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J Telemed Telecare OnlineFirst, published on February 12, 2015 as doi:10.1177/1357633X15572203

Review Article

Journal of Telemedicine and Telecare

0(0) 1–11
The use of mobile apps to improve nutrition ! The Author(s) 2015
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outcomes: A systematic literature review sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/1357633X15572203
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Kristen N DiFilippo1, Wen-Hao Huang2, Juan E Andrade1 and

Karen M Chapman-Novakofski1

Summary
We conducted a systematic review to determine if the use of nutrition apps resulted in improved outcomes, including know-
ledge and behavior, among healthy adults. Using app(s), cellular phone, iPads, mobile phone, mobile telephone, smart phone,
mobile and mHealth as search terms with diet, food and nutrition as qualifiers we searched PubMed, CINAHL (January 2008–
October 2013) and Web of Science (January 2008–January 2014). Inclusion criteria were peer-reviewed randomized controlled
trials, non-controlled trials, and cohort studies published in English that used apps to increase nutrition knowledge or improve
behavior related to nutrition. Studies that were descriptive, did not include apps, focused on app development, app satisfaction
app feasibility, text messaging, or digital photography were excluded. We evaluated article quality using the Academy of
Nutrition and Dietetics Evidence Analysis Manual. Data was extracted for knowledge, behavior and weight change. Our initial
search identified 12,010 titles from PubMed, 260 from CINAHL and 4762 from Web of Science; of these, only four articles met
all search criteria. Positive quality ratings were given to three articles; only one reported knowledge outcomes (non-significant).
All four articles evaluated weight loss and suggested an advantage to using nutrition apps. Behavioral changes in reviewed studies
included increased adherence to diet monitoring (p < 0.001) and decreased effort to continue diet without app (p ¼ 0.024). Few
studies, however, have explored the use of nutrition apps as supportive educational interventions. Most apps focus on weight
loss with inconsistent outcomes. We conclude that using apps for education needs additional research which includes behavior
theory within the app and improved study design.

Keywords
Nutrition apps, mobile apps, behavior, nutrition, diet, app

Accepted: 4 December 2014

at all times, a potential benefit in engaging consumers

Introduction with health interventions.3
The aggressive evolution of telemedicine services from Mobile platforms could be used as a critical source
desktops to mobile platforms has demonstrated a signifi- of information and motivation for behavioral change.
cant impact on the future of healthcare. Mobile technol- This strategy is particularly suited for nutrition interven-
ogy now allows consumers to access their clinical records tions, where the consumer is faced with nutrition and diet
to obtain nutrition and physical activity tips on the go. questions and decisions throughout the day. Indeed, the
Consumers can access this information and much more daily presence of and access to mobile devices represents
on their mobile devices through self-contained applica- ample opportunities to deliver supporting information at
tion programs also known as apps. This technology has any time and any place; therefore, mobile devices increase
experienced impressive gains in popularity in recent the potential to promote healthy nutrition behaviors (i.e.,
years. Between May 2011 and January 2014, smartphone keeping a healthy weight, counting calories, making a
ownership by U.S. adults increased from 35% to 58%.1
Among young adults in the U.S., ownership rates are 1
Division of Nutritional Sciences, University of Illinois at Urbana-Champaign,
even higher, where 83% and 74% of those within the USA
2
18–29 and 30–49 years old sub-groups, respectively, Department of Education Policy, Organization and Leadership, University of
own a smartphone.2 Tablet computer usage also Illinois at Urbana-Champaign, USA
increased from a meager 3% in 2010 to 42% in 2014
Corresponding author:
among adult consumers in the U.S.1 In addition, people Kristen DiFilippo, Division of Nutritional Sciences, University of Illinois, 238
typically develop a strong attachment to their mobile Bevier Hall 905 S. Goodwin Avenue, Urbana, IL 61801, USA.
devices, and frequently keep this technology with them Email: kdifilip@illinois.edu

