Dietary needs to be recorded during a specified period

          Dietary assessment is one of the four major components in Nutrition
assessment process, which includes , biochemical markers, anthropometry
measures and physical examination  to
have a complete information about a person’s diet and overall health, assessing
the nutritional status for different population groups conceders a major
priority by governments to improve their overall health, generating public
health polices, nutritional and educational programs and to support low income
individuals, In addition to nutritional epidemiologist and researchers who
tries to investigate the relationship between diet and health. 1 

In order to get a complete assessment
for an individual diet, types and amount of foods and beverages consumed needs
to be recorded during a specified period time, then analyzed manually by specialists
through food composition tables, that identifies nutrient intake precisely,
many dietary assessment tools are available to aids in the recording process,
which can be categorized by different purposes, if the interest is about daily
food consumption then the use of food records and 24 hour food recall is
encountered ,or if there was an interest to know the average food consumed
there will be a use of diet history and food frequency questioners(FFQ), they
can be done by the individuals theme selves and called self-administered or by
the help of a professional and called interviewer-administered, administration
is done mainly through the use of pen and paper (until 90s).1

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It can be stated that these are some
of the classically or conventionally available methods used, each has its own
strength and limitations regarding memory, accurate estimation of portion size,
reporting errors (subjective difficulties), time burden to both researcher and
participant while recording, analyzing and coding1,2, adherence issues and real representativeness of individuals usual
intake.3

 According to Basiotis et.al3 who found out that recording intake for one day or a week
full appeared unrepresentative of the usual intake instead records of 3 to 4
days a week appears more accurate when estimating energy and protein for an
entire year, moreover traditional 24 hour food recalls have been expensive and
not practical when used in large scale as they require trained interviewers and
other procedures to estimate intake.4

Validating problems can also stems
from conventional methods, leading  to
the use of two methods which one can serve as a reference for the other, or
using a more accurate and reliable tool such as the biochemical markers more frequently,
these are some of the factors that must be known by the researcher when using
one of these methods or when combining more than one, due to collecting food
intake from study participants, also the study design, available resources,
participants characteristics, and sample size needs to be taken into account.1,3

Soon researchers have realized, the
work load and time consuming conventional methods take to process, and started
to look for a more applicable, easier, valid, accurate and time saving tools to
facilitate dietary assessment, so they did by the introduction of computerized
systems and software’s in 70’s and 80’s (which were more available at that
time).3

Modern day recent technological
advancement in the field of computer programs and software’s, invented smart
phones, tablets and wearable monitoring devices, their relative easier usage, portability
, attractive appearance ,enjoyable using and some are found affordable in cost,
multiple functions they perform, most recently health care systems started to employ
these technological devices.5

Integrating between new technology
and highly advanced devices, with conventional dietary assessment methods, had
been the goal for many researchers and nutritional epidemiologist to avoid most
of the limitations and to promote more accurate assessment tools6, so the international journal of epidemiology announced
their need for papers that covers the topic of using a new technology in
assessing the diet.

The aim of this paper is to briefly
review some of the new available technological tools that are used in dietary
assessment, their characteristics and using conditions, advantages and
disadvantages, ability to use in the middle east countries, Saudi Arabia in
particular. 

Methods :

Database search using Google search
engine, websites like pupmed and science direct have been accessed to search
for the topic new technology in dietary assessment. 

Results :

Computer and web-based dietary
assessment tools:

Computerized dietary assessment
programs have been used several years ago, since the 70’s and 80’s, at that
time they were used as a reference that have food composition tables with
specific coding for each food item then the researcher or dietitian used to
access them to analyze nutrient content of food and beverages consumed,
converting food amount into nutrient content seems to be made easier with
computers.1

However, with enhanced technology and
software constant developments, so have computer programs used in assessing the
diet, whether the delivery was via interactive computer based programs
specifically constructed for diet assessment (uses audio or image to aid
participants to understand instructions), or delivery is made simply by
non-interactive programs tends to be totally self-administered 7, software programs have different forms as the
conventional ones , some may use either food frequency questioner or 24 hours
recall or food records , some software have the ability to use more than one of
these assessments.

