A New mHealth App for Monitoring and Awareness of Healthy Eating: Development and User Evaluation by Spanish Users

Abstract

Modern-day society has moved towards a more sedentary lifestyle. Advances in technology and changes in habits in our daily lives have led a large part of the population towards a spiralling sedentary lifestyle and obesity. The main objective of this work is to develop and subsequently assess a mobile app, named DietApp, that provides advice about obtaining a healthy diet according to age, clinical history and physical condition. DietApp has been developed for iOS and Android systems, and a survey comprising 7 simple questions enabled the app to be evaluated on a user level by taking into account aspects such as its usefulness and ease of use. DietApp was assessed by 150 Spanish individuals between 18 and 69 years of age, and 84% of them thought it was easy to use. 80% of users also considered the dietary suggestions provided by the app to be very useful while 62% were of the opinion that it is very useful in general. All of them would recommend the app to other users. During the six months when the app was used, any dietary excess or shortcomings were corrected in 72% of those interviewed. A mobile app has been created that is easy to use and attractive, providing personalised suggestions according to illness that are useful for the individual.

Full text

MOBILE & WIRELESS HEALTH
A New mHealth App for Monitoring and Awareness of Healthy
Eating: Development and User Evaluation by Spanish Users
Isabel de la Torre Díez
1
&Begoña Garcia-Zapirain
2
&Miguel López-Coronado
1
&
Joel J. P. C. Rodrigues
3,4,5,6
&Carlos del Pozo Vegas
7
Received: 17 March 2017 / Accepted: 17 May 2017 /Published online: 29 May 2017
#Springer Science+Business Media New York 2017
Abstract Modern-day society has moved towards a more
sedentary lifestyle. Advances in technology and changes in
habits in our daily lives have led a large part of the population
towards a spiralling sedentary lifestyle and obesity. The main
objective of this work is to develop and subsequently assess a
mobile app, named DietApp, that provides advice about
obtaining a healthy diet according to age, clinical history
and physical condition. DietApp has been developed for iOS
and Android systems, and a survey comprising 7 simple ques-
tions enabled the app to be evaluated on a user level by taking
into account aspects such as its usefulness and ease of use.
DietApp was assessed by 150 Spanish individuals between 18
and 69 years of age, and 84% of them thought it was easy to
use. 80% of users also considered the dietary suggestions pro-
vided by the app to be very useful while 62% were of the
opinion that it is very useful in general. All of them would
recommend the app to other users. During the six months
when the app was used, any dietary excess or shortcomings
were corrected in 72% of those interviewed. A mobile app has
been created that is easy to use and attractive, providing
personalised suggestions according to illness that are useful
for the individual.
Keywords App .Diet .Healthy eating .mHealth .User
evaluation
Background
Despite all the advantages offered by evolution in technology,
there are still a number of disadvantages, one of the most
important ones being the fact that the lifestyle of a large part
of the population is changing towards more sedentary atti-
tudes [1,2]. In evolutionary terms, humans are not ready to
spend much of their daily lives seated in front of a computer or
TV, although technical advances are leading humanity to-
wards this scenario. Large amounts of our daily time (e.g.
remaining seated for hours) are examples of how human cus-
toms have adapted to modern physical and social environ-
ments [3]. In contemporary society, it is very common for
people to be seated when they are having fun or to work,
which implies most of the time. Moreover, people tend to be
This article is part of the Topical Collection on Mobile & Wireless Health.
*Isabel de la Torre Díez
isator@tel.uva.es
Begoña Garcia-Zapirain
mbgarciazapi@deusto.es
Miguel López-Coronado
miglop@tel.uva.es
Joel J. P. C. Rodrigues
joeljr@ieee.org
Carlos del Pozo Vegas
sonriemas@gmail.com
1
Department of Signal Theory and Communications, and Telematics
Engineering, University of Valladolid, Paseo de Belén, 15,
47011 Valladolid, Spain
2
University of Deusto, Avenida de las Universidades 24,
48007 Bilbao, Spain
3
National Institute of Telecommunications (Inatel), Santa Rita do
Sapucaí, MG, Brazil
4
Instituto de Telecomunicações, Universidade da Beira Interior,
Covilhã, Portugal
5
University of Fortaleza (UNIFOR), Fortaleza, CE, Brazil
6
University ITMO, St. Petersburg, Russia
7
Emergency Department, University Clinical Hospital of Valladolid,
C/. Real de Burgos, 2, 47011 Valladolid, Spain
J Med Syst (2017) 41: 109
DOI 10.1007/s10916-017-0753-0

