Patient Education and Counseling 101 (2018) 750–757

Discussion

Smartphone apps and the nutrition care process: Current perspectivesand future considerations

Juliana Chena,*, Luke Gemminga, Rhona Hanningb, Margaret Allman-Farinellia

a School of Life and Environmental Sciences and Charles Perkins Centre, The University of Sydney, Camperdown, NSW, Australiab School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada

A R T I C L E I N F O

Article history:Received 9 September 2017Received in revised form 2 November 2017Accepted 16 November 2017

Keywords:AppsDieteticsCounselingEducationmHealthNutrition care process

A B S T R A C T

Objective: To provide dietitians with practical guidance on incorporating smartphone applications (apps)in the nutrition care process (NCP) to optimize patient education and counseling.Methods: The current evidence-base for mobile health (mHealth) apps was searched using PubMed andGoogle Scholar. Where and how apps could be implemented by dietitians across the four steps of the NCPis 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 delivereducation and nutrition counseling. Dietitians could prescribe apps to provide patients with education onnutrition skills and in counseling for better adherence to behavior change. Improved patient-providercommunication is also made possible through the opportunity for real-time monitoring and evaluationof 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 nutritioncare and counseling delivered by dietitians.Practice implications: Apps should be considered an adjunct to enable dietetic counseling and care, ratherthan to replace the expertise, social support and accountability provided by dietitians.

© 2017 Elsevier B.V. All rights reserved.

Contents lists available at ScienceDirect

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1. Introduction

Nutrition care delivered by registered dietitians (RDs) is afundamental component of health promotion, and chronic diseaseprevention and management [1], particularly given the highprevalence of obesity, diabetes and other non-communicablediseases [2–4]. In 2012, the Dietetic Workforce Demand Study TaskForce predicted only 75% of demand for RDs in the US would be metin 2020 [5]. The study also identified technology as havingpotential to transform how RDs deliver nutrition counseling andpersonalized nutrition [6].

For the delivery of more consistent and effective qualitynutrition care by RDs, the Academy of Nutrition and Dietetics(the Academy) recommends their nutrition care process (NCP)[7,8]. The systematic method allows RDs to diagnose anddevelop treatment plans for nutrition-related problems [7].

* Corresponding author at: The University of Sydney, Level 4 East, Charles PerkinsCentre (D17), John Hopkins Drive, Camperdown 2006, NSW Australia.

E-mail address: jche6526@uni.sydney.edu.au (J. Chen).

https://doi.org/10.1016/j.pec.2017.11.0110738-3991/© 2017 Elsevier B.V. All rights reserved.

Furthermore, having a standardized NCP framework facilitatesoutcomes for research to evaluate the impact of nutrition careon patient health outcomes. Subsequently, the efficacy ofnutrition care can be demonstrated, enabling advocacy for therole of RDs in obesity and chronic disease treatment andprevention [7,9]. Moreover, productivity and communicationbetween RDs and other members of the health care team haveimproved through diagnosis-focused documentation of theNCP [9]. There is now the opportunity for advocating the NCPfurther with technology.

The public market for and acceptance of mobile health(mHealth) technologies, such as smartphone applications (apps)has experienced dramatic growth, with over 259,000 mHealthapps available [10]. Fifty-eight percent of US smartphone ownershave downloaded a health-related app [11], with fitness andnutrition apps most frequently downloaded [12]. The proliferationand low-cost of many nutrition apps may appear a threat to RDsservices. However, if implemented appropriately, apps couldsupport dietetic practice by increasing accuracy, efficiency andquality of clinical decision-making when applying the NCP [13], aswell as improving patient access to point-of-care services and

J. Chen et al. / Patient Education and Counseling 101 (2018) 750–757 751

patient-provider communication, to ultimately improve patientoutcomes [14].

Recent reports indicate the dietetic profession has adoptedhealth apps into their practice. Eighty-three percent of US RDswere found to recommend apps [15]. In Canada, 57% of dietitiansused apps in practice, and a three country study of Australian, NewZealand and British dietitians found 62% used apps in patient careand 84% recommended apps [16].