Computers have advantages of their
use over traditional diet assessment methods, they have improved delivery
systems (available pictures that aids in portion size estimation and audio
directions), less time and effort to complete, reducing bias during answering
some undesirable questions (on face to face interviews) data entry and coding
is somewhat simple, some programs don’t require training7, provide immediate data analysis through graph ,tables
and equations, also decreasing time spent by dietitians to analyze diet, some
of the limitations include, computers presence is required, which could be
difficult when obtaining  information
from low income participants, minimal computer skills are needed to complete the
assessment (may not be suitable for low literate individuals), most tools are made
in English language ( or Spanish in some instances),which can have a language
barrier to other non-English speakers participants.7,8

One of the most famous tool which have
been developed by the National Cancer Institute (NCI), the Automated
Self-Administered 24 hours dietary assessment tool(ASA24), basically by
modifying the AMPM tool, described as an automated yet self-administered
interactive web based tool for collecting 24 hour recalls or food records,
available as free version for professional researchers and participants, and
used for probing, coding and estimating dietary intake by asking detailed
information about food, portion size quantification ( images representing
portions helping low literate and young children) allowing respondents to
choose from a wide list of foods organized by categories ( has a massive food
data base), drinks and in the most recent version supplements, a penguin figure
can give some explanations by clicking it, the tool provide a website for
respondents to gather dietary intake data, and other for researchers that
enables them to collect results from recalls and records for analyzing nutrient
content with regard to research time frame and comparing intakes with the US
dietary guide lines, available tools in Spanish and specifically for children
(ASA24 KIDS).9   

When tested for validity of the
ASA24, one study demonstrated that it could be a valid tool in assessing the
diet by 24 hour recalls in contrast to the conventional one, relating that to
the fact that ASA24 is built upon the AMPM that has been tested several times
by the National Health and Nutrition Examination survey4, other validation study conducted by Diep et.al 10on the ASA24-KIDS, for children between 9-11 years
showed that the automated tool was less accurate than interviewed administered
24 hours recall, indicating that  additional
research should be done to modify the appropriate age where recalls can be
completed without help, another trial compared the ASA24 with
interviewed administered AMPM, concluded that the ASA24 performed well and
holds a promising approach for studies aiming to observe populations diet and
evaluating intervention effectiveness on diets.11

From the other computerized tools is
MyFood24, this project was developed by the school of science and nutrition at
Leeds university in Britain, in purpose of evaluating the diet of different age
group, this project shares similar characteristics with the ASA24, with a
featured immediate feedback on intake to participants, can be self or
interviewed administered and the option of generating a recipe is available.12 
validating
MyFood24 trails are still preformed, where is one trial conducted on adolescent
highlighted that MyFood24 had approximately similar results with interviewer administered
recalls regarding caloric intake.13  

Other computer tools available to
evaluate the diet that shares related operating principles include ; web-PDHQ a
diet history questionnaire6,FIRSST4 Food Intake Recording
Software System, a dietary recall under development tool (10 years and
above)planned to perform on large scales 14,other
examples involves ,NutriNet Sante, DietDay,INTAKE24,and
Food4ME.15

Camera and Mobil Based technologies:

Unlike the traditional procedure,
where an interviewer (or researcher) contacts the participants by telephone and
asks about dietary intake, or conducts a 24 hour recall1,or even cameras in the 60’s that used to take pictures displaying
different food quantities to allow interviewed participants to compare between
their actual intake(amount consumed), with amounts shown in pictures1,3.

