This document summarizes a webinar presentation on using mobile apps to support nutrition education and diabetes management. The presentation discusses the evidence from studies on using apps for nutrition education and behavior change, provides guidance on how to evaluate app quality, and reviews some popular apps for weight management and diabetes self-management. Some key findings include evidence that apps can improve user engagement and retention in nutrition interventions compared to websites or paper tracking, and that app users often experience greater weight loss. However, many apps have low quality information and limited personalization. The presenters provide a tool to help dietitians systematically evaluate apps.

1. https://learn.extension.org/events/2693
Mobile Apps for RDNs in Patient Care,
What’s the Evidence Say?

2. Connecting military family service providers
and Cooperative Extension professionals to research
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MFLN Intro
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3. Today’s Presenters
Justine Karduck, MS, RDN, LDN, CDE
karduck@Illinois.edu
•Director the Didactic Program in Dietetics at the
University of Illinois.
•Previously worked as a Clinical Dietitian &
Diabetes Educator.
•PhD Student in Human Nutrition in the
Department of Food Science and Human
Nutrition at the University of Illinois.
•Research focus on the efficacy of smartphone
apps in dietetics practice for diabetes
management.
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4. Today’s Presenters
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Kristen DiFilippo, MS, RDN, LDN
kdifilip@illinois.edu
•PhD Student in the Division of Nutritional
Sciences at the University of Illinois
•Previously worked as a wellness Dietitian
•Research interest in apps for nutrition
education

5. Today’s Webinar:
Mobile Apps for RDNs in Patient Care:
What does the evidence say?
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6. Webinar Learning Objectives:
After this presentation, participants should be able to:
1. Identify the most popular health-related mobile apps
being used in dietetics practice.
2. Objectively evaluate apps for selection in nutrition
interventions.
3. Explain current developments and future directions
in apps research relevant for the dietetics practitioner.
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7. Mobile Health (mHealth) Defined
“a component of eHealth, a medical and
public health practice supported by mobile
devices, such as mobile phones, patient-
monitoring devices, personal digital
assistants & other wireless devices.”
7(Ryu 2012)

8. US Smartphone Users
8(Smith 2015)

9. Nutrition Education Using Apps
“Nutrition education is defined as any combination of
educational strategies, accompanied by
environmental supports, designed to facilitate
voluntary adoption of food choices and other food-
and nutrition-related behaviors conducive to health
and well-being.”
What is your go to app to support nutrition
education?
(What apps are you recommending to clients?)
9(Contento, 2010)

10. My Go to App
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11. Apps & Nutrition Education
Systematic Review of Literature
Will nutrition apps result in
– increased knowledge or
– improved nutrition behavior?
•Specifics:
– Adults
– Without disease
– Intervention included nutrition app
(DiFilippo, Huang, Andrade, & Chapman-Novakofski, 2015) 11

12. Apps & Nutrition Education
Systematic Review of Literature
• Very few published studies exploring
behavior and knowledge outcomes
– 3 high quality studies identified from 17,032
reviewed titles
– All focused on weight loss
12(DiFilippo, Huang, Andrade, & Chapman-Novakofski, 2015)

13. Knowledge Measures
• Only one study reviewed measured
knowledge
• No change in knowledge found
13(DiFilippo, Huang, Andrade, & Chapman-Novakofski, 2015)

14. Behavior Change Measures
• No app = less willing to continue diet1
• App = higher participant retention2
• App = increased use of intervention tools2
• App = more user control3
• App = recorded twice as many days3
Take home:
People are more likely to remain engaged with your
recommendations with the support of an app.
1
Brindal et al., 2013
2Carter et al., 2011
3
Turner-McGrievy &Tate, 2011
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15. Weight Change Measures
• But does this mean they lose weight?
• Yes:
• Weight loss with app was similar or greater than
the same diet education without app1,2,3
• Weight change at 6 months2
• With app: -4.6 kg (10 pounds)
• With paper diary: -2.9 kg (6 pounds)
• With website: -1.3 kg (3 pounds)
• Same results found in another review4
15
1
Brindal et al., 2013
2
Carter et al., 2011
3
Turner-McGrievy &Tate, 2011
Mateo et al., 2015

16. Most Common Behavior Change
Techniques in Apps
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FeedbackGoal setting Self-monitoring
(Bardus et al., 2016)

17. Apps for Weight Management
• App quality assessment
– Moderate overall
– Higher in functionality & aesthetics
– Lowest in information quality
17(Bardus et al., 2016)