Despite the rates of app adoption by dietitians, the professionhas expressed their desire for more education and training aroundincorporating apps into dietetic practice, especially privatepractice [15,16]. To support app use among RDs, the Academyhas undertaken science-based reviews of nutrition apps, which areincluded in their Food & Nutrition magazine [17]. However, therehas been no systematic process proposed of how to incorporateapps into the NCP. Therefore, the purpose of this paper was first toidentify the areas in which an RD could practically implementhealth apps across the four steps of the NCP (i.e. nutritionassessment, nutrition diagnosis, nutrition intervention and nutri-tion monitoring and evaluation). Secondly, the medical nutritionliterature (PubMed) and more general sources (Google Scholar)were searched for research on implementation of health apps tosupport weight loss, diabetes, healthy lifestyles, nutrition care, anddietetic practice. Finally, a framework to guide the use of apps inthe NCP was constructed.

2. Nutrition assessment

During patient assessment, RDs will obtain, verify and interpretanthropometric, biochemical, medical, social and client history, aswell as dietary information [8]. RDs usually conduct a diet historyto estimate nutritional adequacy and meal patterns but sometimesask patients to keep a diet record in advance of their consultation.However, paper-based dietary records are burdensome for patientsand labor-intensive for RDs to analyze, thereby reducing counsel-ing time available [18].

Eighty-three percent of US adults use their smartphone whileeating [19]. Apps provide a convenient means to record data innear real-time during eating occasions and have demonstratedgreater acceptability than paper-based food diaries [20–22].Dietitians and health care providers also show acceptance towardstechnology-assisted dietary assessment [16,23]. Most nutritionapps convert the food intakes into nutrients and provide validestimates of energy and nutrient intake comparable to traditionaldietary assessments [24–26]. An evaluation of variance across 23commercial weight loss apps revealed that 17 of 23 apps assessedwere within �100 kcal of weighed food records [27].

Some commercial apps also include image logs to complementthe digital dietary record and assist with prompting memory whenreviewing records or by dietitians for qualitative assessment[27,28]. Sole image-based dietary record apps show promise inlowering the burden of logging, though challenges remain forautomated computer vision approaches to reliably assess the vastarray of foods [29].

Collection of anthropometric measurements and monitoringcould also be enhanced. Apps and wireless scales provide a popularand simple method to assess, monitor and visualize weight history[27]. The Academy’s NutriCare Tools app contains a compilation ofevidence-based tools, including calculators that assess energy andfluid requirements and a range of anthropometric tools [30].Fitness and exercise wearables, such as Fitbit or smart watches, canalso support the passive assessment of physical activity, includingvalid estimates of step counts and energy expenditure [31,32].

Apps for diabetes management enable patients to log bloodglucose levels, track insulin injections and oral medication andrecord exercise, carbohydrate and other dietary intake [33]. These

‘all-in-one’ apps are convenient for patients, and allow RDs topinpoint certain foods, carbohydrate intake patterns or physicalactivity sessions influencing patients’ blood glucose. Somediabetes apps also allow patients to synchronize blood glucosemeasurements from glucometers for simplified recording andvisualization of trends [34–36]. Certain diabetes apps have beenapproved by the US Food and Drug Administration [33,37].

3. Nutrition diagnosis

From data gathered in nutrition assessment, RDs can identifythe etiology, signs and symptoms of nutrition problems, which canthen be targeted through a treatment or nutrition intervention [8].With many complex terminology references in this step, theformer IDNT app, now integrated into the Kalix software [38,39], is auseful tool for guiding RDs on the selection of relevant andappropriate nutrition diagnoses. Nutrition diagnostic domainsmost likely to be established by health apps include the intakedomain for energy, nutrients and fluids; clinical domain diagnoses,such as weight loss or weight gain and behavioral-environmentalaspects, such as knowledge and beliefs and physical activity [8].

Identifying the etiology of a nutrition problem is necessary forsubsequent implementation of nutrition interventions. Etiologiesrelated to the behavior category of the Nutrition Diagnosis Etiologymatrix (e.g. disordered eating pattern, excessive or inadequateenergy intake, excessive physical activity) [8] are readily identifiedby health apps. With continued recording, dietary patterns andanomalies can be detected, albeit dependent on patient input ofthe data. Therefore, examining patient-generated health data(PGHD) via app records may also allow RDs to uncover additionalinformation about other etiological categories, such as beliefs-attitudes, cultural or knowledge, that may be contributing to thenutrition problem.