Nowadays, mobile phones are supplied
with camera and  highly improved
operating systems (such as smart phones using IOS or Android systems) using
these tools as a way to measure diet, basically can be made by either taking a
photo of the food before and after eating (noticing  plate wastes), or recording a short video of
the meals before and after consumption (allowing for 3D estimation), sending
voice notes or additional text description about intake, researcher may
instruct participants on the appropriate recording technics, then recorded data
will be transferred to the dietitian or a server where they can be analyzed for
evaluation using 3D image processing visualization technology that are able to
convert actual intake (amount of food) into nutrient content on their own which
tends to be relatively accurate in terms of measuring intake.3,6,2

 Some mobile devices and digital cameras are
made with sophisticated techniques enables them to make portion size estimation
without having to be sent to dietitian or computer server, they may require
three photos captured for a meal or only one photo or a video, these tools
practicability of estimating actual intake is still needs to be more examined, all
mobiles with camera have advantages of ,reducing participant burden regarding
memory, recall and the need to keep diary to document foods eaten at each meal,
also the fact that smartphones are easy to carry and can be afforded by many
individuals in the population (with different socioeconomic status) data can be
sent directly from their device to the dietitian ,in addition reducing burden
on dietitians time rather than having to deal with analyzing each foods and
trying to anticipate actual portion size besides dealing with participants
delay on feedback submission, recorded data may be lost (loss of diary), new
tools overcome these problems in many possible ways .6,2

Some disadvantages may appear by
using camera and mobile phones as an intake estimation practice, for example ,
participants may find it difficult to capture all what they have eaten and
drunk all day long (may not adhere to the procedures), some tools may demand
participants to first upload intake images to the computer and send them
afterwards via email to the dietitian, some issues may relate to the device
itself like battery or charging problems, camera resolution and image quality,
in the case of wireless ability loss of communication is another problem.3,6

Famous examples include; the Japanese
“Wellnavi” instrument for measuring food intake which is basically a mobile
phone with a digital camera and a phone card, enables participants to take
pictures of food intake at each meal time that works in the same manner as
previously described, intake data are saved on an internal phone card, then
data will be transformed to dietitian for analysis electronically, results may
be sent back to participants.6,16

In an attempt to validate this
instrument, a trial made by Kikunaga et.al16,
who recognized that intake measured by Wellnavi, had lower estimation of
dietary intake compared with weighed records ,referring to technical problems
like low image quality that led to inaccurate estimation plus, recording error
made by participants, conflicted with what other study findings on the same
tool, that there were no significant difference between nutrient intake results
compared with weighed food records except in some nutrients.17

From other available tools, funded by
the National Institute of Health is TADA (technical Dietary Assessment
Project), allowing participants by the use of their mobile phone made with
complex technology, to capture photos during their meal time, soon images will
be sent directly to a server for analysis, portion size estimation and
translating food items on images into food volume, then nutrient content generation
occur, quick food evaluation process, also feedback can be quickly sent with
motivational massages to help for goals and plans setting18, similar to the Wellnavi tool ,unless there is no
need for memory card and uploading pictures to computer, data transformation is
done by the TADA immediately, the ability of the TADA to accurately record ,
measure portion size and food volume have been performed and recognized in many
trails3,18.

The Mobile Phone Food Record , is
another example found as a mobile app (FDapp) that has been tested by
adolescents use19, other available apps include;
MyFittness Pal, Calorie counter and my Net Dairy.20

Other Technologies :

PDA (personal digital assistance)
tools used since 90’s to assess diets6,7,
they work by similar principles as the smart phones to assess diet, regarding
data analysis and recording technics and shares many advantages as well, except
that PDAs are not made with cameras or for voice Calles , and on top PDA  have a list of various food options to select
from them (based on the USDA data base), aids in calculating intake (amounts in
grams), some PDAs require training, food items may be difficult to find, they may
not give accurate measures on intake21, others
are expensive in cost.

