passive capture device images in free-living environments.

PEGASO e-Diary: User Engagement and Dietary Behavior Change of a Mobile Food Record for Adolescents

Background

Obesity amongst children and adolescents is becoming a major health problem globally and mobile food records can play a crucial role in promoting healthy dietary habits.

Objective

To describe the methodology for the implementation of the e-Diary mobile food record, to assess its capability in promoting healthy eating habits, to evaluate the factors associated with its usage and engagement.

Methods

This is a descriptive study that compared the characteristics of participants engaged in the e-Diary, which was part of the PEGASO project in which an app to provide proactive health promotion was given to 365 students at 4 European sites enrolled during October to December 2016: England (UK), Scotland (UK), Lombardy (Italy), and Catalonia (Spain). The e-Diary tracked the users' dietary habits in terms of food groups, dietary indexes, and 6 dietary target behaviors relating to consumption of: fruit; vegetable; breakfast; sugar-sweetened beverages; fast-food; and snacks. The e-Diary provided also personalized suggestions for the next meal and gamification.

Results

The e-Diary was used for 6 months by 357 adolescents (53.8% females). The study showed that females used the e-Diary much more than males (aOR 3.8, 95% CI 1.6-8.8). Participants aged 14 years were more engaged in the e-Diary than older age groups (aOR 5.1, 95% CI 1.4-18.8) as were those with a very good/excellent self-perceived health status compared to their peers with fair/poor health perception (aOR 4.2, 95% CI 1.3-13.3). Compared to the intervention sites, those living in Catalonia (aOR 13.2 95% CI 2.5-68.8) were more engaged. In terms of behavior change, a significant positive correlation between fruit (p < 0.0001) and vegetables (p = 0.0087) intake was observed in association with increased engagement in the e-Diary. Similarly, adolescents who used the app for more than 2 weeks had significantly higher odds of not skipping breakfast over the study period (aOR 2.5, 95% CI 1.0-6.3).

Conclusions

The users highly engaged with the e-Diary were associated with improved dietary behaviors: increased consumption of fruit and vegetables and reduced skipping of breakfast. Although the overall usage of the e-Diary was high during the first weeks, it declined thereafter. Future applications should foster user engagement, particularly targeting adolescents at high risk.

Clinical Trial Registration

https://www.clinicaltrials.gov/, identifier: NCT02930148.

A mobile phone application intervention to promote healthy salt intake among adults: Protocol for a randomized controlled study (Preprint)

Background

There is sound evidence associating high salt intake and a greater risk of cardiovascular and noncardiovascular diseases. High salt intake has been observed in several populations worldwide. Therefore, promoting healthier salt consumption has been encouraged as a low-cost strategy to reduce this risk factor. However, these strategies need to be sound, built on theoretical and methodological bases, and consider the target population’s context.

Objective

This protocol aims to describe a mobile phone app intervention to promote healthy salt intake among adults.

Methods

This is an experimental and longitudinal study protocol conducted in three modules. Module 1 refers to the planning of the intervention based on the Behaviour Change Wheel framework. Module 2 is the development of the mobile phone app intervention based on the date of module 1. In module 3, the intervention will be evaluated using a randomized controlled study, with three steps of data collection in a 2-month follow-up in a sample of 86 adults (43 participants for each group: the control group and intervention group) recruited from the primary health care centers of a Brazilian town. The discretionary salt intake questionnaire will assess salt consumption, the app usability will be assessed using the System Usability Scale, and psychosocial variables (habit, intention, and self-efficacy) will also be measured.

Results

Recruitment began in October 2021, and the follow-up will end in August 2022. The results of this study are expected to be published in 2023.

Conclusions

Results from this study will help people to control salt intake when cooking at home, will stimulate self-care, will work as an alternative or supportive method in the relationship between health care professionals and patients, and will contribute to implementing the app intervention to promote healthy salt intake on a large scale.

Trial Registration

The Brazilian Clinical Trials Registry RBR-4s8qyyq; https://ensaiosclinicos.gov.br/rg/RBR-4s8qyyq

International Registered Report Identifier (IRRID)

DERR1-10.2196/37853

Design issues in personalized nutrition advice systems (Preprint)

The current health status of the general public can substantially benefit from a healthy diet. Using a personalized approach to initiate healthy dietary behavior seems to be a promising strategy, as individuals differ in terms of health status, subsequent dietary needs, and their desired behavior change support. However, providing personalized advice to a wide audience over a long period is very labor-intensive. This bottleneck can possibly be overcome by digitalizing the process of creating and providing personalized advice. An increasing number of personalized advice systems for different purposes is becoming available in the market, ranging from systems providing advice about just a single parameter to very complex systems that include many variables characterizing each individual situation. Scientific background is often lacking in these systems. In designing a personalized nutrition advice system, many design questions need to be answered, ranging from the required input parameters and accurate measurement methods (sense), type of modeling techniques to be used (reason), and modality in which the personalized advice is provided (act). We have addressed these topics in this viewpoint paper, and we have demonstrated the feasibility of setting up an infrastructure for providing personalized dietary advice based on the experience of 2 practical applications in a real-life setting.

