1. Chapter One: Introduction
1.7 Conclusion to chapter
Against a background of increasing health, economic and social burdens resulting from obesity, dietitians have a fundamental role in modifying individual health behaviours, preventing weight gain and managing patient health outcomes. The challenges that limit nutrition care service delivery to the largest proportion of the population might be lessened through innovative technologies, such as smartphone mHealth apps, that are incorporated or act as mediums for dietary and weight management interventions. Attention should be
focused on how specifically apps could be used to support improvements in nutrition care for patients receiving dietetic input, which will be explored further in the narrative review
25 | Chapter Two
2. Chapter Two: Smartphone apps and the nutrition care process
Juliana Chen1, Luke Gemming1, Rhona Hanning2, Margaret Allman-Farinelli11
School of Life and Environmental Sciences and Charles Perkins Centre, The University of Sydney, Camperdown, NSW, Australia
2
School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada
2.1 Publication details
This chapter presents a more extensive version of the manuscript entitled ‘Smartphone apps and the nutrition care process: Current perspectives and future considerations’ published in
Patient Education and Counselling, 2018, Volume 101, Issue 4, Pages 750-757. DOI:
10.1016/j.pec.2017.11.011 (see Appendix 2.1). Identical text from the published manuscript appears in various sections of this chapter.
2.2 Author contribution
I Juliana Chen (the candidate) was the primary researcher involved in conducting the search, selecting the studies, and extracting and synthesising the data. Conception and design of this study was conducted by the candidate and co-author Professor Margaret Allman-Farinelli. I summarised the information and wrote the initial draft of this manuscript for publication. All co-authors (Dr Luke Gemming, Professor Rhona Hanning and Professor Margaret Allman- Farinelli) contributed to writing and reviewed and approved the final manuscript.
26 | Chapter Two
2.3 Introduction to chapter
Chapter Two is a narrative review that introduces the topic of using smartphone apps in the
context of dietetic practice, and particularly in a private practice setting. This chapter documents the existing evidence-base for using apps to support lifestyle-related medical nutrition therapy guided by the nutrition care process.
27 | Chapter Two
2.4 Abstract
Objective: To provide dietitians with practical guidance on incorporating smartphone
applications (apps) in the nutrition care process (NCP) to optimise patient education and counselling.
Methods: The current evidence-base for mobile health (mHealth) apps was searched using
Ovid MEDLINE and Web of Science. Where and how apps could be implemented by dietitians across the four steps of the NCP is discussed.
Results: With functionality to automatically convert patient dietary records into nutrient
components, nutrition assessment can be streamlined using nutrition apps, allowing more time for dietitians to deliver education and nutrition counselling. Dietitians could prescribe apps to provide patients with education on nutrition skills and in counselling for better adherence to behaviour change. Improved patient-provider communication is also made possible through the opportunity for real-time monitoring and evaluation of patient progress via apps. A practical framework termed the ‘Mobile Nutrition Care Process Grid’ provides dietitians with best-practice guidance on how to use apps.
Conclusions: Including apps into dietetic practice could enhance the efficiency and quality of
nutrition care and counselling delivered by dietitians.
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2.5 Introduction
Nutrition and dietetic care delivered by dietitians is a fundamental component of health
promotion, and chronic disease prevention and management 1, particularly given the high
prevalence of obesity, diabetes and other non-communicable diseases 2-4. In 2012, the
Dietetic Workforce Demand Study Task Force predicted that only 75% of demand for
dietitians in the US would be met in 2020 5. The study also identified technology as having
potential to transform how dietitians deliver nutrition counselling and personalised nutrition;
and how their patients manage their own diet 6.
For the delivery of more consistent and effective quality nutrition care by dietitians, the
Academy of Nutrition and Dietetics recommends their nutrition care process (NCP) 7,8. This
process is not only used in the US, but has been adopted in other countries, such as Australia. The systematic method allows dietitians to diagnose and develop treatment plans for
nutrition-related problems 7. Furthermore, having a standardised NCP framework facilitates
outcomes for research to evaluate the impact of nutrition care on patient health outcomes. Subsequently, the efficacy of nutrition care can be demonstrated, enabling advocacy for the
role of dietitians in obesity and chronic disease treatment and prevention 7,9. Moreover,
productivity and communication between dietitians and other members of the health care
team have improved through diagnosis-focused documentation of the NCP 9. There is now
the opportunity to advance the NCP further with technology.