Sensor technology, can be used in
many health care field, they can sense motion, heat, UV light respiration and
heart rates, they come as cameras that can be worn on clothes with transmitter
built and battery unit, recording 24 hours events that occurs in a day as a
video, dietitians can use them to monitor food intake as they exclude the
demands of daily food self-reporting activity, high technology for determining
food volume that aids in the analyzation process ,settings are important with
sensor technology, as more accurate results could be seen in restraints and
cafés, from the drawback of these technics is the very long time spent by the
researcher to watch long videos recorded by the device to find out each meals
and snacks eaten, food purchasing activities (type of food, brands and amount
bought) for accurate measurement and analysis, which makes them difficult to
implement on large scales, sensors such as eButton device is one example22, that was compared with computer to check analyzing
accuracy, computers showed less biased measures23.  

Lastly, voice recordings and speech
recognition software which can record foods and portion size by voice such as;
Viocare’s (FIVR), there are other tools that can scan bar codes from food
packages to help nutrient intake identification but may require additional
information by participants.6  

 Discussion:

Regarding validity and reliability
studies of most previously prescribed technologies, more studies are needed for
verification and accuracy especially when measuring food intake portion sizes6, for instance a study showed that PDA didn’t gave accurate
estimates of true portion sizes compared with one conventional method21, also mobile based Wellnavi tool had issues with
accuracy and images quality 16,which leads
to further technical enhancement and development, computers, smart phones and
sensors devices appears accurate than other tools, but still further
enhancement are needed, as with conventional methods which one can be used as a
reference to validate the other, the same can be done with these new tools for
example, validating the ASA24 was done by comparison of both interviewer
administered 24 hour diet recall and also with other computerized tool as AMPM4,10, many validity options can be performed.

Many of them shares similar
advantages, like less dependence on memory (can benefits elderly and kids),
less time and effort to preform, easier to use by different age groups,
portable and light in weight, except for computers (though they give the most
accurate analysis results), the fact that they can support studies with large
number of participant’s, also sharable disadvantages may relate to low literacy
,language, charge and battery issues, accuracy and precisions problems,
subjective reporting errors are also presented with new technology referring to
one’s own integrity 6, knowing these issues will benefit
in future development, for instance the introduction of computerized tools into
mobile phones (making ASA24 available as a smart phone app).     

Most of these devices are relatively
safe, but can poses electrical problems (when charging for example) most of the
wireless, particularly sensors devices safety might be questionable as they may
expose subjects when worn for long times to unnecessary radiations.24

According to their applicability and
suitability to the Saudi Arabia population, and taking into account the Islamic
preservative nature of the Saudi society, some technological instrument may not
be acceptable, as they may considered invading privacy (females in particular)
such as the sensor devices which are cameras worn for 24 hours that records all
day events in a video for later analysis, also voice recording tools might be
seen inappropriate, researcher needs to know the appropriate conditions and
intended study subjects very well before choosing any tool, many tools and
operating software needs to be adjusted in Arabic before they are used, Smart
phones with all provided apps and computers seems to be a much more desirable
options, but also not all individuals can afford them, moreover some instrument
require the participants to be literate to a certain degree which could
represents a problem when conducted on elderly low literate individuals, also
when preforming evaluation on rural areas, where internet connections in some
areas may be inappropriate leading to poor technological devices performance
and delay in summations, if new technologies are to be used by dietitian, they
need to receive training for their use in order to train participants, until
now pen and pencil and some web based surveys and questioners are preformed,
the government should establish future plans to enhance public health and
reduces nutrition related diseases, by taking advantages of efforts made by IT,
nanotechnologies, nutritionist and epidemiologist efforts, that corresponds
with the Kingdoms 2030 vision.

Conclusion:   

New technological devices, give an
excellent alternative for dietitians and nutrition epidemiologist to measure
food and nutrient components, for large number of the populations, and also to
respondents as most of them considered user friendly and affordable by many,
challenges are still imposed particularly when estimating portion size and
accurate analysis, computers and smart phones are the most widely available and
favorable tools, validity and reliability studies are still needed for most of
them ,in Saudi Arabia researchers should be careful when using technology
tools, as governments should encourage the introductions of these instruments
in many health care settings including food and nutrition. 

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