18. mHealth & You Poll
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19. App Evaluation
• Hundreds of apps available
• Aspects to consider when evaluating apps
– Quality of content
– Technology
– Usability
19
(Bardus et al. 2016;
DiFilippo, Andrade, Huang, & Chapman-Novakofski, 2016, 2015 )

20. App Evaluation
• App Quality Evaluation Tool (AQEL)
– Quantitative tool for Dietitians to use for
nutrition app evaluation
– Allows for comparison of apps based on
various aspects of app content, design, and
function
20(DiFilippo, Andrade, Huang, & Chapman-Novakofski, 2016, 2015 )

21. App Evaluation
• Categories:
– Purpose
– Knowledge Building
– Skill Building
– Behavior Change
– Appropriateness for Target Age Group
– Appropriateness for Target Audience
– Educational Quality
– Functionality
– Personal App Use
21(DiFilippo, Andrade, Huang, & Chapman-Novakofski, 2016, 2015 )

22. App Evaluation
22(DiFilippo, Andrade, Huang, & Chapman-Novakofski, 2016, 2015 )

23. App Evaluation
23(DiFilippo, Andrade, Huang, & Chapman-Novakofski, 2016, 2015 )

24. Question Break
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25. Why use Health Apps in
Patient Care Settings?
• Improved scalability & feasibility of health
services
– Decreased health care costs & burden
• Frequent engagement
– Consistency
– Convenience
– Feedback w/ pts
***Superior effectiveness on health
outcomes & related behaviors?
25(Sutton & Redman 2016)

26. Limitations to Using Apps
in Patient Care Settings
• Evidence-based app quality poor
– Rate of app dissemination outpaces research
• Lack of personalization, health care expert
involvement, behavior theory, & scientific
evaluation in apps
• Time consuming data entry & analysis of apps-
continuing patient engagement
• Data safety & privacy
• High level of health & technology literacy of
patients and providers needed
– Training & Charting for HCPs?
26
(Brzan et at al. 2016)

27. Patient Perceptions
of Health Apps
• 58% downloaded a health app
• 42% downloaded more than 5 health apps¹
– Apps positively influence eating & exercise behaviors²
• Health App Users = obese, younger, with higher income & ed levels,
Latino/Hispanic or African American
• Nutrition & Fitness apps are most popular w/ daily use
– Trust in accuracy & data safety high
– Perceived improved health
• Preferred App Features
– provider communications, reminders, tracking, progress charts,
view medical records, personalized recs
• Barriers to App Use
– cost, data entry burden, attrition
27(¹Krebs & Duncan 2015)
(²Wang et al. 2016)

28. Dietitian Perceptions
of Health Apps
(Sauceda, Frederico, Pellechia, Starin
2016)
• Surveyed RDs at FNCE 2015
(n = 72)
– 83% recommend apps
– PA, nutrition, food journals
• Favorite Apps = My Fitness
Pal™ & Fitbit™
– Few collect & analyze data
from pt. apps
(Karduck & Chapman-Novakofski
2016)
• Surveyed US clinicians (n =
719)
– 93% use smartphone apps
– 62% use apps to assess pt’s
diet & PA levels
• Most Recommended Apps =
My Fitness Pal™, Calorie
King™, Fitbit™ & Weight
Watchers™
• Desired Apps Features = diet,
PA, & wt tracking, progress
charts, barcode scanning,
SMBG, & recipe sharing
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29. mHealth & You Poll
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30. Review of Apps for
DM Management
30(Brzan et al. 2016)
• Systematic review of apps in popular app stores
– Which free diabetes apps provide basic features for successful self-
management?
– What are the characteristics of these apps?
• Initial search (n = 956), only 9 met all inclusion criteria
– Diabetes: M, Diabetes Tracker, Glucose Buddy: Diabetes Log, Diabetes
Journal, Diabetes Connect, Diabetes App Lite, Diabetes in check,
Carburetor: Diabetes Logbook Manager, dbees.com
• Apps should support (Chomutare et al. 2011):
– Insulin & meds management
– Diet, PA, Wt & BP Ed
– Social media & alerts
– Communication with health care team
• Most only provide some of the basic features
– Designed for type of DM

31. Challenges & Opportunities of
Apps for DM Management
Features:
• Self-management metrics
with progress charts in
one app:
• Education
– Diet tips, GI, Recipes,
Research Findings
• Personalized feedback
• Enhanced reminder
system
• Daily goal setting
Barriers:
• Information gap
• Technical Illiteracy
• Already satisfied with
current self management
tools
• Not yet recommended by
their health care team
• Accountability
• Required time & effort
31(Peng, Yuan, & Holtz 2016)