Mobile applications for the sport and exercise nutritionist: a narrative review

Mobile technology is widespread in modern society, and the applications (apps) that they run can serve various purposes. Features such as portability, ease of communication, storage, and relative low cost may make such technology attractive to practitioners in several fields. This review provides a critical narrative on the existing literature for apps relevant to the field of sport and exercise nutrition. Three main areas are discussed: (1) dietary analysis of athletes, (2) nutrition education for athletes, (3) estimating body composition. The key purpose of the review was to identify what literature is available, in what areas apps may have a benefit over traditional methods, and considerations that practitioners should make before they implement apps into their practice or recommend their use to coaches and athletes.

Performance of the Digital Dietary Assessment Tool MyFoodRepo

Digital dietary assessment devices could help overcome the limitations of traditional tools to assess dietary intake in clinical and/or epidemiological studies. We evaluated the accuracy of the automated dietary app MyFoodRepo (MFR) against controlled reference values from weighted food diaries (WFD). MFR's capability to identify, classify and analyze the content of 189 different records was assessed using Cohen and uniform kappa coefficients and linear regressions. MFR identified 98.0% ± 1.5 of all edible components and was not affected by increasing numbers of ingredients. Linear regression analysis showed wide limits of agreement between MFR and WFD methods to estimate energy, carbohydrates, fat, proteins, fiber and alcohol contents of all records and a constant overestimation of proteins, likely reflecting the overestimation of portion sizes for meat, fish and seafood. The MFR mean portion size error was 9.2% ± 48.1 with individual errors ranging between -88.5% and +242.5% compared to true values. Beverages were impacted by the app's difficulty in correctly identifying the nature of liquids (41.9% ± 17.7 of composed beverages correctly classified). Fair estimations of portion size by MFR, along with its strong segmentation and classification capabilities, resulted in a generally good agreement between MFR and WFD which would be suited for the identification of dietary patterns, eating habits and regime types.

Perspective: Opportunities and Challenges of Technology Tools in Dietary and Activity Assessment: Bridging Stakeholder Viewpoints

The science and tools of measuring energy intake and output in humans have rapidly advanced in the last decade. Engineered devices such as wearables and sensors, software applications, and Web-based tools are now ubiquitous in both research and consumer environments. The assessment of energy expenditure in particular has progressed from reliance on self-report instruments to advanced technologies requiring collaboration across multiple disciplines, from optics to accelerometry. In contrast, assessing energy intake still heavily relies on self-report mechanisms. Although these tools have improved, moving from paper-based to online reporting, considerable room for refinement remains in existing tools, and great opportunities exist for novel, transformational tools, including those using spectroscopy and chemo-sensing. This report reviews the state of the science, and the opportunities and challenges in existing and emerging technologies, from the perspectives of 3 key stakeholders: researchers, users, and developers. Each stakeholder approaches these tools with unique requirements: researchers are concerned with validity, accuracy, data detail and abundance, and ethical use; users with ease of use and privacy; and developers with high adherence and utilization, intellectual property, licensing rights, and monetization. Cross-cutting concerns include frequent updating and integration of the food and nutrient databases on which assessments rely, improving accessibility and reducing disparities in use, and maintaining reliable technical assistance. These contextual challenges are discussed in terms of opportunities and further steps in the direction of personalized health.

Nutrient and Food Group Prediction as Orchestrated by an Automated Image Recognition System in a Smartphone App (CALO mama): Validation Study

Background

A smartphone image recognition app is expected to be a novel tool for measuring nutrients and food intake, but its performance has not been well evaluated.

Objective

We assessed the accuracy of the performance of an image recognition app called CALO mama in terms of the nutrient and food group contents automatically estimated by the app.

Methods

We prepared 120 meal samples for which the nutrients and food groups were calculated. Next, we predicted the nutrients and food groups included in the meals from their photographs by using (1) automated image recognition only and (2) manual modification after automatic identification.

Results

Predictions generated using only image recognition were similar to the actual data on the weight of meals and were accurate for 11 out of 30 nutrients and 4 out of 15 food groups. The app underestimated energy, 19 nutrients, and 9 food groups, while it overestimated dairy products and confectioneries. After manual modification, the predictions were similar for energy, accurately capturing the nutrients for 29 out of 30 of meals and the food groups for 10 out of 15 meals. The app underestimated pulses, fruits, and meats, while it overestimated weight, vitamin C, vegetables, and confectioneries.

