Dietary assessment is one of the four major components in Nutritionassessment process, which includes , biochemical markers, anthropometrymeasures and physical examination tohave a complete information about a person’s diet and overall health, assessingthe nutritional status for different population groups conceders a majorpriority by governments to improve their overall health, generating publichealth polices, nutritional and educational programs and to support low incomeindividuals, In addition to nutritional epidemiologist and researchers whotries to investigate the relationship between diet and health. 1 In order to get a complete assessmentfor an individual diet, types and amount of foods and beverages consumed needsto be recorded during a specified period time, then analyzed manually by specialiststhrough 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 dailyfood consumption then the use of food records and 24 hour food recall isencountered ,or if there was an interest to know the average food consumedthere will be a use of diet history and food frequency questioners(FFQ), theycan be done by the individuals theme selves and called self-administered or bythe help of a professional and called interviewer-administered, administrationis done mainly through the use of pen and paper (until 90s).1It can be stated that these are someof the classically or conventionally available methods used, each has its ownstrength and limitations regarding memory, accurate estimation of portion size,reporting errors (subjective difficulties), time burden to both researcher andparticipant while recording, analyzing and coding1,2, adherence issues and real representativeness of individuals usualintake.
3 According to Basiotis et.al3 who found out that recording intake for one day or a weekfull appeared unrepresentative of the usual intake instead records of 3 to 4days a week appears more accurate when estimating energy and protein for anentire year, moreover traditional 24 hour food recalls have been expensive andnot practical when used in large scale as they require trained interviewers andother procedures to estimate intake.4 Validating problems can also stemsfrom conventional methods, leading tothe use of two methods which one can serve as a reference for the other, orusing 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 usingone of these methods or when combining more than one, due to collecting foodintake from study participants, also the study design, available resources,participants characteristics, and sample size needs to be taken into account.1,3Soon researchers have realized, thework load and time consuming conventional methods take to process, and startedto look for a more applicable, easier, valid, accurate and time saving tools tofacilitate dietary assessment, so they did by the introduction of computerizedsystems and software’s in 70’s and 80’s (which were more available at thattime).3Modern day recent technologicaladvancement in the field of computer programs and software’s, invented smartphones, 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 employthese technological devices.
5Integrating between new technologyand highly advanced devices, with conventional dietary assessment methods, hadbeen the goal for many researchers and nutritional epidemiologist to avoid mostof the limitations and to promote more accurate assessment tools6, so the international journal of epidemiology announcedtheir need for papers that covers the topic of using a new technology inassessing the diet. The aim of this paper is to brieflyreview some of the new available technological tools that are used in dietaryassessment, their characteristics and using conditions, advantages anddisadvantages, ability to use in the middle east countries, Saudi Arabia inparticular. Methods :Database search using Google searchengine, websites like pupmed and science direct have been accessed to searchfor the topic new technology in dietary assessment.
Results :Computer and web-based dietaryassessment tools:Computerized dietary assessmentprograms have been used several years ago, since the 70’s and 80’s, at thattime they were used as a reference that have food composition tables withspecific coding for each food item then the researcher or dietitian used toaccess them to analyze nutrient content of food and beverages consumed,converting food amount into nutrient content seems to be made easier withcomputers.1However, with enhanced technology andsoftware constant developments, so have computer programs used in assessing thediet, whether the delivery was via interactive computer based programsspecifically constructed for diet assessment (uses audio or image to aidparticipants to understand instructions), or delivery is made simply bynon-interactive programs tends to be totally self-administered 7, software programs have different forms as theconventional ones , some may use either food frequency questioner or 24 hoursrecall or food records , some software have the ability to use more than one ofthese assessments.Computers have advantages of theiruse over traditional diet assessment methods, they have improved deliverysystems (available pictures that aids in portion size estimation and audiodirections), less time and effort to complete, reducing bias during answeringsome undesirable questions (on face to face interviews) data entry and codingis somewhat simple, some programs don’t require training7, provide immediate data analysis through graph ,tablesand equations, also decreasing time spent by dietitians to analyze diet, someof the limitations include, computers presence is required, which could bedifficult when obtaining informationfrom low income participants, minimal computer skills are needed to complete theassessment (may not be suitable for low literate individuals), most tools are madein English language ( or Spanish in some instances),which can have a languagebarrier to other non-English speakers participants.7,8 One of the most famous tool which havebeen developed by the National Cancer Institute (NCI), the AutomatedSelf-Administered 24 hours dietary assessment tool(ASA24), basically bymodifying the AMPM tool, described as an automated yet self-administeredinteractive web based tool for collecting 24 hour recalls or food records,available as free version for professional researchers and participants, andused for probing, coding and estimating dietary intake by asking detailedinformation about food, portion size quantification ( images representingportions helping low literate and young children) allowing respondents tochoose from a wide list of foods organized by categories ( has a massive fooddata base), drinks and in the most recent version supplements, a penguin figurecan give some explanations by clicking it, the tool provide a website forrespondents to gather dietary intake data, and other for researchers thatenables them to collect results from recalls and records for analyzing nutrientcontent with regard to research time frame and comparing intakes with the USdietary guide lines, available tools in Spanish and specifically for children(ASA24 KIDS).9 When tested for validity of theASA24, one study demonstrated that it could be a valid tool in assessing thediet by 24 hour recalls in contrast to the conventional one, relating that tothe fact that ASA24 is built upon the AMPM that has been tested several timesby the National Health and Nutrition Examination survey4, other validation study conducted by Diep et.