4. Nutrition intervention

To address the etiology or signs and symptoms of the nutritiondiagnosis, RDs plan individualized interventions and providenutrition education and counseling [8]. Dietitian-specific tools,such as NutriGuides, an app developed by the Academy, contains anaccessible compilation of the Evidence Analysis Library to help RDsdetermine best-practice treatment [40].

Emerging evidence provides some support for using apps inlifestyle change [41,42], and weight [42,43] and chronic diseasemanagement [44–46]. However, apps appear to be more effectivewhen complemented with counseling sessions, education or othermHealth technologies (e.g. text messaging) in multi-componentinterventions rather than with standalone use [41,47,48]. Theimportance of dietitians in providing coaching [48,49] is affirmedby the lack of success when nurses or physicians provided suchcare [50–52]. It should be noted, most effective interventionsinvolved younger adults, who typically engage with apps moresuccessfully than older participants. Thus, RDs must assess theappropriateness of prescribing apps in nutrition interventionsbased on individual patient demographics and motivations.

Nutrition education is a NCP intervention strategy [8], and usingapps to deliver information is likely to be acceptable to patients,given 63% of US smartphone users access information about healthconditions via smartphones [53]. Calorie or nutrient informationprovided by apps are reported to be a useful resource in patientnutrition care [16]. Educational information on diabetes, includingmanaging blood glucose and diabetes-related treatments are alsoaccessible in some diabetes apps [33,54]. However, there isopportunity for more personalized patient education, particularlyapps centered around dietary and clinical guidelines [27,33,54–56].Nutricare Tools app provides education on reading food labels [30].

752 J. Chen et al. / Patient Education and Counseling 101 (2018) 750–757

Fooducate provides interpretations of nutrients and ingredients offood labels from scanned product barcodes [57,58], and ShopWellscores foods based on individual dietary preferences, with contentthat has been reviewed and developed by RDs [59,60]. FoodSwitchis a commercial-research partnership app that utilizes a trafficlight system for identifying healthier packaged foods [61].Researchers have also developed the MyNutriCart app based onthe Dietary Guidelines for Americans [62].

An important strategy RDs use to enable behavior change issetting mutually acceptable and tailored goals with patients.Generic goal setting is a common feature in apps [27,33,63–69].However, personalized goal setting is often only available inpremium subscription versions of commercial apps. Dietitians ofCanada developed eaTracker, an app allowing users to choose from87 ‘ready-made’ SMART goals, covering 13 different categories, orto write their own goals [70,71]. Data mining of health app datarevealed greater odds of weight loss success with the morecustomization features users implemented, such as customizedgoals, recipes, foods as some examples [72].

Regular and frequent self-monitoring is a foundational compo-nent of weight loss [73] and improved glycemic control in diabetesmanagement [74]. Adherence to self-monitoring is superior withapps compared to traditional pen and paper-based records[22,43,55,75,76], making apps a good choice for increasing patientcompliance with self-monitoring and achieving positive weightand dietary outcomes [72,76–79]. Self-monitoring increasespatient awareness of behaviors, giving them confidence to self-manage their health, for example adjusting insulin based on self-monitored blood glucose readings [46].

When RDs are considering what apps to recommend for self-monitoring, it has been demonstrated that weight loss success is

Fig. 1. A hypothetical patient case outlining how smartphone applications (apps) could bmanagement.

predicted by consistent dietary monitoring through an app,irrespective of the actual app used to track diet [75]. Long-termsustained use of apps for dietary self-monitoring is challenging tomaintain, and adherence to app use rapidly declines over time[22,50,80]. Patient engagement with apps can be increasedthrough human support and accountability [81]. Retention ratesfor mHealth apps are higher when health care professionalsprescribe mHealth apps to patients rather than making generalrecommendations [12]. Thus, RDs should define a realisticfrequency and pattern of tracking tailored to patients’ individualcapacities for self-monitoring and lifestyles when they prescribeapps. Self-monitoring consistently over consecutive days may beunnecessary, with evidence highlighting that long-term intermit-tent self-monitoring over 6 months was more successful andassociated with greater weight loss compared to short-term self-monitoring [78]. Where patients are less compliant with self-monitoring, encouraging frequent logging of only specific mealoccasions, such as dinner, can assist in the maintenance of weightloss [77]. Logging physical activity for sustained periods usingwearables presents fewer challenges due to their passive natureand ability to sync automatically with apps.