Conclusions

The results of this study suggest that manual modification after prediction using image recognition improves the performance of the app in assessing the nutrients and food groups of meals. Our findings suggest that image recognition has the potential to achieve a description of the dietary intakes of populations by using “precision nutrition” (a comprehensive and dynamic approach to developing tailored nutritional recommendations) for individuals.

Does the use of mobile applications or mobile health technology improve diet quality in adults? A protocol for a systematic literature review

Background: Mobile technology has grown at an exceptional rate and is now a huge part of our daily living. This use of mobile technology has opened up new possibilities in treating health, with almost half of the current applications linked to the mHealth sector. In particular, dietary measurement, applications have become very accessible and very popular. As dietary issues have become more prevalent, more mobile and mHealth applications offer various solutions. This systematic review aims to address if the use of such mobile applications or mobile health technology can improve diet quality in adults that interact with them. Methods: A systematic review of randomised controlled trials (RCTs) and non-randomised controlled trials (NRCTs) will be conducted. The Cumulative Index to Nursing and Allied Health Literature (Cinahl), The American Psychological Association’s (APA Psycinfo), and PubMed will be searched from January 2010 to November 2021. Primary outcomes will include identifying if adults who use mobile applications and health technology improve their diet quality compared to adults who do not use this technology. Study selection will follow the Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA) guidelines. The methodological appraisal of the studies will be assessed independently by two different reviewers (AS and JR) using the Cochrane Risk-of-Bias Tool for RCTs and the Risk-of Bias In Non-Randomised Studies Tool for NRCTs. Ethics and dissemination: Ethical approval is not essential for this systematic review. Only data from studies that are publically available from previously published studies will be used. The findings of this systematic review will be submitted for publication in a peer-reviewed journal and presented at relevant conferences. PROSPERO registration: CRD42021240224 (01/03/2021).

Accuracy and Cost-effectiveness of Technology-Assisted Dietary Assessment Comparing the Automated Self-administered Dietary Assessment Tool, Intake24, and an Image-Assisted Mobile Food Record 24-Hour Recall Relative to Observed Intake: Protocol for a Randomized Crossover Feeding Study

BACKGROUND

The assessment of dietary intake underpins population nutrition surveillance and nutritional epidemiology and is essential to inform effective public health policies and programs. Technological advances in dietary assessment that use images and automated methods have the potential to improve accuracy, respondent burden, and cost; however, they need to be evaluated to inform large-scale use.

OBJECTIVE

The aim of this study is to compare the accuracy, acceptability, and cost-effectiveness of 3 technology-assisted 24-hour dietary recall (24HR) methods relative to observed intake across 3 meals.

METHODS

Using a controlled feeding study design, 24HR data collected using 3 methods will be obtained for comparison with observed intake. A total of 150 healthy adults, aged 18 to 70 years, will be recruited and will complete web-based demographic and psychosocial questionnaires and cognitive tests. Participants will attend a university study center on 3 separate days to consume breakfast, lunch, and dinner, with unobtrusive documentation of the foods and beverages consumed and their amounts. Following each feeding day, participants will complete a 24HR process using 1 of 3 methods: the Automated Self-Administered Dietary Assessment Tool, Intake24, or the Image-Assisted mobile Food Record 24-Hour Recall. The sequence of the 3 methods will be randomized, with each participant exposed to each method approximately 1 week apart. Acceptability and the preferred 24HR method will be assessed using a questionnaire. Estimates of energy, nutrient, and food group intake and portion sizes from each 24HR method will be compared with the observed intake for each day. Linear mixed models will be used, with 24HR method and method order as fixed effects, to assess differences in the 24HR methods. Reporting bias will be assessed by examining the ratios of reported 24HR intake to observed intake. Food and beverage omission and intrusion rates will be calculated, and differences by 24HR method will be assessed using chi-square tests. Psychosocial, demographic, and cognitive factors associated with energy misestimation will be evaluated using chi-square tests and multivariable logistic regression. The financial costs, time costs, and cost-effectiveness of each 24HR method will be assessed and compared using repeated measures analysis of variance tests.

RESULTS

Participant recruitment commenced in March 2021 and is planned to be completed by the end of 2021.

CONCLUSIONS

This protocol outlines the methodology of a study that will evaluate the accuracy, acceptability, and cost-effectiveness of 3 technology-enabled dietary assessment methods. This will inform the selection of dietary assessment methods in future studies on nutrition surveillance and epidemiology.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12621000209897; https://tinyurl.com/2p9fpf2s.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/32891.