32. App Outcomes &
Efficacy in DM Self-Management
• Pubmed searched through January 2016 (n = 485)
• Limited data available on effectiveness of apps for DM
self-management
– Some clinical improvements, but only 3 studies with statistically
significant improvements in HbA1c
• Preliminary data encouraging
– Few apps support the AADE7 self-management behaviors
• Self-monitoring with provision of feedback common
• DM education lacking in apps
• Apps as FDA medically regulated devices
32(Hood et al. 2016)

33. 33(Ristau, Yang, & White, 2013)

34. Conclusions
• mHealth & health apps are in their infancy
• Apps show promise for:
– Supporting nutrition education
– Promoting behavior change
– Improving health outcomes
• Careful evaluation and selection of apps
is warranted before use
34

35. References
1. Bardus, M., van Beurden, S., Smith, J., & Abraham, C. (2016). A review and content analysis of engagement, functionality, aesthetics, information quality, and change
techniques in the most popular commercial apps for weight management. Int J Behav Nutr Phys Act, 13(1). http://dx.doi.org/10.1186/s12966-016-0359-9.
2. Boudreaux, E., Waring, M., Hayes, R., Sadasivam, R., Mullen, S., & Pagoto, S. (2014). Evaluating and selecting mobile health apps: strategies for healthcare providers and
healthcare organizations. Translational Behavioral Medicine, 4(4), 363-371. http://dx.doi.org/10.1007/s13142-014-0293-9.
3. Brindal, E., Hendrie, G., Freyne, J., Coombe, M., Berkovsky, S., & Noakes, M. (2013). Design and pilot results of a mobile phone weight-loss application for women starting
a meal replacement programme. Journal of Telemedicine and Telecare, 19, 166–174.
4. Brzan, P., Rotman, E., Pajnkihar, M., & Klanjsek, P. (2016). Mobile Applications for Control and Self Management of Diabetes: A Systematic Review. J Med Syst, 40(9).
http://dx.doi.org/10.1007/s10916-016-0564-8.
5. Carter, M. C., Burley, V. J., Nykjaer, C., & Cade, J. E. (2013). Adherence to a Smartphone Application for Weight Loss Compared to Website and Paper Diary: Pilot
Randomized Controlled Trial. Journal of Medical Internet Research, 15(4), e32. http://doi.org/10.2196/jmir.2283
6. Contento, I. R. (2010). Nutrition Education: Linking Research, Theory, and Practice. 2010.
7. DiFilippo, K. N., Andrade, J. E., Huang, W.-H., & Chapman-Novakofski, K. M. (2015). Development of a tool to evaluate the quality of nutrition apps. Journal of the Academy
of Nutrition and Dietetics, 115(9), A15.
8. DiFilippo, K. N., Andrade, J. E., Huang, W.-H., & Chapman-Novakofski, K. M. (2016). Reliability testing of a mobile app quality assessment tool. Journal of Nutrition
Education and Behavior, 48(7S), P87.
9. DiFilippo, K. N., Huang, W.-H., Andrade, J. E., & Chapman-Novakofski, K. M. (2015). The use of mobile apps to improve nutrition outcomes: A systematic literature review.
Journal of Telemedicine and Telecare, 21(5), 243–253. http://doi.org/10.1177/1357633X15572203
10. Flores Mateo, G., Granado-Font, E., Ferré-Grau, C., & Montaña-Carreras, X. (2015). Mobile Phone Apps to Promote Weight Loss and Increase Physical Activity: A
Systematic Review and Meta-Analysis. J Med Internet Res, 17(11), e253. http://dx.doi.org/10.2196/jmir.4836
11. Hood, M., Wilson, R., Corsica, J., Bradley, L., Chirinos, D., & Vivo, A. (2016). What do we know about mobile applications for diabetes self-management? A review of
reviews. J Behav Med. http://dx.doi.org/10.1007/s10865-016-9765-3.
12. Jospe, M., Fairbairn, K., Green, P., & Perry, T. (2015). Diet App Use by Sports Dietitians: A Survey in Five Countries. JMIR Mhealth Uhealth, 3(1), e7.
http://dx.doi.org/10.2196/mhealth.3345
13. Karduck, J., & Chapman-Novakofski K. (2016) Results of the Clinician Apps Survey, How Do RDNs Use Health-related Smartphone Apps in Patient Care Settings? Journal
of the Academy of Nutrition and Dietetics , Volume 116, Issue 9 , A93. http://dx.doi.org/10.1016/j.jand.2016.06.338.