Finally, the time and frequency of conventional nutrition careare generally limited to face-to-face encounters at fortnightly ormonthly consultations. While immediately after the consultation,patients may be motivated to implement discussed strategies,motivation and adherence to dietary plans between consultationsmay decline. Stein has previously discussed a range of apps thatenable remote nutrition counseling and could enhance dieteticpractice models [82]. The ability of apps to allow remote near real-time monitoring of weight, nutrition and physical activity canincrease the frequency of patient-dietitian interactions, and allow

e implemented into each step of the nutrition care process to support patient weight

J. Chen et al. / Patient Education and Counseling 101 (2018) 750–757 753

monitoring and adjustment to the nutrition intervention to occurin a timelier manner, even between consultations [82].

5. Nutrition monitoring and evaluation

Given the ultimate aim of the NCP is to help patients bettermeet their nutrition and health goals [7], monitoring, measuringand evaluating the effectiveness and overall impact of medicalnutrition therapy intervention is essential [8]. These processesallow RDs to judge when to continue, modify or cease inter-ventions.

If patients are compliant with self-monitoring via apps,patterns in patient’s dietary intake may be revealed and factorsassisting or hindering goal attainment identified. Examples includefrequency of meals or snacking, eating out, physical inactivity,sourcing of foods or even highlighting emotional eating episodesfor eating disorder patients [83], which would allow RDs to discusstailored strategies with patients to overcome barriers and lapses.The literature affirms that patient self-management and behav-ioral regulation is more effective when self-monitoring iscombined with other components of control theory, such as theprovision of feedback on performance and reviewing of goals[84,85]. To promote patient accountability after app prescription,review of app records of PGHD should be routine in nutrition care.In current practice, reviewing of app data as part of every follow-upconsultation is infrequent among dietitians [16]. More commonlypatient progress made with apps is only reviewed in someconsultations via patient reporting without direct reference to theapp data [16].

Key: Nutri on Care Process Terminology termsNutri on Care Process elements that are supported by smartphone ap

Energy and nutrient in

Physical ac vity informa on

FH-7.3

FH-1.1.1FH-1.2.1FH-1.2.2FH-1.4.1FH-1.5.1FH-1.5.2

FH-1.5.3FH-1.5.4FH-1.6.1FH-1.6.2FH-5.3

NNNNNNNNNN

Anthropometric measures

AD-1.1

Daily blood glucose

measuresBD-1.5

Comparison to standards

CS-1.1CS-2.1CS-2.2CS-2.3CS-2.4CS-3.1CS-4.1CS-4.2CS-5.1

Nutri on Assessment

Nutri on Monitoring &

Evalua onPa ent-provider communica on

FH-5.5

Pa ent compliance to recommenda ons

FH-5.1 FH-5.1

Remote monitoring of

pa ent progressFeedback on pe

mNCP

Fig. 2. The mobile Nutrition Care Process (mNCP

Apps with data sharing functionalities that innately integrateinto dietitian-designed health record platforms (e.g. Healthie, EasyDiet Diary Connect and MyPace) [86–89] present opportunities toincrease the convenience of accessing and reviewing app records[90]. In turn, the quality of patient-provider communication anddegree of support between consultations from remote nutritioncare is enhanced through the greater connectivity of apps[33,82,90]. Many diabetes apps have capabilities to export datavia email, unlike most weight loss apps [27,36,65]. Through suchplatforms, timely feedback from an RD at the point of patientlapses occurring can increase patient autonomy and empowerthem to respond to triggers and self-regulate their own healthbehaviors [88].

While it may not be feasible or financially viable for RDs tomonitor all their patients in real-time to provide instant feedback,adjustments in work task schedules or care delivery models canallow more timely responses [91]. Advances in software and datamining will assist this in the future [92,93]. Health apps ofteninclude standardized criteria for weight, glycemic control, orrecommended physical activity, calorie and nutrient intake makingautomatic comparisons possible. Alerts could be integrated intothe platforms for review on a daily basis [90]. However, the validityand country-specificity of the reference standards in algorithmsshould be ensured [27,90]. Provision of RD fees that allowmonitoring of PGHD from apps would facilitate the suggestedmodel of care [82].

