The not only about food choices, but

The Use of New Technology in Dietary
Nutritional Epidemiology
Submitted by:
Amnah M. Darwish
Salwa Ali Albar
The Use of New Technology in Dietary Assessment
Because traditional dietary assessment tools are often too
complicated, expensive and time-consuming to administer in a clinical setting,
recently there have been many developments using a computer and web-based
platforms to collect food intake data using the principles of the 24HDR
technique. Dietary assessment tools for the use in a healthcare practice
environment should meet specific criteria. It should be easy to administer by
health care providers or office staff, be easy for patients to complete; ideally
without assistance, provide feedback that is immediate and compatible with
in-office evaluation, have low associated costs, and address dietary issues
that are national nutrition priorities for adults. These new technology
assessment tools when developed were evaluated to meet all these criteria and
then be validated and used for both adults and children.
Smart card based systems:
Smart cards can be employed, among other functions, as
payments for meals. The smart card is allocated a certain monetary value that
can be spent in participating cafeterias or restaurants. When the consumer
pays for a meal using the smart card, the foods on the tray are immediately
recorded at the cash desk and sent to a central computer. Through this,
information can be collected not only about food choices, but also about the
date and time of the transaction, costs incurred and the smart card number.
Subsequently, the data are stored on the computer and can be linked to a
nutrient database.
Although it is approved as an accurate and feasible tool, it
still has some error because researchers have to observe and measure the waste
leftovers. They also consider it time consuming tool.
An advantage of using the smart card system to measure food
choice is that it can collect long-term data from large groups on individual
food behavior. Furthermore, the costs are relatively low as smart cards are
inexpensive and fewer researchers are needed since data are stored when the
diner uses the smart card to pay for the meal. However, the smart card-based
system also has limitations in its usability as a dietary assessment method.
Lambert et al. observed that children exchanged trays or paid for each other’s
meal. 1 Furthermore, diners could buy foods and beverages for consumption at
a different time. As such, the application of this tool is better indicated to
collect information about subjects’ food selection and not their food intake.
PDA-BASED Dietary assessment & DietMatePro:
A PDA (Personal digital assistants) is a handheld computer
that can be used for various purposes. This technology has been applied for
data collection in medical settings for over 15 years. PDA with specifically
designed dietary software program can be used to register and self-monitor
dietary intake. Subjects are required to record their food intake immediately
after consumption by scrolling through a list of foods or by selecting a food
group and then a specific food item. After food item selection, portion sizes
are entered.2
PDA-based food records have several advantages as
individuals can be provided with immediate feedback and data stored on the PDA
can be reviewed at any point in time. Uploading data to a computer allows the
researcher or dietitian to analyze dietary intake as often as the user
provides them with information. PDA-based self-monitoring greatly decreases
the burden of the researcher or dietitian, as the time required to analyze
food records is reduced by removing the need for data entry. Another advantage
with respect to paper diaries is that it is possible to date and timestamp
every recorded food item, which makes it possible to avoid fallacious results
on adherence. Furthermore, audible alarms make it possible to alert the
participant at specific times to record food intake. Although the advantages
of PDA show their potential to improve data quality, there are several
limitations. The use of PDA-based food records increases the respondent burden
compared with paper diaries. Studies report subjects having difficulty using
the search function and experienced inability to find certain foods.
Furthermore, like paper diaries, PDA-based food records require participants
to be literate. As such, older or less educated individuals might have
difficulty using a PDA for recording food intake. However, although limited in
size, a pilot study in a group of older participants with no prior computer
experience showed that they easily learned how to use a PDA. Despite certain
obstacles, studies demonstrated that PDA can simplify intake registration and
self-monitoring, thus increasing the quality of dietary-intake data. As this
dietary-assessment tool still has limitations, further development of PDA and
dietary software program is necessary. In regards to studies using PDA with a
camera, dietitians could not always accurately estimate portion sizes as
subjects took photos at the wrong angle and digital photo images were
inadequate. The exactness of this method can be increased by improving the
quality of the digital photos and by including a PDA-based food list for users
to select the foods and drinks consumed. More research is required to
determine whether this method can be used in other and more diverse population