seated when travelling to places of work or leisure by car or
train –a great many workers spend much of their time
performing the duties required from their seat, specifically in
telecommunications-related jobs. Therefore, most individuals
tend to be sedentary over a large part of their lives [1,4–6].
In addition, society itself places great importance on time.
Individuals are becoming increasingly less interested in
cooking or setting aside a lengthy period of time for meals.
This leads directly to increased access to fast and pre-cooked
food, characterised by being dense in energy. A sedentary life
and dietary shortcomings combined are very harmful, and to a
large extent contribute to the appearance of excess body
weight and obesity, which are major risk factors in producing
illnesses such as diabetes, vascular diseases and cancer [6–8].
Overeating combined with a sedentary lifestyle offset the
daily energy balance that the individual needs to survive.
Generally speaking, the energy consumed should be similar
to that ingested, and so any imbalance means that surplus
calories are stored in the form of fats that will only be used
when the organism has no other source of food. Developed
countries currently find themselves in a residual situation,
whereby the food that is converted into fats is not often used
and remains stored for an indefinite period of time. It is there-
fore important to maintain a balanced calorie intake [7].
Physical inactivity contributes to premature death and mor-
bidity and has a direct influence on the increase in excess
weight and obesity in developed countries. There are different
activities that encourage sedentary behaviour, with the most
common ones being passive leisure activities (watching TV,
reading, etc.) and work. The World Health Organization
(WHO) and other international bodies (as World Heart
Federation,Diabetes International Federation,among
others) are currently pursuing certain strategies to try and con-
tain high levels of obesity and physical inactivity. The general
guidelines they set out are based on a change in the type of
food in order to reduce fat consumption and the ingestion of
calories, and to increase physical activity in the individual [8,
9]. At the 57th World Heart Assembly, the WHO approved the
Global Strategy on Diet, Physical and Health which proposed
national plans of action to prevent the epidemic, since which
time prevention strategies have been steadily applied on a
national level. In short, experts, academics and politicians all
coincide in that the best way of reducing sedentary lifestyles
and obesity in the world is to educate and warn about healthy
living habits [7–10].
Within another context is the rise of Smartphones and the
great variety of applications available of all types.
Approximately 22% of the world’spopulationownsatleast
one Smartphone, and these figures increase especially in
Europe and North America where percentages rise to nearly
50%. It is precisely in these parts of the world where above-
average obesity levels are evident. Thus, the use of mobile
applications is a channel of paramount importance in raising
the population’s awareness about the harm caused by a sed-
entary lifestyle [11–14].
In this sense, the aim of this research work is to provide a
mobile application that may attempt to raise people’saware-
ness and guide them about healthy living habits –especially in
cases of patients with diet-related illnesses–despite the fact
that there are a great many mobile applications related to
weight loss on the market, as has been shown following a
state-of-the-art review. An exhaustive search was conducted
at Apple [15] and Google virtual stores [16], and Table 1
shows the features of some of the apps analysed in this work.
Ten were selected that were considered the most interesting
from the functional standpoint. Most focus on trying to ensure
the user loses weight quickly without dealing with the nutri-
tional shortcomings or excesses in individuals –an aspect that
Tabl e 1 Main features and operative systems supported for several mhealth apps
Name Operative systems supported Features
Calorie Counter - My Fitness Pal Android and iOS Enables the food consumed and calories ingested to be controlled
Diet Point · Weight Loss Android and iOS Mainly focuses on diet planning
Fat Secret Android and iOS Enables the user to record what they eat, what exercise they do and
their daily energy balance according to the data inserted
Jefit Workout Exercise Trainer Android and iOS Provides different physical routines to develop the body muscles
chosen by the user
Cardio Trainer Android Geared to burning calories, and focuses on doing aerobics-type
exercises such as walking, running, swimming and skiing, etc.
Lifesum Android and iOS Advises the user to record what they eat and the exercise they
day every day
My Diet Diary Calorie Counter Android and iOS Tracks the food, calories, exercise, weight, cholesterol,
carbohydrates and calories burned, among other nutrition-related data
Calorie Counter PRO MyNetDiary Android and iOS Analyses the diary and guides via personalised dietary tips
Calorie Counter & Diet Tracker Android and iOS Enable nutritional breakdowns for individual meals, and uses hash tags
Lose It! Android and iOS Helps the user lose weight quickly
109 Page 2 of 7 J Med Syst (2017) 41: 109