The Influence of the COVID-19 Pandemic on the Food Supply in the Emergency Food System: A Case Study at 2 Food Pantries

BACKGROUND

The onset of the coronavirus disease 2019 (COVID-19) pandemic increased demand for emergency food assistance and has caused operational shifts in the emergency food system.

OBJECTIVE

This research explored how the initial phase of the COVID-19 pandemic influenced the food supply of 2 food pantries.

METHODS

A case study approach was applied to collect data during the initial phase of the COVID-19 pandemic. Food supply data were collected weekly at 2 food pantries in southwest Montana for 17 wk in 2020. Surveys and interviews were conducted with food pantry clients and staff, respectively. Descriptive statistics and inferential statistics were applied to analyze quantitative data. Food supply data were analyzed using the Healthy Eating Index (HEI)-2015, NOVA system, and Unprocessed Pantry Project (UP3) Framework. Thematic analysis was applied to qualitative data.

RESULTS

The food boxes collected between the 2 food pantries (n = 43) had a mean (± SD) total HEI-2015 score of 76.41 ± 7.37 out of a possible score of 100. According to both the NOVA and the UP3 Framework, 23.4% of the total food distributed was ultra-processed food. Of the food distributed, 50.0% and 48.3% was fresh, unprocessed food according to NOVA and UP3 Frameworks, respectively. From staff interviews, 3 themes arose that describe the food pantry operations that experienced change during the COVID-19 pandemic, including food procurement, distribution preparation, and food distribution. Nine supporting subthemes describing the causes and consequences of the operational themes were identified. Staff perceived that the nutrient quality of the food boxes increased from food distributed previously to the COVID-19 pandemic, whereas over one-third (39.4%) of food pantry clients who responded to surveys preferred the food box model.

CONCLUSIONS

The COVID-19 pandemic has caused enormous operational challenges within food pantries. Food pantries overcame these challenges by swiftly and effectively altering operations so as to continue to distribute nutritious food boxes to pantry clients.

Evaluation of the Diet Tracking Smartphone Application Keenoa™: A Qualitative Analysis

Keenoa™ is a novel Canadian diet application (app) currently used by Canadian dietitians to collect diet-related data from clients. The goal of this study was to evaluate Keenoa™ based on user feedback and compare it to a conventional pen and paper method. One hundred and two participants were recruited and randomly assigned to record their diets using this application for 3 nonconsecutive days. Following this, participants were invited to complete an online "exit" survey. Seventy-two subjects responded, with 50 completing an open-ended question asking for general feedback about the app. Data were reviewed and 3 main themes emerged: strengths, challenges, and future recommendations. Strengths associated with the app consisted of picture recognition software, the additional commentary feature, and the overall pleasant data collection process. Challenges that were identified included inconsistencies with the barcode scanning features, the limited food database, time to enter food details, and software issues. Future recommendations included using a larger food database, pairing dietary intake with physical activity monitoring, and having accessible nutritional data. Despite these limitations, participants preferred using mobile apps to record diet compared with traditional written food diaries.

Energy Intake Evaluation by a Learning Approach Using the Number of Food Portions and Body Weight

An accurate quantification of energy intake is critical; however, under-reporting is frequent. The aim of this study was to develop an indirect statistical method of the total energy intake estimation based on gender, weight, and the number of portions. The energy intake prediction was developed and evaluated for validity using energy expenditure. Subjects with various BMIs were recruited and assigned either in the training or the test group. The mean energy provided by a portion was evaluated by linear regression models from the training group. The absolute values of the error between the energy intake estimation and the energy expenditure measurement were calculated for each subject, by subgroup and for the whole group. The performance of the models was determined using the test dataset. As the number of portions is the only variable used in the model, the error was 26.5%. After adding body weight in the model, the error decreased to 8.8% and 10.8% for the normal-weight women and men, respectively, and 11.7% and 12.8% for the overweight women and men, respectively. The results prove that a statistical approach and knowledge of the usual number of portions and body weight is effective and sufficient to obtain a precise evaluation of energy intake after a simple and brief enquiry.

Improving routine immunization data quality using daily short message system reporting platform: An experience from Nasarawa state, Nigeria