al 10on the ASA24-KIDS, for children between 9-11 yearsshowed that the automated tool was less accurate than interviewed administered24 hours recall, indicating that additionalresearch should be done to modify the appropriate age where recalls can becompleted without help, another trial compared the ASA24 withinterviewed administered AMPM, concluded that the ASA24 performed well andholds a promising approach for studies aiming to observe populations diet andevaluating intervention effectiveness on diets.11From the other computerized tools isMyFood24, this project was developed by the school of science and nutrition atLeeds university in Britain, in purpose of evaluating the diet of different agegroup, this project shares similar characteristics with the ASA24, with afeatured immediate feedback on intake to participants, can be self orinterviewed administered and the option of generating a recipe is available.12 validatingMyFood24 trails are still preformed, where is one trial conducted on adolescenthighlighted that MyFood24 had approximately similar results with interviewer administeredrecalls regarding caloric intake.13 Other computer tools available toevaluate the diet that shares related operating principles include ; web-PDHQ adiet history questionnaire6,FIRSST4 Food Intake RecordingSoftware System, a dietary recall under development tool (10 years andabove)planned to perform on large scales 14,otherexamples involves ,NutriNet Sante, DietDay,INTAKE24,andFood4ME.
15Camera and Mobil Based technologies:Unlike the traditional procedure,where an interviewer (or researcher) contacts the participants by telephone andasks about dietary intake, or conducts a 24 hour recall1,or even cameras in the 60’s that used to take pictures displayingdifferent food quantities to allow interviewed participants to compare betweentheir actual intake(amount consumed), with amounts shown in pictures1,3.Nowadays, mobile phones are suppliedwith camera and highly improvedoperating systems (such as smart phones using IOS or Android systems) usingthese tools as a way to measure diet, basically can be made by either taking aphoto of the food before and after eating (noticing plate wastes), or recording a short video ofthe meals before and after consumption (allowing for 3D estimation), sendingvoice notes or additional text description about intake, researcher mayinstruct participants on the appropriate recording technics, then recorded datawill be transferred to the dietitian or a server where they can be analyzed forevaluation using 3D image processing visualization technology that are able toconvert actual intake (amount of food) into nutrient content on their own whichtends to be relatively accurate in terms of measuring intake.3,6,2 Some mobile devices and digital cameras aremade with sophisticated techniques enables them to make portion size estimationwithout having to be sent to dietitian or computer server, they may requirethree photos captured for a meal or only one photo or a video, these toolspracticability of estimating actual intake is still needs to be more examined, allmobiles with camera have advantages of ,reducing participant burden regardingmemory, 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 manyindividuals in the population (with different socioeconomic status) data can besent directly from their device to the dietitian ,in addition reducing burdenon dietitians time rather than having to deal with analyzing each foods andtrying to anticipate actual portion size besides dealing with participantsdelay on feedback submission, recorded data may be lost (loss of diary), newtools overcome these problems in many possible ways .
6,2Some disadvantages may appear byusing camera and mobile phones as an intake estimation practice, for example ,participants may find it difficult to capture all what they have eaten anddrunk all day long (may not adhere to the procedures), some tools may demandparticipants to first upload intake images to the computer and send themafterwards via email to the dietitian, some issues may relate to the deviceitself like battery or charging problems, camera resolution and image quality,in the case of wireless ability loss of communication is another problem.3,6Famous examples include; the Japanese”Wellnavi” instrument for measuring food intake which is basically a mobilephone with a digital camera and a phone card, enables participants to takepictures of food intake at each meal time that works in the same manner aspreviously described, intake data are saved on an internal phone card, thendata will be transformed to dietitian for analysis electronically, results maybe sent back to participants.6,16In an attempt to validate thisinstrument, a trial made by Kikunaga et.al16,who recognized that intake measured by Wellnavi, had lower estimation ofdietary intake compared with weighed records ,referring to technical problemslike low image quality that led to inaccurate estimation plus, recording errormade by participants, conflicted with what other study findings on the sametool, that there were no significant difference between nutrient intake resultscompared with weighed food records except in some nutrients.17From other available tools, funded bythe National Institute of Health is TADA (technical Dietary AssessmentProject), allowing participants by the use of their mobile phone made withcomplex technology, to capture photos during their meal time, soon images willbe sent directly to a server for analysis, portion size estimation andtranslating food items on images into food volume, then nutrient content generationoccur, quick food evaluation process, also feedback can be quickly sent withmotivational massages to help for goals and plans setting18, similar to the Wellnavi tool ,unless there is noneed for memory card and uploading pictures to computer, data transformation isdone by the TADA immediately, the ability of the TADA to accurately record ,measure portion size and food volume have been performed and recognized in manytrails3,18.The Mobile Phone Food Record , isanother example found as a mobile app (FDapp) that has been tested byadolescents use19, other available apps include;MyFittness Pal, Calorie counter and my Net Dairy.