will try to be covered by the app developed in this work,
named DietApp. The main contributions of this research work
are to develop and assess a new health app to help people with
nutritional problems. The results of this work can serve as
basis to other communities about the importance of nutrition
and how mobile apps can contribute in this aim.
An attempt is made below to lay the foundations for what
are understood to be healthy living habits. The methods used
to develop the DietApp application will then be described
followed by subsequent user evaluation. The results obtained
from this research will then be shown and lastly, these will be
discussed and the conclusions explained.
Healthy living habits
A healthy living habit can be said to be based on a general
factor known as RDI (Recommended Daily Intake), which
includes the basic nutrients a person need to consume to main-
tain their state of health. The RDI is a good method to use if
the aim is to maintain a balanced diet and if the person’s
physical features correspond to those of an average user.
However, each individual is different and, therefore, so is their
appropriate lifestyle.
Given the impossibility of assigning a nutritionist to every
individual, certain heuristic features have been established in
order to gauge a healthy living habit approach for different
people [12,14].
Each individual needs a certain amount of energy to keep
their vital functions in working order, i.e. what is known as
basal metabolism. This includes activity carried out by the
external organs and maintaining body temperature, etc.
Basal metabolism depends on weight, size, build (the muscle
consumes more energy than the fat even when in a state of
rest), gender (less in women) and age (decreases with age).
Basal metabolism is divided into different factors, from which
we will focus on three for the purpose of carrying out this
project: basic energy expenditure, physical activity and
growth of the individual.
Basal metabolic expenditure is essential for ensuring that
the vital functions work properly without putting one’shealth
at risk. Although 24 kcal/kg/day is accepted internationally as
a basic energy need [12], this figure can be personalised for a
specific individual according to Eq. 1. In this equation, P
represents the individual’sweightinkg,Atheir height in cm
and Etheir age in years [12].
Women ¼65:5þ9:6PðÞþ1:7AðÞ−4:7EðÞ
Men ¼66 þ13:7PðÞþ5AðÞ−6:8E
ðÞ ð1Þ
In Eq. 1, the most modifiable factor of basal metabolism is
left out. It is the physical activity. The energy requirements of
basal metabolism increase considerably depending on the type
of physical activity undertaken and its duration.
Taking into account the body mass index (BMI), there is
another parameter of great interest regarding healthy living
habits which is the Recommended Daily Intake (RDI). The
RDI measures the nutrients and kilocalories a specific individ-
ual needs to consume to maintain a balanced diet and healthy
weight [17–19].
Guaranteeing an appropriate ingestion of calories is not
enough to maintain a healthy diet –relatively, this must also
be together with the types of nutrient. Figure 1shows the
Proteins
12%
Lipids
33%
Carbohydrates
55%
Fig. 1 Percentage of calories in a balanced diet
Fig. 2 DietApp structure
J Med Syst (2017) 41: 109 Page 3 of 7 109