Routine immunization (RI) delivery was declared a public health concern in Nigeria in 2017 because of persistently low immunization coverage rates reported in independent surveys. However, administrative coverage rates remain high, suggesting serious data quality issues. We posit that a shorter timespan between service provision and data reporting can improve the monitoring of RI data, and developed a short message system (SMS) text reporting strategy to generate daily RI data points from health facilities (HFs). The goal was to assess whether daily data collection produces complete, reliable and internally consistent data points. The SMS reporting platform was piloted between December 2017 and April 2018 in two Local Government Areas (LGAs, equivalent to districts) of Nasarawa state, Nigeria. The 145 healthcare workers from 55 HFs received one mobile phone and pre-configured SIM card, and were trained to send data through predefined codes. Healthcare workers compiled the data after each vaccination session and transmitted them via SMS. We analyzed completeness, number of weekly sessions, and supportive supervision conducted. During the pilot phase, we received data from 85% (n = 47) of the 55 HFs. We expected 66 fixed-post sessions and 30 outreach sessions per week, but received data for 33 fixed-post and 8 outreach weekly session on average. More HFs reported on Tuesdays compared to other days of the week. When assessing internal consistency, we observed that the reported number of children vaccinated was sometimes higher than the number of doses available from opening a given number of vaccine vials. When found, this discrepancy was noted for all antigens during fixed-post and outreach vaccination sessions. Despite these initial discrepancies, transmitting RI data sessions via texting is feasible and can provide real-time updates to the performance of the RI services at the HF level.

Applicability of machine learning techniques in food intake assessment: A systematic review

The evaluation of food intake is important in scientific research and clinical practice to understand the relationship between diet and health conditions of an individual or a population. Large volumes of data are generated daily in the health sector. In this sense, Artificial Intelligence (AI) tools have been increasingly used, for example, the application of Machine Learning (ML) algorithms to extract useful information, find patterns, and predict diseases. This systematic review aimed to identify studies that used ML algorithms to assess food intake in different populations. A literature search was conducted using five electronic databases, and 36 studies met all criteria and were included. According to the results, there has been a growing interest in the use of ML algorithms in the area of nutrition in recent years. Also, supervised learning algorithms were the most used, and the most widely used method of nutritional assessment was the food frequency questionnaire. We observed a trend in using the data analysis programs, such as R and WEKA. The use of ML in nutrition is recent and challenging. Therefore, it is encouraged that more studies are carried out relating these themes for the development of food reeducation programs and public policies.

The church bridge project focus group results: African American perspectives of weight management programs to improve nutrition and physical activity behaviors

Background

The prevalence of obesity is disproportionately high among African Americans in the Southern US. More information is needed about factors that influence participation in nutrition and physical activity programs to promote healthy weight.

Objective

The purpose of this study is to explore the weight management perceptions of young to middle aged adult African Americans.

Methods

The Church Bridge Project intervention participants were recruited for two focus groups. Qualitative data were recorded, transcribed and a thematic content analysis was conducted to identify major themes.

Results

Barriers included technology learning curve/burden and competing priorities. Facilitators included support, limited cost, convenience, and health. Participants perceived the term “weight management” program as overwhelming and defeating.

Conclusion

The Church Bridge Project model confirmed social support and disease prevention as key factors for weight management. Further work should substantiate social support as a key factor to guide minority health efforts.

Performing nutrition assessment remotely via telehealth

Performing nutrition assessment remotely via telehealth is a topic of significant interest given the global pandemic in 2020 that has necessitated physical distancing and virtual communications. This review presents an evidence-based approach to conducting nutrition assessments remotely. The authors present suggestions for adaptations that can be used to perform a remote nutrition-focused physical exam. Direct-to-consumer technologies that can be used in remote nutrition assessment are discussed and compared. Practice tips for conducting a telehealth visit are also presented. The aim of this publication is to provide interdisciplinary clinicians a set of guidelines and best practices for performing nutrition assessments in the era of telehealth.

Validity of New Technologies That Measure Bone-Related Dietary and Physical Activity Risk Factors in Adolescents and Young Adults: A Scoping Review

New technologies may improve the validity of dietary and physical activity assessment and thereby associated findings for lifestyle-related bone health research. This scoping review mapped the evidence for the validity of new technologies that measure bone-related dietary and physical activity risk factors in adolescents and young adults. A systematic literature search was conducted using seven electronic databases for peer-reviewed studies published from January 2008 to 2021. Four studies from four countries were deemed eligible and included in the qualitative synthesis for this review. Two studies assessed diet, reporting the validity or usability of apps. Apps were shown to be a valid tool to measure the dietary intake of vitamin D (r = 0.84) and calcium (r = 0.63). Two studies assessed physical activity and reported the validity of wearable devices to measure impact loading. Hip-worn raw acceleration output correlated positively with ground reaction forces (GRF) for both studies (r range = 0.50–0.87), but wrist-worn accelerations and loading outcomes differed between studies, reporting poor to strong correlations (r range = 0.17–0.87). More research to provide robust evidence concerning validity, reliability, usability and engagement for the use of newer technologies is needed for future diet and physical activity bone research.