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nutritious meal); and consumers as much as developers Table 1. Key Words of Articles from Preliminary Search Related
are catching up. A search for Android apps using the to Nutrition and Mobile Apps with Identification of Potential Search
term ‘‘nutrition’’ in Google Play, for example, reveals Terms.
250 apps related to nutrition.4 Nutrition App
With the potential and availability of nutrition related Search Term Terms Terms
mobile apps, research is needed to determine what charac-
teristics make these apps effective in supporting behavioral App X
change or increased knowledge among populations at risk Behavior Change
of nutrition associated illnesses such as obesity, diabetes Cellular Phone X
and cardiovascular disease among others. While previous Diet X
reviews have examined the role of mobile technology in Diet-Related Behavior Change X
weight loss5 and in food intake record keeping and ana- Dietary Assessment X
lysis,6,7 to the best of our knowledge, no reviews have solely Disease Management
focused on the role of mobile apps in supporting desired e-Health X
nutrition-related behaviors including behaviors associated
Epidemiological Studies
with healthy weight loss or weight maintenance, diet self
Everyday Health Technology
monitoring or goal setting. The objective of this systematic
review was to explore whether the use of mobile apps could Food X
improve nutrition associated knowledge or behaviors in Food Diary X
recently published interventions. Food Intake X
Food Recording X
Food Values X
Methodology Health Applications X X
Determination of Search Terms Health Behavior X
Health Communications X
To determine the appropriate search terms, as well as Innovative
inclusion and exclusion criteria, a preliminary search on internet
nutrition apps was conducted in PubMed and the
iPads X X
Cumulative Index to Nursing and Allied Health
Lifestyle
Literature (CINAHL) prior to developing the research
question because the topic of mobile learning in nutrition Methodology
is relatively new. In the Fall of 2013, one researcher com- Mobile Application X
pleted this preliminary search including articles from Mobile Health X
January 2008 to August 2013, using the following search Mobile Phone X
terms: nutrition applications, nutrition apps, mobile nutri- Mobile Telephones X
tion and e-learning & nutrition. This resulted in: Monitoring
Nutrition X X
. 776 titles from PubMed for ‘‘nutrition applications,’’ Nutritional Dietary Methodologies
8 from CINHAL; Obesity
. 7 titles from PubMed for ‘‘nutrition apps,’’ 5 from Patient Education
CINHAL;
Primary Prevention
. 229 titles from PubMed for ‘‘mobile nutrition,’’ 5 from
Qualitative Methods
CINHAL; and
. 8 titles from PubMed for ‘‘e-learning & nutrition,’’ Randomized Controlled Trial
3 from CINHAL. Self-Management
Smartphone X
These titles were reviewed by two researchers to confirm Tailoring
whether or not they referred to nutrition apps. Titles that Technology X
clearly referred to a different scientific field were excluded; Technology and Health X
titles that clearly referred to nutrition apps, mobile nutri- Text Messaging X
tion education or technology, or nutrition and smart- Web Application X
phones were kept for a later abstract review. All titles Web- and Mobile-Based Nutrition Tools X X
where this distinction was unclear were also kept for
abstract review. Abstracts were retained if they pertained
to nutrition apps. The keywords of these articles were used The preliminary search resulted in the selection of the
to compile a list of potential search terms to be utilized for following search terms related to apps: app(s), applica-
a formal literature review. These search terms are listed in tion(s), cellular phone, iPads, mobile phone, mobile tele-
Table 1. phone, smart phone and mobile. An additional researcher

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Table 2. Inclusion & Exclusion Criteria for Papers where Abstract or Title Indicated Congruence with Research Question.

Inclusion Criteria Exclusion Criteria

Language Published in English Not in English

Peer Review Peer reviewed Not peer reviewed
Participants Human study Animal study
Adults over 18 Exclusively children under 18
Disease diagnosis
Dates of Publication PubMed & CINAHL: 1/1/08-10/31/13
Web of Science: 2008–2014 (searched on 1/31/14)
App Criteria Apps used to increase nutrition knowledge Studies of web based programs
No app used
And/or App development
App satisfaction
Apps used to improve nutrition behavior App feasibility
Text messaging
Digital photography
Type of Study Randomized controlled trials Descriptive studies
Non-controlled trials
Cohort studies
Review studiesa
Meta-Analysisa
a
Not used in final analysis