DietMatePro, a PDA-based dietary assessment program, supplies
a method of assessing energy and macronutrient intakes. 3 DietMatePro food
records may provide a valid assessment of dietary intake. Though PDA programs
require additional training compared to food diaries, the information returned
does not need to be entered into a nutrient analysis program by another person,
thereby improving time efficiency and reducing possibilities for error in
transferring the data from paper to database. Immediate tailored feedback, as
well as other PDA program features, may enhance adherence to dietary regimens
compared to paper-based monitoring of food intake. 4

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The WAVE acronym and tool is designed to encourage
provider/patient dialogue about the pros and cons of the patients’ current
status related to weight, Activity, Variety, and Excess. The objectives of WAVE
are to provide a fast tool for primary care providers to consider weight,
physical activity and eating habits with their adult patients. Also the presence
of a four-letter acronym that is easy to remember and use in provider-patient
interactions. Furthermore, the ability to identify weight, nutrition and
physical activity issues that need to be addressed during the office visit or
by referral to a dietitian. Strengthen the importance of nutrition and physical
activity in health promotion and disease prevention is also an objective. 5


Rapid Eating and Activity Assessment for Patients (REAP):

REAP has been planned to assess diet related to the Food Guide
Pyramid and the 2000 U.S. Dietary Guidelines. REAP includes questions to
determine intake of whole grains, calcium-rich foods, fruits and vegetables,
fat, saturated fat and cholesterol, sugary beverages and foods, sodium,
alcoholic beverages and physical activity. REAP also includes questions
regarding whether the patient shops and prepares his/her food; ever have
difficulty being able to shop or cook; follows a specific diet; eats or limits
some foods for health or other reasons, and how desired the patient is to make
changes to eat healthier.5

REAP has sufficient reliability and validity to be used in
primary care practices for nutrition assessment and counseling, and is also
user-friendly for providers. 6


The Mini-Nutritional Assessment (MNA), a modern and
extensively tested instrument, attain many criteria for both screening and
diagnostic measures. It was progressed and validated on large representative
samples of elderly persons worldwide. 7 The MNAR is reliable and can be
easily administered by health professionals using its two-step procedure for
screening (MNAR-SF) followed by assessment (full MNAR). It can be done in
general practice or on admission to the hospital or nursing home to detect
risks of malnutrition early.  Persons
identified as “at risk” on the MNA-SF, would receive additional assessment to
confirm the diagnosis and plan interventions. The MNAR is easy to administer,
patient-friendly, and inexpensive requiring no laboratory investigations. It is
very sensitive & specific and reproducible. 8



ASA24 is composed of two web-based applications, the
Respondent and Researcher Websites. The Respondent Website is used by
participants to complete recalls. The Researcher Website is used by researchers,
clinicians, or educators to register, configure, and monitor studies. The
Researcher Website also provides access to nutrient and food group analyses.
Both sites require high-speed internet connections and standard computer
monitors (not including netbooks or mobile phones) and are compatible with
common internet browsers.

It approved its feasibility and cost-effectiveness of
collection of high-quality dietary data. ASA24 is now freely available for use
by researchers, clinicians, and educators and is in use in numerous studies in
the US.9


This is an online 24-h dietary assessment tool (with the
flexibility to be used for multiple 24 h-dietary recalls or as a food diary),
has been developed for use in the UK population. Development of myfood24 was a
multi-stage process. Myfood24 is considered the first online 24-h dietary
recall tool for use with different age groups in the UK. Usability testing
indicates that myfood24 is suitable for use in UK adolescents and adults. The
device is hosted and maintained by the University of Leeds to remain up-to-date
concerning new products or reformulations of existing foods. The tool has been
developed such that it can be made available to researchers worldwide through a
unique login. Overall, the system is intuitive and easy to use. 10

The Oxford WebQ:

This is a web-based 24-h dietary assessment tool developed
for repeated administration in large prospective studies, and to report the
preliminary assessment of its performance for estimating nutrient intakes. It
is an easy to use tool with low cost, even when need to use it for large scale.
The main limitations are less detailed dietary information and inability to
probe for in-depth information on food preparation methods, food brands, and
unusual food items that may have been consumed.11

Web-based Dietary Assessment Software for Children (WebDASC):

WebDASC is part of the OPUS project (‘Optimal well-being,
development, and health for Danish children through a healthy New Nordic Diet’)
and was intended to measure dietary change resulting from a school-based
intervention. It was developed as a self-administered tool that could be used
by 8–11-year-old children with or without parent’s aid. The development of
WebDASC followed a prototyping approach: focus groups, informal interviews,
literature review, and usability tests preceded its release. Special
consideration was given to age-appropriate design issues.

Because children are visually skilled, the initial idea was
that all food searches should be geared towards the display of a food image
(digital photography) as a visual reinforce (Biltoft-Jensen, 2009). This effort
would require a picture of every item in the food list, and, ideally, one that
closely matches a kid’s mental representation of the item. Compared to other
computer-based dietary assessment systems, such as the ASA 24, uses a sequence
of three questions to obtain portion size of drinks (container type, container
size, and percent volume), WebDASC does this in a single step by showing a
standard glass with four different levels of fill-up. WebDASC was developed as
an intuitive, simple, cost-effective, and it was well accepted by both children
and their parents. The validity of WebDASC remains to be documented. 12

Self-Completed Recall and Analysis of Nutrition (SCRAN24):

It is a prototype computerized 24-h recall system for use
with 11– 16-year-olds. It is based on the Multiple Pass 24-h Recall method and
includes prompts and checks throughout the system for forgotten food items.
Initially, it was redeveloped from the old computerized method (INTERACTIVE
PORTION SIZE ASSESSMENT SYSTEM, IPSAS) which is based on portion sizes consumed
by British children. The accuracy of portion size estimates using IPSAS was
good and children aged 11 years and older were as accurate as their parents in
estimating food portion sizes using the tool. The development of SCRAN24 was
informed by an extensive review of the literature and available systems, a
series of focus groups and usability testing.

SCRAN24 is appealing and engaging to young people and
therefore may capture and maintain their attention, making taking part in
dietary assessment less exhausting, as well as potentially improving
participation and completion rates. It also has the advantage of ensuring standardization
of methods because the quality of the interview process, and therefore the data
collected (as well as the accuracy of food coding and data entry) will not vary
with the experience and diligence of the dietitian or researcher. Finally, the
removal of the need for a trained interviewer and a vastly reduced data
processing, along with the reduced time and, for web-based systems, the cost of
travel, means that the cost of dietary surveys is very much reduced, making the
assessment of large samples more attainable. SCRAN24 is currently being
developed further to improve the usability of the system and to extend the
system so that it is suitable for 11– 24-year-olds. This work is being funded
by the Food Standards Agency Scotland. 13



There is no evidence that new technology assessment tools
have been used in Saudi Arabia, and even in the Arabic countries. Although some
tools are expensive and time-consuming, still many tools are applicable and
will be easy to conduct in the Arabic countries. It will be a good idea for
researchers to develop their own web-based program that includes the food known
in the society and the brands available. Or, at least they can cooperate with
researchers of some of the existing programs, and do some changes to make it
usable in the Arabic countries.

Most of the new technologies in dietary assessment were seen
to have overlapping methodological features with the conventional methods
predominantly used for nutritional epidemiology. Their main potential to
enhance dietary assessment is through more cost- and time-effective, less hard
ways of data collection and higher subject acceptance, through their
integration in epidemiological studies would need additional considerations,
such as the study objectives, the target population and the financial resources
available. However, even in innovative technologies, the inherent individual
bias related to self-reported dietary intake will not be resolved. More
research is, therefore, crucial to investigate the validity of creative dietary
assessment technologies. 14