proportion of nutrients to be ingested according to the
WHO for an adult of average who is in a normal phys-
ical condition [18].
In this paper, a mobile app will be developed and subse-
quently assessed. This app, named DietApp, provides advice
about obtaining a healthy diet according to different parame-
ters such as clinical history, age and physical condition.
Methods
Used software and app structure
Android Studio and the SDK Android (Software Development
Kit Android)havebeenusedtodeveloptheapplication,which
includes a set of tools for native Android applications.
The version used to develop the application is the 4.0 Ice
Cream Sandwich, whereby the application will function for
81% of devices equipped with the Google operative system,
and takes up 20 MB of internal memory space –meaning it is
considered to be light. The version of the application has also
been developed in iOS [20], and been optimised from version
3.2. In Fig. 2can be clearly seen the structure of the DietApp
application, which consists of four modules that we will ex-
plain in the results section.
User survey
One of the most important aspects to be taken into account
when developing an application is the opinion users have of it
–usability is one of the most important factors to be taken into
consideration in rating the quality of an application [21]. The
following criteria have been taken into account to evaluate the
DietApp: Content: the information included in the application
according to its objectives. Dynamics: how users move and
interact with information-based elements and components.
Structure: how the content of the application is organised.
Interaction: how the dynamic components are used.
Presentation: how the content and functions of the application
are shown to users.
A survey with 7 questions that is accessible via mobile was
developed in this case, the contents of which can be seen in
Tab le 2.
Results
DietApp
The application comprises 4 modules. The details of which are
provided below:
Home This module is the first to be displayed when the
application is started, and its design is therefore vital to
ensure the user feels comfortable when using the appli-
cation. The user can access any section of the applica-
tion from this module, which makes it easy to use. If
the user has opened a session, a summary showing the
Tabl e 2 Survey about DietApp
Question Evaluation
Using the app has been Very easy Easy Average Difficult Very difficult
Have the dietary suggestions
proved useful?
Very little Little Somewhat Average A lot
Have you managed to lose
weight while using it?
No Yes
I think it is attractively designed Very little Little Somewhat Average A lot
You have found it useful Very little Little Somewhat Average A lot
Do you think this app has resolved
your dietary shortcomings or excesses?
Very little Little Somewhat Average A lot
Would you recommend this app? No Yes
Fig. 3 Home
109 Page 4 of 7 J Med Syst (2017) 41: 109

user features will be displayed on the screen (see email,
age, weight, height and gender), as well as any other
relevant aspects such as BMI, RDI and any advice or
specific risk depending on their condition. Figure 3
shows an image of the screen for this section.
User management This module stores all the information
about the user as name, password, email, weight, height, gen-
der and any illnesses that the user may suffer from. This mod-
ule manages everything related to the user’s registration and
session and within it can be found the user’s case history
containing their energy balance. The user may also add vari-
ous foods to their case history via the Foods/Exercises
module. According to the amount and size of the por-
tion chosen by the user, an energy balance is imple-
mented which indicates the total energy balance and
also warns the user if the balance is either extremely
positive or negative (with a margin of 500 Kcal).
Nutritional consultation This section shows the informa-
tion about listed foods and exercises (see Fig. 4). Some
aspects are described in detail such as the calories
contained in a specific food or those burned when
performing a specific exercise, whether a type of food
may be harmful or beneficial to the user depending on
its features, or when a type of food or exercise is added
to the user’s case history.
For instance, when the user has selected a category, they are
shown the corresponding foods with a photo of the type of
food in question, name, number of calories and two notices
indicating whether the food is harmful to or recommended for
theuserincasetheydecidetoproceed.
Dietary suggestions With this module, the user can re-
ceive personalised suggestions via this section, whereby
any illnesses they may suffer from are gathered and
used to define certain advice for their physical condi-
tion. These suggestions are classified according to the
user in such a way as to provide them with more de-
tailed information. Thanks to these suggestions, the end
user may have at their disposal sufficient data to help
them pursue a sufficiently healthy diet. Many sugges-
tions are done according to the food pyramid.
Fig. 5 Use of DietApp
Fig. 6 Usefulness of dietary suggestions
Fig. 7 Have you managed to lose weight?
Fig. 4 Nutritional consultation
J Med Syst (2017) 41: 109 Page 5 of 7 109