reviewed the keywords and suggested also using: e-learn- feasibility of diet tracking were not included. Either
ing, mobility of learning and mHealth. It was determined behavior related to healthy eating (primary outcome) or
that: diet, food and nutrition would be qualifiers utilized knowledge (secondary outcome) was included as
with each of the terms to isolate nutrition related studies. desired outcomes. Other outcomes related to psycho-
social mediators of healthy eating behavior such as adher-
ence to dietary monitoring were also noted during the
review.
Research Question Development
Derived from the PICOS (Participants, Interventions,
Comparators, Outcomes, Study design) guidelines,8–10
Database Identification
two researchers developed the following research question Initially three experts, two in nutrition, one in educational
for this systematic review: For adults without disease, will technology recommended searching in PubMed,
the use of nutrition apps result in increased knowledge or CINAHL, Web of Science and Google Scholar. Before
improved nutrition behavior as compared to other educa- searching, researchers eliminated Google Scholar due to
tional delivery types or compared to participants’ baseline the lack of precision.12–14
knowledge or behavior in the case of pre/post evaluation? The review followed PRISMA guidelines for literature
Participants were adults without disease to reflect the reviews by including the four phases of the PRISMA flow
broad goals of health promotion rather than medical diagram: Identification, screening, eligibility, and included
nutrition therapy as might be associated if targeting papers evaluation.15
adults with a chronic disease. Children under 18 were
excluded due to the variations in cognitive and physical
development through the age span. There were no restric-
Search
tions on race, ethnicity or gender, again to maintain the
broadest target group. The intervention had to include a Two researchers independently searched PubMed,
nutrition app. Educational apps were specifically sought CINAHL, and Web of Science utilizing the identified
out. As described by Contento11 nutrition education is search terms and qualifiers. Inclusion and exclusion cri-
considered to be instruction, an intervention to change teria are provided in Table 2. In PubMed and CINHAL
behavior such as goal setting and self-monitoring, or an researchers limited the search to articles published
environmental or policy change. As such, nutrition edu- between 1 January 2008 and 31 October 2013 as the
cation for this review was considered any app that directly iPhone and App store debuted in June 2007.16 In Web
taught users or indirectly attempted to change nutrition- of Science, the researchers limited the search to articles
related behavior. Studies that evaluated the reliability or in between years of 2008 and 2014, on 31 January 2014

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as the search configuration for this article search database categories of the Behavior Change Technique
did not allow limiting to months. Taxonomy18 (Table 5).

Screening Results
In PubMed and CINAHL, each ‘‘term’’ AND ‘‘qualifier’’
combination was searched, limited to 1 January 2008
Identification
through 31 October 2013 and articles published in The search resulted in 17,032 titles: 12,010 from PubMed,
English. Filters for human research were used 260 from CINAHL, and 4762 from Web of Science
in CINAHL, but not in PubMed as applying this filter (Figure 1).
in PubMed resulted in the elimination of titles meeting
the search criteria. CINAHL did not recognize ‘‘(s)’’;
therefore, researchers used both ‘‘app’’ and ‘‘apps’’ in
Screening
place of ‘‘app(s)’’ and ‘‘applications’’ instead of ‘‘applica- In PubMed, 93 titles met the search criteria (Table 2).
tion(s)’’. Article search within Web of Science was com- These reduced to six articles meeting the search criteria
pleted similar to CINAHL. After completing searches in after screening abstracts, full articles and comparison by
PubMed and CINAHL, researchers identified the search two researchers (Figure 1).19–24 In CINAHL eight titles
term ‘‘applications’’ as unproductive, as no unique articles met the search criteria (Table 2), which reduced to two
were identified with this term. Consequently, ‘‘applica- full articles (Figure 1). These two duplicated articles
tions’’ was removed from the search of Web of Science. identified in the PubMed search.20,22 In Web of
Each term and qualifier combination was entered with Science, 47 titles met the search criteria (Table 2). These
the following options selected: Database limited to reduced to seven full articles (Figure 1), of which all but
Web of Science; Research areas limited to Nutrition one25 had been previously identified in the PubMed
Dietetics, Behavioral Sciences, Science Technology search.
Other Topics, Healthcare Science Services, Computer
Science, Medical Informatics, Communication,
Articles included in the evaluation-quality analysis
Telecommunications, and Life Sciences Biomedicine
Other Topics. Two researchers independently read and evaluated the
Two researchers independently read the resulting titles. quality of the seven articles using the Quality Criteria
When titles met the inclusion criteria or were unclear, Checklist for Primary Research in the Evidence Analysis
abstracts were read. The same process was completed Manual of the Academy of Nutrition and Dietetics17
for abstracts, retaining abstracts that met inclusion cri- (Table 3). This revealed that two of the articles did not
teria or were unclear. Researchers met after completing meet the inclusion/exclusion criteria outlined in Table 2;
each database search to compare findings and determine one studied only Personal Digital Assistants19 and the
appropriate abstracts for further review. When only one other was a descriptive study.25 The researchers eliminated
researcher classified an abstract as relevant, the research- a third study20 as a duplicate study.23
ers discussed that study until reaching agreement. Finally, The researchers completed quality analysis of the four
articles were read and those that met all inclusion criteria studies independently, then deliberated the results until
were kept for review. reaching consensus. Three articles received a positive qual-
ity rating.21,23,24 One article received a negative quality
rating eliminating it from further analysis.22
Articles included in the evaluation
For the selected articles, each researcher evaluated the
Articles included in the evaluation-summary of papers
quality of the research as presented using the guidelines Study one. Brindal and colleagues’ randomized controlled
set forth by the Academy of Nutrition and Dietetics’ trial piloted an app designed to support weight loss among
Evidence Analysis Manual17 (Table 3). Based on these overweight/obese women enrolled in a partial meal
criteria, two researchers assigned each article a quality replacement program (Table 4).21 The primary outcomes
rating of positive, neutral or negative (þ, Ø, or ), dis- were weight loss and user engagement. Messages included
cussing their rankings until reaching agreement. The with the app were designed to target self-regulation and
researchers then reviewed each article, noting primary planning, components of the Health Action Process
and secondary outcome measures, characteristics of the Aproach26 with the goal of moving participants from
app used, any behavior theory, participant characteristics, pre-intention to behavior change using goal setting and
statistical findings and results. Data were extracted for planning.21 The supportive app group had a higher esti-
measures of knowledge and behavior change, as well as mated mean percent weight loss at eight weeks (3.18%,
weight change, noting p-values for significance. SE ¼ 0.38) compared to the control group (2.22%,
Retrospectively, the behavior change strategies used SE ¼ 0.37); however, this was not statistically significant
by each study were classified based on the main (p ¼ 0.08).21 Brindal also found that when measuring