A hypothetical case study is presented in Fig. 1, with samplepractice data outlining how apps could be included across the NCP.

plica ons

take informa on

I-1.1I-1.2I-1.3I-1.4I-2.1I-2.2I-2.9I-3.1I-3.2 I-5.1

NI-5.2NI-5.3NI-5.4 NI-5.6.1NI-5.6.2NI-5.6.3NI-5.7.1NI-5.7.2NI-5.7.3 NI-5.8.1

NI-5.8.2NI-5.8.3NI-5.8.4NI-5.8.5NI-5.8.6NI-5.9.1NI-5.9.2NI-5.10.1NI-5.10.2NI-5.11.1NI-5.11.2

NB-2.1NB-2.2

Physical ac vity informa on

NC-3.1NC-3.2NC-3.3NC-3.4

Anthropometric measures

Nutri on Diagnosis

NB-1.4NB-1.5NB-1.6NB-1.7

Behavioural knowledge and

beliefs

Nutri on Interven on

E-1E-2 Nutri on educa on

C-1C-2 Social support

C-1C-2

C-1C-2

Pa ent self-monitoring

rformance Goal-se ng

) grid to support Medical Nutrition Therapy.

754 J. Chen et al. / Patient Education and Counseling 101 (2018) 750–757

6. Mobile nutrition care process grid

Fig. 2 outlines a framework termed the mobile Nutrition CareProcess (mNCP) grid that has been developed to support RDs in theiruse of apps throughout the steps of the NCP. Under each of thesesteps, the uses of apps have been matched to Nutrition Care Processterminology. Features related to the uses of apps and theircontributions to nutrition care are outlined in Table 1.

7. The future of apps and wearables for dietetic practice

As competition increases to meet consumer expectations forhigh quality, convenient and accessible health services, andsimultaneously ensure that health care costs are minimized, appsand other mHealth technologies present an opportunity to supportdietitians. Dietitians would like continuing education and trainingfrom their professional associations to improve their capacity andmotivations for using apps, such as understanding how apps couldbe used as supportive tools that add value rather than threatentheir practice [6,16]. Incorporating apps into the NCP could permit

Table 1The functions of smartphone applications (apps) that contribute to the Nutrition Care

NCP element App functions

Energy or nutrientintakeinformation

Automatic quantitative calculations of energy and macro- (includalcohol) and micronutrient intake values based on foods inputte

Physical activityinformation

Automatic tracking of physical activity intensity and duration whlinked to wearable devices and apps. Steps can also be tracked. Mlogging of activities in some apps.

Anthropometricmeasures

Record weight measures through manual input or via Bluetooth

Anthropometry calculators (e.g. BMI calculators).

Data in graphical forms.

Blood glucosemeasures

Record blood glucose, HbA1C.

Connectivity to glucometer.

Comparison tostandards

Automatic comparison of intake to Dietary Reference Intakes valenergy, macro- and micronutrients.

Behavioralknowledge andbeliefs

Regular app records of dietary intake.

Nutritioneducation

Information about foods available for therapeutic diets, calorie anutrient content of foods.Nutrition information to enable healthy choices in the supermar

Social supportfrom dietitian

Messaging and coaching functions from within the app.

Newsfeeds.

Patient self-monitoring

Tracking of diet, weight and other health behaviours e.g. physical ablood glucose.

Goal-setting Setting goals for diet, weight, physical activity, blood glucose.

Goals negotiated in the consultation can be entered into the apppatients to track.Graphs/visuals to show progress against goals.

Feedback onperformance

Immediate feedback on data logged. Algorithms can allow forpersonalised feedback for individuals.

Remotemonitoring ofpatientprogress

Remote monitoring of progress and performance between consult

Patientcompliance torecommendations

App records provide information to determine patient adherencedietary prescriptions.

Patient-providercommunication

Exporting of patient-generated health data collected by apps via eminto a platform for dietitians to view.

the dietitian to devote more practice time to nutrition behavioralcounseling.

RDs have reported that video conference apps and smartphonesare among the technologies they were currently or expecting to usefor telehealth within the next five years [94]. Nutrition and dieteticservices delivered via telehealth in the US is reimbursable by third-party payers, but not in most other countries [94]. However, RDsstill identified barriers to existing payer coverage. Revisions toreimbursement schemes to accommodate incorporation of appsinto telehealth and remote nutrition care may be necessary toprovide monetary incentive for private practice dietitians toreview patient app records and provide feedback within andbetween patient consultations.