A Systematic Review and Meta-Analysis of Validation Studies Performed on Dietary Record Apps

Mobile dietary record apps have been increasingly validated by studies with various study designs. This review aims to evaluate the overall accuracy of dietary record apps in measuring the intake of energy, macro- and micronutrients, and food groups in real-life settings and the designs of validation studies. We systematically searched mobile dietary record validation studies published during the period from 2013 to 2019. We identified 14 studies for the systematic review, of which 11 studies were suitable for meta-analyses on energy intake and 8 studies on macronutrient intake. Mean differences and SDs of nutrient estimations between the app and the reference method from studies were pooled using a random-effects model. All apps underestimated energy intake when compared with their reference methods, with a pooled effect of -202 kcal/d (95% CI: -319, -85 kcal/d); the heterogeneity of studies was 72%. After stratification, studies that used the same food-composition table for both the app and the reference method had a lower level of heterogeneity (0%) and a pooled effect of -57 kcal/d (95% CI: -116, 2 kcal/d). The heterogeneity of studies in the differences in carbohydrate, fat, and protein intake was 54%, 73%, and 80%, with the pooled effect of -18.8 g/d, -12.7 g/d, and -12.2 g/d, respectively, after excluding outliers. The intakes of micronutrients and food groups were statistically nonsignificantly underestimated by the apps in most cases. In conclusion, dietary record apps underestimated food consumption compared with traditional dietary assessment methods. Moreover, varying study designs have been found across studies. Recommended practices for conducting validation studies were formulated including considering biomarkers as the reference, testing in a larger and more representative study population for a longer period, avoiding the learning effect of each method, and comparing food group or food item consumption in addition to comparing energy and nutrient intakes.

Evaluation of PIQNIQ, a Novel Mobile Application for Capturing Dietary Intake

BACKGROUND

Accurate measurement of dietary intake is vital for providing nutrition interventions and understanding the complex role of diet in health. Traditional dietary assessment methods are very resource intensive and burdensome to participants. Technology may help mitigate these limitations and improve dietary data capture.

OBJECTIVE

Our objective was to evaluate the accuracy of a novel mobile application (PIQNIQ) in capturing dietary intake by self-report. Our secondary objective was to assess whether food capture using PIQNIQ was comparable with an interviewer-assisted 24-h recall (24HR).

METHODS

This study was a single-center randomized clinical trial enrolling 132 adults aged 18 to 65 y from the general population. Under a provided-food protocol with 3 menus designed to include a variety of foods, participants were randomly assigned to 1 of 3 food capture methods: simultaneous entry using PIQNIQ, photo-assisted recall using PIQNIQ, and 24HR. Primary outcomes were energy and nutrient content (calories, total fat, carbohydrates, protein, added sugars, calcium, dietary fiber, folate, iron, magnesium, potassium, saturated fat, sodium, and vitamins A, C, D, and E) captured by the 3 methods.

RESULTS

The majority of nutrients reported were within 30% of consumed intake in all 3 food capture methods (n = 129 completers). Reported intake was highly (>30%) overestimated for added sugars in both PIQNIQ groups and underestimated for calcium in the photo-assisted recall group only (P < 0.001 for all). However, in general, both PIQNIQ methods had similar levels of accuracy and were comparable to the 24HR except in their overestimation (>30%) of added sugars and total fat (P < 0.001 for both).

CONCLUSIONS

Our results suggest that intuitive, technology-based methods of dietary data capture are well suited to modern users and, with proper execution, can provide data that are comparable to data obtained with traditional methods. This trial was registered at clinicaltrials.gov as NCT03578458.

Harnessing SmartPhones to Personalize Nutrition in a Time of Global Pandemic

The soar in COVID-19 cases around the globe has forced many to adapt to social distancing and self-isolation. In order to reduce contact with healthcare facilities and other patients, the CDC has advocated the use of telemedicine, i.e., electronic information and telecommunication technology. While these changes may disrupt normal behaviors and routines and induce anxiety, resulting in decreased vigilance to healthy diet and physical activity and reluctance to seek medical attention, they may just as well be circumvented using modern technology. Indeed, as the beginning of the pandemic a plethora of alternatives to conventional physical interactions were introduced. In this Perspective, we portray the role of SmartPhone applications (apps) in monitoring healthy nutrition, from their basic functionality as food diaries required for simple decision-making and nutritional interventions, through more advanced purposes, such as multi-dimensional data-mining and development of machine learning algorithms. Finally, we will delineate the emerging field of personalized nutrition and introduce pioneering technologies and concepts yet to be incorporated in SmartPhone-based dietary surveillance.

The Human Factor in Automated Image-Based Nutrition Apps: Analysis of Common Mistakes Using the goFOOD Lite App

Background

Technological advancements have enabled nutrient estimation by smartphone apps such as goFOOD. This is an artificial intelligence–based smartphone system, which uses food images or video captured by the user as input and then translates these into estimates of nutrient content. The quality of the data is highly dependent on the images the user records. This can lead to a major loss of data and impaired quality. Instead of removing these data from the study, in-depth analysis is needed to explore common mistakes and to use them for further improvement of automated apps for nutrition assessment.