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Table 3. Article Quality Analysis.

Validity Questions

Description
DiFilippo et al.

of intervention/
therapeutic
regimens/
exposure
factor or Clearly Conclusions Bias
Subject procedure, defined supported due to
Final Clearly selection Description comparisons outcomes, by results, study’s
Quality stated free Comparable of method and valid and Appropriate biases and funding
[9.2.2015–10:19am]

Rating First Author / research from study for handling Blinding to intervening reliable statistical limitations or sponsorship
þ,Ø, Location Title Evaluator question bias groups withdraws avoid bias factors measurements analysis considered unlikely

þ Brindal 2013 Design and pilot results of a KD yes yes yes yes unclear yes yes yes yes yes
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/ Australia mobile phone weight-loss

application for women
(JTT)

starting a meal replace-

ment programme.
KCN yes yes yes yes unclear yes yes yes yes yes
þ Carter 2013/UK Adherence to a smartphone KD yes yes yes yes na yes yes yes yes yes
application for weight loss
[PREPRINTER stage]
[1–11]

compared to website and

paper diary: pilot rando-
mized controlled trial.
KCN yes yes yes yes na yes yes yes yes yes
þ Turner 2011 / Tweets, Apps, and Pods: KD yes yes yes yes no yes yes yes yes yes
USA Results of the 6-month
Mobile Pounds Off
Digitally (Mobile POD)
randomized weight-loss
intervention among adults.

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KCN yes yes yes yes no yes yes yes yes yes
 Lee 2010 / Korea Evaluation of a mobile phone- KD no no no no no unclear no no yes no
based diet game for weight
control.
KCN no no no no no unclear no no yes no
Turner 2013 / Comparison of traditional Omit-duplicate study to Turner 2011
USA versus mobile app self-
monitoring of physical
activity and dietary intake
among overweight adults
participating in an
mHealth weight loss
program.
(continued)
5
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6 Journal of Telemedicine and Telecare 0(0)

or sponsorship
perceived motivation, citing the Theory of Planned
Behavior27 at eight weeks the control group’s willingness

unlikely
funding
due to
study’s
to stay on the diet decreased compared to those using the

Bias
intervention app (p ¼ 0.024).21 The support group also
reported an increase in positive affect (estimated mean-

