Is there really an app for that?: exploring the appropriateness of utilizing diet & nutrition smartphone apps as extensions of the dietetic practice

Adult and childhood obesity remains a significant public health challenge in the United States, where adult obesity is expected to affect nearly half of the adult population by 2030. The condition not only puts a considerable strain on the U.S. healthcare system but is also associated with notable co-morbidities, including cardiovascular disease, diabetes, hypertension, sleep apnea, chronic kidney disease, stroke, and certain types of cancer. This makes obesity prevention and treatment a national public health priority. While several treatment modalities based in medical, surgical, and pharmacological interventions have been utilized to address obesity, lifestyle modification through behavior change has been consistently recognized as the most effective approach to achieving desirable and sustainable weight loss outcomes. In general, health behavior change-based interventions have the advantage of being low in implementation costs. However, they often suffer from low rates of compliance and high rates of attrition over time. Behavior-based interventions supported by information technology have been shown capable of improving participant compliance, leading to successful health behavior changes. Information technologies capable of supporting health behavior change are known as mobile health (or m-Health) technologies. They feature a broad range of portable monitoring medical devices such as continuous glucose monitors (CGMs), blood pressure monitors, and blood oximeters as well as multifunctional devices like smartphones, smartwatches, tablets, and mobile devices. In recent years, the number of mobile smartphone apps dedicated to nutrition and weight management has exploded, as consumer interests in establishing personal agency for one’s own health and wellbeing have increased. Despite growing interests among consumers, diet and nutrition smartphone apps for weight management have their limitations. Notably, these tools suffer from a considerable lack of evidence-based behavior change content and adherence to nutrition practice guidelines, weak efficacy study designs, and potential issues with data privacy. Altogether, these limitations have left many healthcare professionals, notably registered dietitian nutritionists (RDNs) unwilling to endorse these tools for use in a professional practice capacity. The aim of this project is to clarify the functional nature of diet and nutrition apps by further exploring their two critical deficits; lack of adherence to evidence-based guidelines and poor inclusion of behavior change content. In doing so, we seek to ultimately determine the capacity with which diet and nutrition mobile apps could be appropriate to support aspects of clinical or private professional dietetic practices. This broader research question was systematically addressed by executing a series of three studies of popular diet and nutrition apps. The project began with an assessment of the features of the most popular nutrition apps. The second study evaluated the apps’ adherence to evidence-based nutrition practice guidelines for adult weight management. The project concluded with an investigation of the extent of strategy and construct operationalization for behavior change features present in selected, popular nutrition apps. The app feature assessment study evaluated free and premium upgraded versions of fifteen popular smartphone diet and nutrition apps for weight management. Metadata statistics including app ratings, installations, cost, and ranking were also evaluated and used as a proxy for app popularity and consumer impact. App features were organized into dietary intake, anthropometrics, physical activity, and behavior change feature categories. Results from this assessment indicated that most app features are dedicated to fulfilling functions related to the tracking of dietary intake while being devoid of behavior change content features. Additionally, positive correlations between app rating and macronutrient tracking features may be indicative of consumer desires for more features aligned with individualized and personalized dietary intake. Using the results from the feature assessment, eight nutrition apps were selected to be included in the guideline adherence study. In this study, apps were assessed for adherence to the Evidence-Based Nutrition Guidelines for Adult Weight Management developed by the Academy of Nutrition and Dietetics' Evidence Analysis Library workgroup. The guidelines feature 21 practice-based recommendations for implementing nutrition care to support adult weight management and are based on the (4) stepwise components of the Nutrition Care Process: (1) nutrition assessment, (2) nutrition diagnosis, (3) nutrition intervention, and (4) nutrition monitoring and evaluation. Results from this assessment found most guideline adherence was associated with those recommendations related to nutrition intervention. Correlation analysis of the app metadata showed that total recommendation adherence was negatively associated with app ratings, suggesting that as guideline adherence improves so does app complexity, leading to more complicated user experiences with nutrition apps. The final study in this project investigated the extent of strategy and construct operationalization for behavior change strategies recommended by the Evidence-Based Nutrition Guidelines for Adult Weight Management. This recommendation included five strategies that were graded as strong and imperative, as well as 7 additional strategies graded as fair and conditional. Overall, this study did not reveal any significant associations between app metadata statistics for popularity and operationalized behavior change content However, this study did find diet and nutrition apps offering greater behavior change content were also more likely to operationalize that content appropriately. However, this investigation also revealed some strategies such as collaborative goal setting and relapse prevention in which the behavior change content was not properly implemented. Furthermore, the positive correlation between app cost and the strategy of problem-solving may be related to the direct cost of including more sophisticated software and associated programming as nutrition apps become accustomed to addressing nutrition-related problem solving rather than exclusively functioning as calorie and nutrient trackers. Altogether, these studies demonstrate that there is potential for diet and nutrition apps to be utilized as behavior change support systems in professional dietetic practice, specifically by enhancing components of the Nutrition Care Process such as nutrition assessment and intervention. Ultimately, the determination of which apps are best for addressing weight management depends mostly on the personal preferences, nutrition priorities, and readiness to change of the individual users. Insights from this project highlight the need for RDNs to appropriately guide the use of these tools among clients. They also reveal opportunities for RDNs and nutrition app developers to collaborate to ensure that nutrition apps are optimized to facilitate personalized weight management interventions and are better suited to support nutrition-related behavior change efforts.Ph.D.Includes bibliographical reference