20Other 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, regardingdata analysis and recording technics and shares many advantages as well, exceptthat PDAs are not made with cameras or for voice Calles , and on top PDA have a list of various food options to selectfrom them (based on the USDA data base), aids in calculating intake (amounts ingrams), some PDAs require training, food items may be difficult to find, they maynot give accurate measures on intake21, othersare expensive in cost.Sensor technology, can be used inmany health care field, they can sense motion, heat, UV light respiration andheart rates, they come as cameras that can be worn on clothes with transmitterbuilt and battery unit, recording 24 hours events that occurs in a day as avideo, dietitians can use them to monitor food intake as they exclude thedemands of daily food self-reporting activity, high technology for determiningfood volume that aids in the analyzation process ,settings are important withsensor technology, as more accurate results could be seen in restraints andcafés, from the drawback of these technics is the very long time spent by theresearcher to watch long videos recorded by the device to find out each mealsand snacks eaten, food purchasing activities (type of food, brands and amountbought) for accurate measurement and analysis, which makes them difficult toimplement on large scales, sensors such as eButton device is one example22, that was compared with computer to check analyzingaccuracy, computers showed less biased measures23. Lastly, voice recordings and speechrecognition 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 foodpackages to help nutrient intake identification but may require additionalinformation by participants.6 Discussion:Regarding validity and reliabilitystudies of most previously prescribed technologies, more studies are needed forverification and accuracy especially when measuring food intake portion sizes6, for instance a study showed that PDA didn’t gave accurateestimates of true portion sizes compared with one conventional method21, also mobile based Wellnavi tool had issues withaccuracy and images quality 16,which leadsto further technical enhancement and development, computers, smart phones andsensors devices appears accurate than other tools, but still furtherenhancement are needed, as with conventional methods which one can be used as areference to validate the other, the same can be done with these new tools forexample, validating the ASA24 was done by comparison of both intervieweradministered 24 hour diet recall and also with other computerized tool as AMPM4,10, many validity options can be performed.Many of them shares similaradvantages, 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 mostaccurate analysis results), the fact that they can support studies with largenumber 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 toone’s own integrity 6, knowing these issues will benefitin future development, for instance the introduction of computerized tools intomobile phones (making ASA24 available as a smart phone app). Most of these devices are relativelysafe, but can poses electrical problems (when charging for example) most of thewireless, particularly sensors devices safety might be questionable as they mayexpose subjects when worn for long times to unnecessary radiations.24According to their applicability andsuitability to the Saudi Arabia population, and taking into account the Islamicpreservative nature of the Saudi society, some technological instrument may notbe acceptable, as they may considered invading privacy (females in particular)such as the sensor devices which are cameras worn for 24 hours that records allday events in a video for later analysis, also voice recording tools might beseen inappropriate, researcher needs to know the appropriate conditions andintended study subjects very well before choosing any tool, many tools andoperating software needs to be adjusted in Arabic before they are used, Smartphones with all provided apps and computers seems to be a much more desirableoptions, but also not all individuals can afford them, moreover some instrumentrequire the participants to be literate to a certain degree which couldrepresents a problem when conducted on elderly low literate individuals, alsowhen preforming evaluation on rural areas, where internet connections in someareas may be inappropriate leading to poor technological devices performanceand delay in summations, if new technologies are to be used by dietitian, theyneed to receive training for their use in order to train participants, untilnow pen and pencil and some web based surveys and questioners are preformed,the government should establish future plans to enhance public health andreduces nutrition related diseases, by taking advantages of efforts made by IT,nanotechnologies, nutritionist and epidemiologist efforts, that correspondswith the Kingdoms 2030 vision.
Conclusion: New technological devices, give anexcellent alternative for dietitians and nutrition epidemiologist to measurefood and nutrient components, for large number of the populations, and also torespondents as most of them considered user friendly and affordable by many,challenges are still imposed particularly when estimating portion size andaccurate analysis, computers and smart phones are the most widely available andfavorable tools, validity and reliability studies are still needed for most ofthem ,in Saudi Arabia researchers should be careful when using technologytools, as governments should encourage the introductions of these instrumentsin many health care settings including food and nutrition.