The public market for and acceptance of mobile health (mHealth) technologies, such as smartphone applications (apps) has experienced dramatic growth, with over 325,000 mHealth
apps available10. Fifty-eight percent of US smartphone owners have downloaded a health-
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proliferation and low-cost of many nutrition apps may appear a threat to nutrition care services provided by dietitians. However, if implemented appropriately, apps could support dietetic practice by increasing accuracy, efficiency and quality of clinical decision-making
when applying the NCP 13, as well as improving patient access to point-of-care services and
patient-provider communication, to ultimately improve patient outcomes 14. For example
when considering use of electronic systems to document the nutrition care process, a time-
saving of 13 minutes per consultation over paper-records was provided 15.
Previous studies indicate that the dietetic profession have adopted health apps into their
practice. In 2012, 57% of Canadian dietitians used apps in practice 16, and 32% of sports
dietitians used apps for assessment and tracking of patient dietary intake. Eighty-three percent of US dietitians were found to recommend apps in the Academy of Nutrition and
Dietetics’ Consumer Health Informatics 2015 survey 17.
However, there has been no systematic process proposed of how to incorporate apps into the NCP. Therefore, the purpose of this paper was firstly to conduct a narrative review of the literature to determine the current knowledge for using health apps across the four steps of the NCP (i.e. nutrition assessment, nutrition diagnosis, nutrition intervention and nutrition monitoring and evaluation). A narrative rather than systematic review was selected to capture a broader scope of research into this newly emergent field of mHealth apps in relation to the nutrition care delivered primarily by private practice dietitians and mainly to patients
requiring weight management. Secondly, the areas in which dietitians, particularly those working in private practice, could practically implement health apps across the NCP were identified. Finally, a framework to guide the use of apps in the NCP was constructed.
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2.5.1 Search strategy
The medical nutrition literature (Ovid MEDLINE and Web of Science) was searched for research on the implementation of smartphone or mobile health apps, particularly those related to diet and nutrition, in order to support weight management, diabetes or healthy lifestyles in the context of nutrition care and/or dietetic practice. The search terms “(smartphone$ or mobile or "mobile phone$" or health or mHealth) near/2 (app$ or
application$)” were combined by ‘AND’ with the terms “(diet* or nutrition or diabet* or "nutrition care" or "dietetic practice" or weight or "healthy lifestyle")”. The search period of
July 2008 to February 2018 was selected because the start date corresponded to the release of commercial smartphone apps by the Apple and Android Google Play app stores. From these two databases 2308 unique articles were retrieved (495 duplicates removed). From title and abstract screening, 149 articles were deemed relevant to the nutrition care process, of which 93 of the articles retrieved from these two databases were included in the following review. Additional references were obtained through hand-searching reference lists of included articles and a search of more general sources (Google Scholar) to find other relevant articles.
2.6 Nutrition assessment
To form a nutrition assessment of their patient’s nutrition and health status, dietitians will obtain, verify and interpret anthropometric, biochemical, medical, social, as well as dietary
information 8. Typically, to collect food or nutrition-related history in dietetic practice,
dietitians administer an in-person diet history to estimate usual food intake and nutritional adequacy and meal patterns. Sometimes patients may be asked to keep a diet record in advance of their consultation. However, paper-based dietary records are burdensome for
patients to complete and labour-intensive for dietitians to analyse 18, thereby reducing
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2.6.1 Smartphone app-based dietary records
Smartphones are a highly accessible medium for patients to record their food intake. US
smartphone owners reported looking at their phones approximately 47 times per day, with 83%
using their phone while eating 19. Smartphone apps provide a convenient means to record
data in near real-time during eating occasions and have demonstrated greater acceptability
than paper-based food diaries 20-23. As wearable technologies develop, there may be even
further opportunities to record dietary data using such methods 24,25. Dietitians and health care
providers also show acceptance towards technology-assisted dietary assessment 26,27. In the
private practice setting for example, to make nutrition assessment more efficient, patients could be provided with instructions on how to download and use a nutrition app, using methods such as YouTube videos, then asked to record 3-5 days of their usual food intake, including one weekend day, prior to the face-to-face consultation with their dietitian. The subsequent sharing of patient-generated health data from app records for direct viewing in
electronic health record systems 28, offers dietitians more convenient access to review dietary
intake data. Thereby, dietitians have the opportunity to spend more time providing higher- value services, such as formulating tailored dietary intervention strategies and behavioural counselling.
Most nutrition apps automatically convert food intakes into nutrients 29,30 and evidence
indicates that researcher-developed nutrition apps provide valid estimates of energy and
nutrient intake comparable to traditional dietary assessments 31-34. An evaluation of variance
across 23 commercial weight loss apps revealed that 17 of 23 apps assessed were within ±400
kJ of weighed food records 29. Among 50 adults, a modified version of the Australian