14. Krebs, P. & Duncan, D. (2015). Health App Use Among US Mobile Phone Owners: A National Survey. JMIR Mhealth Uhealth, 3(4), e101.
http://dx.doi.org/10.2196/mhealth.4924.
15. Lieffers, J., Vance, V., & Hanning, R. (2014). Use of Mobile Device Applications In Canadian Dietetic Practice. Canadian Journal Of Dietetic Practice And Research, 75(1),
41-47. http://dx.doi.org/10.3148/75.1.2014.41.
16. Peng, W., Yuan, S., & Holtz, B. (2016). Exploring the Challenges and Opportunities of Health Mobile Apps for Individuals with Type 2 Diabetes Living in Rural Communities.
Telemedicine And E-Health. http://dx.doi.org/10.1089/tmj.2015.0180.
17. Office of Health Policy, & Office of the Assistant Secretary for Planning and Evaluation (ASPE). (2016). Report to Congress: E-health and Telemedicine. Retrieved from
https://aspe.hhs.gov/sites/default/files/pdf/206751/TelemedicineE-HealthReport.pdf
18. Redman, L. & Sutton, E. (2016). Smartphone applications to aid weight loss and management: current perspectives. Diabetes, Metabolic Syndrome And Obesity: Targets
And Therapy, Volume 9, 213-216. http://dx.doi.org/10.2147/dmso.s89839.
19. Ristau, R., Yang, J., & White, J. (2013). Evaluation and Evolution of Diabetes Mobile Applications: Key Factors for Health Care Professionals Seeking to Guide Patients.
Diabetes Spectrum, 26(4), 211-215. http://dx.doi.org/10.2337/diaspect.26.4.211
20. Ryu, S. (2012). Book Review: mHealth: New Horizons for Health through Mobile Technologies: Based on the Findings of the Second Global Survey on eHealth (Global
Observatory for eHealth Series, Volume 3). Healthc Inform Res, 18(3), 231. http://dx.doi.org/10.4258/hir.2012.18.3.231.
21. Sauceda, A., Frederico, C., Pellechia, K., & Starin, D. (2016). Results of the Academy of Nutrition and Dietetics' Consumer Health Informatics Work Group’s 2015 Member
App Technology Survey.Journal Of The Academy Of Nutrition And Dietetics, 116(8), 1336-1338. http://dx.doi.org/10.1016/j.jand.2016.04.009
22. Turner-McGrievy, G., & Tate, D. (2011). Tweets, Apps, and Pods: Results of the 6-month Mobile Pounds Off Digitally (Mobile POD) Randomized Weight-Loss Intervention
Among Adults. Journal of Medical Internet Research, 13(4), e120. http://doi.org/10.2196/jmir.1841
23. Wang, Q., Egelandsdal, B., Amdam, G., Almli, V., & Oostindjer, M. (2016). Diet and Physical Activity Apps: Perceived Effectiveness by App Users. JMIR Mhealth Uhealth,
4(2), e33. http://dx.doi.org/10.2196/mhealth.5114.
24. Wharton, C., Johnston, C., Cunningham, B., & Sterner, D. (2014). Dietary Self-Monitoring, But Not Dietary Quality, Improves With Use of Smartphone App Technology in an
8-Week Weight Loss Trial. Journal Of Nutrition Education And Behavior, 46(5), 440-444. http://dx.doi.org/10.1016/j.jneb.2014.04.291.
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36. What is one significant thing
you learned today?
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37. Join the Conversation Online!
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MFLN Nutrition and Wellness Group
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38. MFLN Intro
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39. Evaluation and CPEUs /
Certificate of Completion
MFLN Nutrition and Wellness CA is offering 1.0
CPEU for today’s webinar.
To receive the credits, please complete the
evaluation online at:
https://vte.co1.qualtrics.com/jfe5/form/SV_em4t9BL5eRU0PMF
*CPEUs available up to 1 year after the webinar
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40. Nutrition and Wellness
Upcoming Event
• Health & Wellness Relationships
• Date: Tues Oct 11
• Time: 11:00 AM - 12:30 PM Eastern (90 minutes)
• Location: https://learn.extension.org/events/2677
For more information on MFLN Nutrition and Wellness go to:
https://blogs.extension.org/militaryfamilies/nutrition-and-
wellness/
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41. www.extension.org/62581
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