Evaluation of the Diet Tracking Smartphone Application Keenoa™: A Qualitative Analysis
Publication: Canadian Journal of Dietetic Practice and Research
28 September 2021
Abstract
Keenoa™ is a novel Canadian diet application (app) currently used by Canadian dietitians to collect diet-related data from clients. The goal of this study was to evaluate Keenoa™ based on user feedback and compare it to a conventional pen and paper method. One hundred and two participants were recruited and randomly assigned to record their diets using this application for 3 nonconsecutive days. Following this, participants were invited to complete an online “exit” survey. Seventy-two subjects responded, with 50 completing an open-ended question asking for general feedback about the app. Data were reviewed and 3 main themes emerged: strengths, challenges, and future recommendations. Strengths associated with the app consisted of picture recognition software, the additional commentary feature, and the overall pleasant data collection process. Challenges that were identified included inconsistencies with the barcode scanning features, the limited food database, time to enter food details, and software issues. Future recommendations included using a larger food database, pairing dietary intake with physical activity monitoring, and having accessible nutritional data. Despite these limitations, participants preferred using mobile apps to record diet compared with traditional written food diaries.
Résumé
Keenoa™ est une nouvelle application canadienne sur l’alimentation que des diététistes canadiens utilisent pour recueillir des données auprès de leurs clients sur leur alimentation. L’objectif de cette étude était d’évaluer Keenoa™ sur la base de commentaires d’utilisateurs et de la comparer à une méthode traditionnelle avec crayon et papier. Cent deux participants recrutés et assignés au hasard ont été invités à consigner leurs prises alimentaires à l’aide de cette application pendant trois jours non consécutifs. Ensuite, ils ont été invités à répondre à un sondage en ligne. Soixante-douze sujets ont répondu, et 50 ont répondu à une question ouverte réservée aux commentaires généraux sur l’application. Les données ont été examinées, et trois thèmes principaux sont ressortis : forces, défis et recommandations pour l’avenir. Les forces de l’application concernaient le logiciel de reconnaissance d’image, la fonction permettant d’ajouter des commentaires et le processus de collecte de données globalement agréable. Les défis soulevés incluaient les incohérences du lecteur de codes-barres, la base de données d’aliments limitée, le temps nécessaire à la saisie des détails sur les aliments et des problèmes de logiciel. Parmi les recommandations pour l’avenir, citons l’utilisation d’une base de données sur les aliments plus vaste, le jumelage de l’apport alimentaire au suivi de l’activité physique et l’accès à des données nutritionnelles. Malgré ces limites, les participants ont préféré utiliser des applications mobiles pour consigner leurs prises alimentaires plutôt que de tenir un journal alimentaire traditionnel par écrit.
INTRODUCTION
Registered dietitians (RD) rely on different methods of dietary assessment to evaluate food intake and obtain information on nutrients consumed [1]. These include pen and paper methods such as 24-hour recalls, 3-day food diaries (3DFD), and food frequency questionnaires [2]. While each of these methods have their strengths, all have limitations that speak to participant burden, inability to recall details of meals, and the lack of literacy and motivation to accurately report dietary intake [3, 4]. For these reasons, the accuracy and validity of dietary assessments are often questioned and more innovative methods, with less limitations, are sought for use in dietetic practice [1, 5].
Mobile applications (apps) have been developed to monitor health, including diet [1]. Diet apps aim to reduce and resolve common limitations associated with the conventional pen and paper dietary assessment methods [3, 4]. As these diet apps increase in popularity, RDs are encountering clients who are interested in using them to monitor their food intake [6, 7]. Benefits of this new technology compared with conventional dietary assessment methods is that it is less reliant on user’s memory, affordable, and generally well accepted [8, 9]. However, there are also limitations associated with using diet apps, for instance, users can become disengaged over time, security infrastructure is needed to store data, and some user training is required [2, 8, 9]. Currently, most studies evaluating these apps focus on their efficacy rather than on proposing and developing changes to reduce these limitations [9]. More qualitative studies are needed to capture the feedback of users. These data will enable developers to continuously revise their design and software to optimize app usage.
Keenoa™ is a Canadian-based app developed by RDs specifically for RDs (www.keenoa.com). This application uses augmented reality to identify and record food items in real time [2]. Prior to the consumption of a meal, app users first take a photo of the food item. Items can range from single (e.g., apple) to complex meals (e.g., hamburger or stew). The app uses artificial intelligence to recognize the food and the user confirms what is on the plate. If the system does not recognize the food item, the app allows the user to manually search and record the food item from a preregistered generic food composition database (the Canadian Nutrient File (2015), Government of Canada), which includes 5690 foods available in the current Canadian market [2, 10, 11].