As in all aspects of dietetic practice, RDs need to apply criticalthinking skills to determine the suitability of prescribing or usingtechnology with their patients in the NCP. Considerations shouldbe given to patient familiarity with technology, ability to adopttechnology, motivation and readiness to change and their ability tosustain use and interest in these technologies [95]. Generally,however, greater engagement and willingness to adopt mHealth

Process (NCP).

Contribution to NCP

ingd.

Electronic food record. Reduces the time required to conduct diet historyand with basic dietary information gathered, additional probing ofdietary habits could be conducted.

enanual

Passive collection of physical activity data can provide more objectiveevidence about a patient’s physical activity.

scales. Track weight against goals.

Convenient access to calculators used in anthropometry.Easy visualization of progress through weight graphs.Allows patients to track blood glucose and identify food and lifestyletriggers for elevated blood glucose levels.Additional source of data for RD.

ues for Time-saving and removes manual analysis by RD.

Detecting deficits in self-monitoring. Providing evidence to supportlimited adherence to nutrition-related recommendations or undesirablefood choices as well as disordered eating.

nd Increasing knowledge and skills about food choices for therapeutic diets,food choices and energy balance.

ket.Enabling the delivery of motivational support from a dietitian betweenconsultations.Enhance patient confidence with making changes to behavior fromcollaborative relationship.

ctivity, Increasing patient awareness of behavior and outcomes. Empoweringpatients to self-regulate behaviors. Enhanced compliance to self-monitoring when using an app. Pinpointing and presenting fine-grainedreal-time data.Tracking of progress against goals promotes dietary behavior change.

for Patients are able to see the goals negotiated with their dietitian to enablegreater awareness of what to achieve before the next consultation.Building confidence through stepwise improvement and achievablegoals.Near real-time feedback compared with standards allows patients toadjust their behaviors as they occur, or guiding patients towards betterfood choices, rather than waiting for the next consultation before they areaddressed.

ations. Adjustments to nutrition intervention occur in timely manner.

to Opportunity to discuss episodes of non-compliance and lapses and toaddress barriers and new enabling strategies with RD. Increasesaccountability of patients.

ail or Enhancing patient-provider communication can increase patientsatisfaction and greater perceived value of dietetic services.

J. Chen et al. / Patient Education and Counseling 101 (2018) 750–757 755

technologies exists among individuals identifying with the‘quantified self’ movement and those who want to take a moreactive role in self-managing their own health care [96,97], andyounger adults where technology is a fundamental part of their life[53]. Therefore, RDs should recommend a medium that is mostappropriate to patient characteristics whether across the entireNCP or at certain steps (e.g. nutrition interventions).

8. Conclusion

Apps are currently under-utilized by dietitians in the NCP, yetthey have the potential to make medical nutrition therapy moreefficient, especially in the private practice setting. Conversion ofthe patient input of food consumed into nutrients by nutrition appswill streamline nutrition assessment and allow more time foreducation and nutrition counseling. RDs could consider prescrib-ing apps in combination with their nutrition counseling, toincrease adherence to self-monitoring of patient-centered goals.Apps could also be used to monitor and evaluate patientcompliance with a nutrition plan through the real-time datacollected and enable bidirectional information exchange.

Practice implications

An app is only as good as the quality of data entry and itsalgorithms, but combined with the critical-thinking expertise,social support and accountability of an RD, they may supportindividualized patient-centered nutrition care. Dietitians have aleading role in directing the design of apps to better support theirpractice and clients. Lastly, funding mechanisms for review ofpatient data outside face-to-face appointments will be needed forRDs and their patients to achieve the full benefits technology canoffer.

Author’s contributions

JC and MAF contributed to the conception and design of thestudy. JC conducted the research and drafted the first version of themanuscript. LG, RH and MAF contributed to writing and editing themanuscript. All authors read and approved the final manuscriptsubmitted.

Funding and conflict of interest disclosures

JC is a PhD student at The University of Sydney, funded by thefunded by the Australian Government Research Training Programscholarship, but declares no personal or financial conflicts ofinterest. The Australian Government Research Council had noinvolvement in this research. LG and RH declare no conflicts ofinterest. MAF has developed food and nutrition based apps forresearch purposes.

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