Conclusions

considered
by results,

limitations
Appropriate biases and
supported
¼ 0.48, SE ¼ 0.14) compared to control (estimated mean-
¼ 0.01, SE ¼ 0.13).21

Study two. Carter and colleagues also performed a pilot

statistical
randomized controlled trial examining the feasibility and
measurements analysis
acceptability of a weight loss app (Table 4).24 While feasi-
bility and acceptability were primary outcomes, anthropo-
metric measures were secondary outcomes that led to the
inclusion of this study for review. These anthropometric
outcomes,
valid and

measures included height, weight and percentage body fat.

defined

reliable
Clearly

The app, My Meal Mate, was developed to be similar to

MyFitnessPal and Calorie Counter apps.28 While a spe-
of intervention/

cific theory is not mentioned in the study, self-efficacy is

comparisons
Description

therapeutic

for handling Blinding to intervening

procedure,

addressed along with the behavioral strategies of goal set-

regimens/
exposure
factor or

ting, self-monitoring, and feedback.24 For comparison,

avoid bias factors

another group utilized a self monitoring website29 while

and

a third group kept a written food diary using a calorie

counting book.30 The study found statistically significant
differences among groups in both participant retention at
six months (p ¼ 0.001) and usage of the intervention tools
Description

at both six weeks (p < 0.001) and six months (p ¼ 0.001)

Comparable of method

withdraws

with results favoring the app intervention.24 Participants

used the app tool more often than the website (p < 0.001)
or paper diary (p < 0.001) groups. In contrast, for the
same variable pairwise comparison showed no difference
between the website and the paper diary (p ¼ 0.14).24
groups
study

Weight at six months differed significantly among the

groups (p ¼ 0.004).24 Carter reported pairwise comparison
Clearly selection
Validity Questions

between app and website in terms of mean change and

Subject

omit-descriptive
research from
free

Evaluator question bias

confidence interval (3.3kg, 95% CI 5.4 to 1.2), and

also reported no difference between app and paper diary
omit-PDA

(p ¼ 0.12).24 While a significant difference was not found

stated

between the app and paper diary groups, the authors

noted that the study lacked power to determine differences
in weight loss.24

Study three. Turner-McGrievy and Tate reported on a

Decision-making in the aisles:
diet and activity: a rando-
Multiple behavior changes in

6 month randomized controlled trial that examined the

informing, overwhelming
using mobile technology

or nudging supermarket
mized controlled trial

effect of a Podcast intervention compared to Podcast

plus mobile components using FatSecret’s Calorie
Counter app31 and Twitter with weight loss as a primary
outcome (Table 4).23 The Podcasts were designed based
shoppers?

on Social Cognitive Theory.32 On average, weight changes

(SD) were in the order of 2.6%(3.8) and 2.6%(3.5) for
Title

women in the Podcast and Podcast þ Mobile groups,

respectively, at three months, and decreased minimally,
Kalnikaite 2013 /

2.7%(5.1) and 2.7%(5.6), respectively, after six

Rating First Author /
Table 3. Continued

Spring 2012 /

months.23 While most participants did not reach the pro-

þ,Ø, Location

posed weight loss (i.e. 5%), the authors noted that the
USA

study occurred over the winter holidays in the United

UK

States, so weight maintenance during this season may

Quality

have been beneficial.23 From the selected articles, this is

Final

the only study that included knowledge change; however,

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DiFilippo et al. 7

Initial Search N= 17,032

PubMed N= 12,010
Web Sci. N= 4,762
CINAHL N= 260

Titles included n= 148

PubMed n= 93
Web Sci. n= 47
CINAHL n= 8

Reasons
Abstracts Abstracts 1. Use of text/SMS
Included Excluded 2. Duplicates from other
N=12 N=136 databases

Reasons
Articles Articles 1. Used text messaging
Included Excluded 2. Only descriptive
N=7 N=5 3. Developmental

Reasons
Included in Excluded from 1. Duplicate study
Discussion Discussion
N=4 2. Only descriptive
N=3 3. Used PDAs

Figure 1. Flow Chart of Search.