Once the food item is recorded, the user must estimate the serving size. Visual aids (e.g., pictures of a tennis ball or measuring cups) are provided within the app to guide the user when estimating serving sizes. If the user is unable to locate their food item in the database, they have the option to describe the food in a text format. This in turn helps the RD adjust the food diaries as needed. Finally, the user confirms their entries by submitting the data. Unique to diet apps, Keenoa™ pairs the user with an RD who can monitor diet input in real-time, adjusts recordings if needed, and is able to evaluate the diets for specific nutrients of interest. Once submitted, data are automatically released to the RD’s private dashboard and can be viewed in real time via their computer or phone. Keenoa™ hosts and stores encrypted data in Canada (Amazon Web Services).
We recently published the results of a trial supporting the use of this app to assess diet in the Canadian context [2]. Thirty-five percent of individuals preferred Keenoa™ compared to 10% who reported preferring the traditional paper and pen 3DFD [2]. However, users’ perspectives and experiences using the app were not reported, an important consideration when choosing an app and identifying areas for improvement. Therefore, the purpose of this paper is to explore users’ experiences associated with the use of the Keenoa™ app.
Methods
Participants and recruitment
This study reports on secondary data from the larger cross-over randomized controlled trial [2]. The methodological approach has been published previously [2]. To summarize, 102 participants were recruited from the PERFORM Centre (Concordia University, Montreal, Quebec, Canada). Participants were English- and French-speaking adults (>18 years) who owned a smartphone (Android or Apple). Exclusion criteria included those who were previously diagnosed with a disease affecting their dietary intake, were following a diet or a weight-loss regime and/or had dietetics training. Compensation for completing the study included a detailed dietary assessment by a RD. Ethical approval was obtained from the University Human Research Ethics Committee of Concordia University and written informed consent was received from all participants [2].
Procedure
The participants were randomly assigned to record their diets using either the Keenoa™ app or the 3DFD and then switched dietary assessment methods the following week, for a total of two weeks [2]. Diets were recorded using the respective methods for 3 nonconsecutive days during the week, including one weekend day. Participants were encouraged to maintain their typical eating habits throughout the study [2].
Exit survey
Once the participants completed the 2 weeks of diet recording, they were invited to respond to an exit (online) survey. This survey included the System Usability Scale (SUS) questionnaire that is used to evaluate users’ perspective of the mobile application [12]. In addition, this survey included the optional open-ended question “any additional comments about Keenoa™ or 3-day food diaries are welcome”, which was used to obtain information on the participants’ experience and opinions regarding the application. The responses to this question alone were used for analysis.
Data analysis
Participant responses were collected and downloaded to a qualitative data management software (Taguette, Version 0.9, Switzerland, 2019) for further analysis. This software supported an open coding method that allowed VB to read over the responses, categorize similar key words, and capture emerging themes. Within each theme, if a concept was mentioned by two or more participants, it was grouped together to form a subtheme. Once all subthemes were identified, they were reviewed to ensure that they corresponded to their respective category. Themes and subthemes were reviewed by HB, TC, and HP, and discrepancies were discussed to ensure that a consensus was reached. Specific quotes were used to support and demonstrate the robustness of each theme and subtheme.
RESULTS
A total of 72 subjects completed the exit survey from which only 50 of them completed the optional question of interest (mean age: 38.5 ± 1 years; 63 % female; 80% University degree). Three themes emerged from the data: (i) strengths, (ii) challenges, and (iii) recommendations for improvement (Table 1 and Supplementary Table 11).
Table 1.
a
Since this study was conducted, Keenoa™ has introduced a feature for the dietitian to allow the user to see personal data, such as total calories or macronutrients consumed.
Strengths associated with the Keenoa™ app
Users identified three positive attributes associated with the app. Nine participants reported on the data collection process, mentioning that the application made the diet recording process easier, joyful, and more convenient. Five participants reported on the benefits associated with the picture recognition software, mentioning it was easier to record their diet using this application compared with the 3DFD. Finally, two participants reported on the benefits of having an additional commentary feature, which allowed them to record details that were not picked up by the application. Quotes that outline more details on the subtheme are found in Table 1 and Supplementary Table 11.
Challenges associated with the Keenoa™ app
Challenges emerged as a theme and included the following subtheme categories: barcode scanning feature, limited food database, and time consuming (Table 1). Twenty-two participants identified the food database to be limited and often unable to recognize meals. Twelve participants encountered challenges with the barcode scanning feature, which also encouraged the consumption of prepackaged food items. Nine individuals expressed that the app was time consuming, and this was often related with technological issues. Finally, five individuals reported having experienced specific software issues such as app crashes.
Additional recommendations for app improvement
Finally, users reported various recommendations for app improvement (Table 1). Nine participants mentioned being able to upload photographs from their camera roll, 7 participants expressed their interest in having accessible nutritional data, 7 participants expressed having better options to describe and quantify food, 3 participants mentioned adding a favorite recipe tab, 3 participants mentioned having optional reminders, 2 participants mentioned their interest in combining their smartwatches with the app, 2 participants mentioned personalizing the display, and 2 participants mentioned their interest in editing previously submitted food entries.