User evaluation
The DietApp app was evaluated by 150 Spanish users
of between 18 and 69 years of age. All live in rural
areas from Zamora and Valladolid, Spain. 84% of users
were of the opinion that the app was easy to use, 6%
found it difficult and 10% very easy, as can be seen in
Fig. 5. 20% of users found the nutritional suggestions
very useful and the remaining 80% useful, as can be
noted in Fig. 6. 30% of users managed to lose weight
over the 6-months period as shown in Fig. 7.Inall
cases, the percentage weight loss was less than 5 kg.
100% of users would recommend using the app and in
terms of design, 42% thought the DietApp was attrac-
tively designed,
Five percent found this very attractive and the re-
maining 53% thought it was average (see Fig. 8). 62%
of users found the app useful while 38% thought it very
useful, as can be seen in Fig. 9. As for the matter of
whether the app can resolve dietary problems as is the
case with individuals who experience dietary excess or
shortcomings, 72% of those interviewed answered yes,
asshowninFig.10. 100% of users would recommend
the app to others.
Discussion and conclusion
The main purpose of this paper has been to provide
users who have nutritional or dietary problems with a
mobile application that may be used as a guide them or
nutritional support to those already existing on the mar-
ket. DietApp was created by highlighting its design and
ease of use. A home page was in turn created from
where any section of the app can be accessed in order
to optimise its intuitiveness.
DietApp covers the most common foods and exer-
cises, lending support to a large percentage of target
users. Secondly, it provides personalised suggestions ac-
cording to illness which are useful for the individual,
and also constitutes an easy application to use that is
attractively designed and can run completely transpar-
ently for the user. The app can be used by adults who
want dietetic tips, mainly people with nutritional prob-
lems. Due to its ease of installation and use can be used
by all type of public (experts and non-expert in mobile
technologies and applications).
One of the major limitations of this application is that ad-
vice about living habits or nutritional suggestions are too gen-
eralised. An interesting aspect to be covered would be to be
able to put nutritionists or endocrinologists in contact with
patients of a certain type to ensure the latter receive even more
personalised care.
Comparing with apps shown in Table 1, DietApp treats
more about nutritional shortcomings or excesses in people.
For example, other apps such as My Diet Diary Calorie
Counter tracks calories, exercise, cholesterol, etc. DietApp
has been developed in Android and iOS as many other apps
(see Table 1).
In this work, DietApp is done in Spanish and English
language. All users in this work have used the Spanish
version. As future lines of work on the application, the
function of implementing nutritional information about
the type of food in question might be added using the
Spanish Agency for Food Safety and Nutrition database.
Fig. 10 Has DietApp resolved your dietary problems?
Fig. 9 Usefulness of DietApp
Fig. 8 Attractive design
109 Page 6 of 7 J Med Syst (2017) 41: 109

Acknowledgements This research has been partially supported by the
European Commission under the project ICT-24-2016–732375 named
BFocusLocus: ADHD management Gaming System for educational
achievement and social inclusion^, by National Funding from the FCT
–Fundação para a Ciência e a Tecnologia through the UID/EEA/500008/
2013 Project, by the Government of the Russian Federation, Grant 074-
U01, and by Finep, with resources from Funttel, Grant No.
01.14.0231.00, under the Centro de Referência em Radiocomunicações
- CRR project of the Instituto Nacional de Telecomunicações (Inatel),
Brazil.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval The ethics board approval was obtained of the
BEthical Committee of Clinical Research of Clinic Hospital of
Valladolid, Spain^.
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