the results lacked statistical significance.23 Other findings example, one study used many additional techniques,
included more user control in the Podcast þ Mobile group including reward and threat, repetition and substitution,
at three months but not at six months (p ¼ 0.08) and a associations and identity,21 while another study added
trend approaching increased elaboration in the self-belief24 and the third added social support.23
Podcast þ Mobile group (p ¼ 0.06).23 An important con-
sideration of this study was the variable use of apps
among participants from both groups. In the group
Discussion
instructed to use an app, only 60% did so; while in the Very few peer-reviewed studies have been published where
Podcast without app group, 32% of participants did in a nutrition app was used to change dietary behavior or
fact use an app for dietary monitoring.23 The uneven improve nutrition knowledge in adults beyond those apps
use of apps could further complicate the analysis of effects used for food record keeping only. All three studies eval-
on knowledge or behavior variables. When comparing uated for quality used apps to support user weight loss,
actual app users to non-app users, the authors found along with tools for food record keeping.21,23,24 Although
that app users kept more consistent daily records, with the quality rating for these studies was good, they were
twice as many days recorded compared to those not limited in the level of control to clearly dissect the effect of
using an app.23 the educational intervention. For example, in one study
Retrospectively, the behavioral techniques used in each the apps sent prompts to complete a food diary or record
of the articles were categorized using a previously pub- weight21 similar to apps without such prompts. In another
lished taxonomy (Table 5).18 This taxonomy revealed study, participants kept food records via apps and
some similarities in the behavior change techniques received motivational feedback in a Twitter group.23
among the three studies. For instance, all three studies Overall, there was limited control in the effect of other
used feedback and monitoring as well as goals and plan- sources of information or motivation, and thus, both of
ning to encourage change. 21,23,24 Two studies used know- these only minimally add to passive record keeping as an
ledge shaping techniques,21,23 although one of these used intervention. Past evidence has shown that the use of diet
knowledge shaping in another part of the intervention, not self-monitoring is an important behavioral strategy for
directly in the app.23 A good deal of variability in the successful weight management.33,34 A study using a
behavior change techniques was also present. For Personal Digital Assistant points to diet-self-monitoring

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Table 4. Summary of Papers.

Brindal 2013 Carter 2013 Turner-McGrievy 2011

Primary outcome Weight loss, user engagement Feasibility, acceptability, (weight Weight loss
loss-secondary outcome)
Study type Pilot RCT Pilot RCT RCT
App used Meal Replacement Program App My Meal Mate Fat Secret’s Calorie Counter
App
Twitter App
App purpose Provide information, reward Goal setting, diet & exercise self Diet and physical activity
positive behavior, diet & monitoring, feedback monitoring
weight self monitoring, Messages from study coordin-
prompt regular interaction ator and interaction with
other study participants
App components Dashboard: Meal calendar, Weight loss goal setting, daily Food diary and physical activity
weight tracker, log of tasks, food diary to target weight diary
trophy room, dietary infor- loss goal, physical activity Messages sent twice daily, study
mation, message board, cus- diary calculating expenditure, coordinator did not respond,
tomizable settings graphs of progress, weekly opportunity for participants
Prompts: Three daily prompts tailored text messages to interact
through Apple Push
Notification Service
Sample 58 women, 19–63 years (mean 128 adults, average age 42 years, 96 adults, 18–60 years, BMI 25 to
42), average weight 92.4 kg BMI greater than 27 kg/m2 45 kg/m2
(SD ¼ 14.7) BMI
26–43 kg/m2 (mean 34).
Intervention group Meal Replacement Program: My Meal Mate App (similar to Two podcasts (approximately 15
Celebrity Slim two times per MyFitnessPal) minutes) per week for 3
day plus one balanced meal months, two minipodcasts
(approximately 5 minutes) per
Interactive Meal Replacement week for next 3 months
Program app
Fat Secret’s Calorie Counter app