Objective

The aim of this study is to analyze common mistakes made by participants using the goFOOD Lite app, a version of goFOOD, which was designed for food-logging, but without providing results to the users, to improve both the instructions provided and the automated functionalities of the app.

Methods

The 48 study participants were given face-to-face instructions for goFOOD Lite and were asked to record 2 pictures (1 recording) before and 2 pictures (1 recording) after the daily consumption of each food or beverage, using a reference card as a fiducial marker. All pictures that were discarded for processing due to mistakes were analyzed to record the main mistakes made by users.

Results

Of the 468 recordings of nonpackaged food items captured by the app, 60 (12.8%) had to be discarded due to errors in the capturing procedure. The principal problems were as follows: wrong fiducial marker or improper marker use (19 recordings), plate issues such as a noncompatible or nonvisible plate (8 recordings), a combination of various issues (17 recordings), and other reasons such as obstacles (hand) in front of the camera or matching recording pairs (16 recordings).

Conclusions

No other study has focused on the principal problems in the use of automatic apps for assessing nutritional intake. This study shows that it is important to provide study participants with detailed instructions if high-quality data are to be obtained. Future developments could focus on making it easier to recognize food on various plates from its color or shape and on exploring alternatives to using fiducial markers. It is also essential for future studies to understand the training needed by the participants as well as to enhance the app’s user-friendliness and to develop automatic image checks based on participant feedback.

Evaluation of the Ability of Diet-Tracking Mobile Applications to Estimate Energy and Nutrient Intake in Japan

We evaluated the energy and nutrient intake estimates of popular Japanese diet-tracking mobile applications (apps). We identified five diet-tracking apps in the iTunes store during August 2020. A researcher entered the dietary data from a one-day paper-based dietary record (DR) previously obtained from apparently healthy free-living adults (15 males and 15 females; 22-65 years) into each app. The energy and nutrient intakes estimated by the apps were compared with those calculated using the Standard Tables of Food Composition in Japan based on the paper-based DR (reference method). The number of dietary variables available ranged from one (energy in Mogutan) to 17 (FiNC). Compared to the DR-based estimates, the median energy intake was significantly overestimated by MyFitnessPal, Asken, Calomiru, and Mogutan. Moreover, the intakes of many nutrients were overestimated by Asken and Calomiru and underestimated by MyFitnessPal. For energy intake, the Spearman correlation coefficient between the DR and the apps was lowest for Mogutan (0.76) and highest for FiNC (0.96). The median correlation coefficient for nutrient intakes was lower in MyFitnessPal (0.50) than in the other three apps (0.80 in Asken, 0.87 in FiNC, and 0.88 in Calomiru). These results suggest that intake calculations differ among apps. Further evaluation is needed in free-living settings, where users input their own food intake.

Occurrence of and Reasons for "Missing Events" in Mobile Dietary Assessments: Results From Three Event-Based Ecological Momentary Assessment Studies

Background

Establishing a methodology for assessing nutritional behavior comprehensively and accurately poses a great challenge. Mobile technologies such as mobile image-based food recording apps enable eating events to be assessed in the moment in real time, thereby reducing memory biases inherent in retrospective food records. However, users might find it challenging to take images of the food they consume at every eating event over an extended period, which might lead to incomplete records of eating events (missing events).

Objective

Analyzing data from 3 studies that used mobile image-based food recording apps and varied in their technical enrichment, this study aims to assess how often eating events (meals and snacks) were missed over a period of 8 days in a naturalistic setting by comparing the number of recorded events with the number of normative expected events, over time, and with recollections of missing events.

Methods

Participants in 3 event-based Ecological Momentary Assessment (EMA) studies using mobile image-based dietary assessments were asked to record all eating events (study 1, N=38, 1070 eating events; study 2, N=35, 934 eating events; study 3, N=110, 3469 eating events). Study 1 used a basic app; study 2 included 1 fixed reminder and the possibility to add meals after the actual eating events occurred instead of in the moment (addendum); and study 3 included 2 fixed reminders, an addendum feature, and the option to record skipped meals. The number of recalled missed events and their reasons were assessed by semistructured interviews after the EMA period (studies 1 and 2) and daily questionnaires (study 3).

Results

Overall, 183 participants reported 5473 eating events. Although the momentary adherence rate as indexed by a comparison with normative expected events was generally high across all 3 studies, a differential pattern of results emerged with a higher rate of logged meals in the more technically intensive study 3. Multilevel models for the logging trajectories of reported meals in all 3 studies showed a significant, albeit small, decline over time (b=−.11 to −.14, Ps<.001, pseudo-R²=0.04-0.06), mainly because of a drop in reported snacks between days 1 and 2. Intraclass coefficients indicated that 38% or less of the observed variance was because of individual differences. The most common reasons for missing events were competing activities and technical issues, whereas situational barriers were less important.