DISCUSSION
To our knowledge, this is the first study investigating users’ experience regarding recording dietary intake using an advanced app. While limitations were discussed, this study identified many strengths and positive areas of improvement that support the use of Keenoa™ by Canadian RDs. Importantly, this study provided suggestions to facilitate and improve this app, as well as important insights for those who wish to create their own diet app.
Themes identified in this report are consistent with other research. In this study, users mentioned that they enjoyed the process of taking photos of their foods rather than writing it down [5]. Similarly, Zepeda and Deal [1] reported that users preferred taking photos of their meals compared with the conventional pen and paper method, as it added value and meaning to their meals. While this study did not include measures of self-efficacy, other studies using photo-based food diaries reported that users feel an enhanced self-awareness of their meals [13] and therefore make healthier food choices [8]. In this study, participants reported that the process of taking photos allowed them to be more conscious of what they were eating, as one participant reported “Taking pictures like this was an excellent way for me to eat mindfully”. Inevitably, by documenting dietary intake it allows participants to be more aware of their diet. This awareness has been reported to influence other behavioural changes such as increasing self-monitoring, both in general and amongst individuals who may require a more restrictive diet [14–16]. For this reason, future studies evaluating this app should consider the effect of self-monitoring on diet improvement.
Among the sub-themes mentioned, the additional commentary feature was identified as a strength. However, it is important to mention that it could have also contributed to the development of other challenges. For instance, having the ability to add details when food items were not identifiable in the database led to increased recording time, which was often negatively viewed by the participants. For this reason, this strength can also be considered as a limitation.
As for challenges experienced by Keenoa™ users, similarities were also found amongst other diet recording apps. For instance, a limited food database often led to unsatisfied users; in this case the Canadian Nutrient File is limited, and food items were often incorrectly recognized by the app and needed to be entered manually [2]. This was a frustrating process that often led to numerous errors in recordings [2]. As one participant mentioned “The database needs to be greatly improved if they want people to continue to use it. The lack of items when I scanned products, texting every ingredient in a recipe is cumbersome.” Limitations of databases are all too common when examining Canadian diet apps. For example, similar challenges were reported using the Dietitians of Canada eaTracker®, which also used the Canadian Nutrient File, with approximately 50% of users reporting issues with missing food items [11]. It is also important to note that the Canadian Nutrient File is only updated every 2–3 years and may be outdated at times [10, 17]. By enlarging or updating the food database more consistently, it will allow more items to be identified, inaccuracies to be reduced, and increase user satisfaction. Another challenge mentioned by the users of the Keenoa™ app is that they often experienced software crashes. Some reasons why this may occur include numerous other applications running at the same time, limited storage space available on the smartphone, and if software updates are required. As for the application itself, software updates are consistently being made and adjusted accordingly.
Qualitative research on user experiences have reported methods to improve user satisfaction. Research suggests that incorporating an attractive interface and personal tailoring can engage the user [9, 18]. Specifically, a well-designed interface that displays graphs and charts that can be used to self-monitor diet is desired [9, 11, 17, 19]. During this study users requested more reports, graphs, and summaries of their intake. Since the time of this study, Keenoa™ has made interface adjustments, such as allowing the user to see nutrients of interest (i.e., calories, protein, fat) as they complete their recordings, if deemed appropriate by their RD. This feature has been shown to enhance user engagement and provide motivation to continue logging data [11].
This study is not without limitations. The sample consisted mostly of younger participants with a higher education (80% university degree) [2], which can lead to bias and is not representative of the general population [2]. Despite this, these results provide valuable insight on users’ experiences with the Keenoa™ app.
RELEVANCE TO PRACTICE
Keenoa™ is a Canadian-based app aimed to collect and monitor diet data using a Canadian database, the Canadian Nutrient File (2015) [10]. Designed by RDs for RDs, this app aims to reduce user burden and improve accuracy in dietary data collection. It is important that RDs consider the limitations that naturally come with using diet apps and discuss these with their clients. Nonetheless, mobile apps like Keenoa™ are preferred over traditional methods; however, future studies should consider testing these platforms in different populations (e.g., older adults) and evaluate acceptability and usability among RDs. App development is an ongoing process that should be continuously monitored and adjusted to the users’ needs.
Financial support: R. Howard Webster Foundation.
Conflicts of interest: The authors declare that they have no competing interests.
Footnote
1
Supplementary data are available with the article through the journal Web site at Supplementary Material.
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Supplementary Material
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Published In
Canadian Journal of Dietetic Practice and Research
Volume 83 • Number 1 • March 2022
Pages: 25 - 29
Editor: Naomi Cahill Ph.D RD
History
Version of record online: 28 September 2021
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© 2022.
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ValerieBouzoBSc, HuguesPlourdePhD, RD, HaileeBeckensteinMScA, RD, and Tamara RCohenPhD, RD. 2022. Evaluation of the Diet Tracking Smartphone Application Keenoa™: A Qualitative Analysis. Canadian Journal of Dietetic Practice and Research.
83(1): 25-29. https://doi.org/10.3148/cjdpr-2021-022
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