Twitter app
Control group Meal Replacement Program: Weight Loss Resources Website Two podcasts (approximately 15
Celebrity Slim two times per Or minutes) per week for 3
day plus one balanced meal Paper food diary, calorie count- months, two minipodcasts
And ing book and calculator (approximately 5 minutes) per
App providing information that week for next 3 months
came with the meal And
replacements Book with calorie and fat gram
information
Study duration 8 weeks 6 months 6 months
Behavior theory Health Action Process No specific theory, self-efficacy Social Cognitive Theory (design
Approach, Theory of Planned targeted of Podcasts)
Behavior

as a significant mediating variable between programed monitoring of food intake and activity and feedback.24
feedback and weight loss.35 This type of self-monitoring This approach is in line with the goal setting and self-
with feedback strategy is similar to that used in apps. regulation components of Bandura’s Social Cognitive
Although many apps use tools for client diet self-monitor- Theory.32,36 A recent systematic review examining goal
ing, more rigorous research is needed to confirm the effect setting as a component of behavior strategies specific to
of app based food records on behavior change. diet and physical activity in community-based interven-
Goal setting is another feature used in apps. This was a tions targeting overweight and obese adults showed sup-
common characteristic in the three studies (Table 5). For port for its use in nutrition interventions.37 The authors
instance, Carter’s study used a behavioral approach, also associated goal setting and self-monitoring as com-
where the app supported goal setting as well as self- ponents in behavior change.37 Finally, the authors also

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DiFilippo et al. 9

Table 5. Taxonomy of Behavior Change Techniques Utilized By Nutrition Interventions Involving Apps.18

Brindal 2013 Carter 2013 Turner-McGrievy 2011

Scheduled consequences N/A N/A N/A

Reward and threat Reward system in app ‘‘trophy N/A N/A
room’’
Repetition and substitution Meal Replacement Supplement N/A N/A
Antecedents N/A N/A N/A
Associations Reminders-3 daily prompts N/A N/A
through Apple Push
Notification Service
Covert learning N/A N/A N/A
Natural consequences N/A N/A N/A
Feedback and monitoring Diet and weight self monitoring Diet and physical activity self Diet and physical activity
monitoring self monitoring
Feedback on energy intake/
expenditure
Goals and planning Same goals for all participants-2 Weight loss goal setting Goal setting activities
meal replacements and up with podcasts
to 3 snacks daily, weekly
feedback on progress
Social support N/A N/A Twitter support group
Comparison of behavior N/A N/A N/A
Self-belief N/A Messages to increase self efficacy N/A
Comparison of outcomes N/A N/A N/A
Identity Self reflection N/A N/A
Shaping knowledge Suggested recipes for meals N/A Podcasts
Snacks defined
Meal plan information
Regulation N/A N/A N/A
N/A-Not applicable, behavior change technique not identified in this study

cautioned that during interventions different factors are at (four with high bias risk and three with low bias risk), but
play (e.g., education sessions, self-monitoring records), looked at all forms of mobile technology, not just apps.
and that dissecting the independent sources of effect This same study focused on articles published between
would be very difficult. These findings in more traditional 1998 and October 2011, and studies included a range
interventions, while supported by one article in our of number of participants per group (19 to 93).
review,24 need further exploration when goal setting stra- Limited sample size, varying lengths and a narrow age
tegies are facilitated by an app. range are all included as limitations of the studies
Some evidence also showed that apps could be superior reviewed.5 All studies identified in our review were pub-
in terms of adherence to record keeping compared to lished after the timeframe of these articles. Another
paper based methods while maintaining the same level review, which included many forms of mobile technology,
of accuracy.6,7 Our study sought to look more closely at examined behavior change in the context of chronic dis-
knowledge and behavior change rather than solely at the eases showing mixed results.38 Articles published between
use of apps for food records. Nevertheless, the role of apps 1990 and September 2010 were included, with the nutri-
in supporting adherence or perceived effort to diet moni- tion-related articles being non-app interventions.38
toring emerged as a theme in all three studies.21,23,24
Indeed, food journaling through apps may be effective
and should be further evaluated in more rigorous studies.
Limitations
While previous literature has examined technology as a The small number of available studies, especially rando-
strategy to provide knowledge or promote behavior mized controlled trials, limits this review. The use of apps
change, this review adds to that literature by specifically for nutrition education is relatively new, and there is much
focusing on educational mobile apps in the context of research to be done. In this study, we sought to explore
nutrition. One review found that mobile technology sup- nutrition education in terms of both knowledge and
ported weight loss in seven randomized controlled trials behavior change as defined by Contento.11 The available

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10 Journal of Telemedicine and Telecare 0(0)

research focused on behavior, not knowledge. Only one Acknowledgements

study mentioned knowledge change as a variable, but with Division of Nutritional Sciences Vision 20/20 program.
non-significant results.23 Another limitation is that all of
the evaluated studies focused on weight loss as a primary
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