Conclusions

Three different indicators (normative, time stability, and recalled missing events) consistently indicated missing events. However, given the intensive nature of diet EMA protocols, the effect sizes were rather small and the logging trajectories over time were remarkably stable. Moreover, the individual’s actual state and context seemed to exert a greater influence on adherence rates than stable individual differences, which emphasizes the need for a more nuanced understanding of the factors that affect momentary adherence.

Validity and Usability of a Smartphone Image-Based Dietary Assessment App Compared to 3-Day Food Diaries in Assessing Dietary Intake Among Canadian Adults: Randomized Controlled Trial

Background

Accurate dietary assessment is needed in studies that include analysis of nutritional intake. Image-based dietary assessment apps have gained in popularity for assessing diet, which may ease researcher and participant burden compared to traditional pen-to-paper methods. However, few studies report the validity of these apps for use in research. Keenoa is a smartphone image-based dietary assessment app that recognizes and identifies food items using artificial intelligence and permits real-time editing of food journals.

Objective

This study aimed to assess the relative validity of an image-based dietary assessment app — Keenoa — against a 3-day food diary (3DFD) and to test its usability in a sample of healthy Canadian adults.

Methods

We recruited 102 participants to complete two 3-day food records. For 2 weeks, on 2 non-consecutive days and 1 weekend day, in random order, participants completed a traditional pen-to-paper 3DFD and the Keenoa app. At the end of the study, participants completed the System Usability Scale. The nutrient analyses of the 3DFD and Keenoa data before (Keenoa-participant) and after they were reviewed by dietitians (Keenoa-dietitian) were analyzed using analysis of variance. Multiple tests, including the Pearson coefficient, cross-classification, kappa score, % difference, paired t test, and Bland-Altman test, were performed to analyze the validity of Keenoa (Keenoa-dietitian).

Results

The study was completed by 72 subjects. Most variables were significantly different between Keenoa-participant and Keenoa-dietitian (P<.05) except for energy, protein, carbohydrates, fiber, vitamin B1, vitamin B12, vitamin C, vitamin D, and potassium. Significant differences in total energy, protein, carbohydrates, % fat, saturated fatty acids, iron, and potassium were found between the 3DFD and Keenoa-dietitian data (P<.05). The Pearson correlation coefficients between the Keenoa-dietitian and 3DFD ranged from .04 to .51. Differences between the mean intakes assessed by the 3DFD and Keenoa-dietitian were within 10% except for vitamin D (misclassification rate=33.8%). The majority of nutrients were within an acceptable range of agreement in the Bland-Altman analysis; no agreements were seen for total energy, protein, carbohydrates, fat (%), saturated fatty acids, iron, potassium, and sodium (P<.05). According to the System Usability Scale, 34.2% of the participants preferred using Keenoa, while 9.6% preferred the 3DFD.

Conclusions

The Keenoa app provides acceptable relative validity for some nutrients compared to the 3DFD. However, the average intake of some nutrients, including energy, protein, carbohydrates, % fat, saturated fatty acids, and iron, differed from the average obtained using the 3DFD. These findings highlight the importance of verifying data entries of participants before proceeding with nutrient analysis. Overall, Keenoa showed better validity at the group level than the individual level, suggesting it can be used when focusing on the dietary intake of the general population. Further research is recommended with larger sample sizes and objective dietary assessment approaches.

Dietary Interventions for Healthy Pregnant Women: A Systematic Review of Tools to Promote a Healthy Antenatal Dietary Intake

Maternal nutrition is essential for the development and lifelong health of the offspring. Antenatal care provides unique opportunities for nutrition communication, and health promotion tools (e.g., guidelines, instruments, packages, or resources) might help to overcome several concurrent barriers. We conducted a systematic literature review to map tools that are available for the promotion of a healthy dietary intake in healthy pregnant women in Western countries, and to identify what makes these tools feasible and effective for these women and their healthcare providers. Seventeen studies were included, evaluating tools with various delivery modes, content, and providers. Nine studies employed multiple, complementary delivery methods and almost all studies (n = 14) tailored the content to varying degrees, based on the individual characteristics and lifestyle behaviors of the participants. We found that the feasibility of a tool was dependent on practical issues, time investment, and providers’ motivation, skills, and knowledge, while the effectiveness was related more to the type of provider and the content. Most effective interventions were provided by dietitians and nutritionists, and were highly tailored. Based on the results of this review, we believe that custom tools that are sensitive to inequalities are needed to support all women in obtaining or maintaining a healthy diet during pregnancy.