Mobile Device-assisted Dietary Ecological Momentary Assessments for the Evaluation of the Adherence to the Mediterranean Diet in a Continuous Manner
Summary
Presented here is a study protocol aimed at monitoring continuous adherence to the Mediterranean diet (MedDiet) by means of ecological momentary assessments. The method evaluates the intake of key food groups of the MedDiet and calculates an index of adherence.
Abstract
Mobile device-assisted dietary ecological momentary assessments (EMAs) have emerged as a new tool allowing the evaluation of dietary intake in real time, in a real-world setting and in a continuous manner. They have the potential to minimize recall bias, participant, and investigator burden, and decrease economic and time investment while maximizing ecological validity.
We developed a set of EMAs aimed at evaluating continuous adherence to the MedDiet. Four multiple-choice EMAs are sent daily in a randomized manner from a total of eight questions. The EMAs enquire about the consumption of 11 key food groups of the Mediterranean diet in the last 24-48 h in a semi-quantitative way. EMAs capture the daily frequency of consumption of fruits, vegetables, and extra virgin olive oil on different days of the week. Additionally, EMAs capture the weekly frequency of consumption of whole grain products, sugary drinks, nuts, legumes, sweets, fish and seafood, and red and processed meats. A designed scoring system behind the EMAs extracts the percentage of adherence to the MedDiet recommendations and calculates a quality index of the diet every week. Individualized reports are sent periodically to the volunteers highlighting the strengths and weaknesses of their diet. EMAs are also expected to have a behavioral effect, reinforcing the choice of Mediterranean foods.
Introduction
The Mediterranean diet (MedDiet) is a dietary pattern associated with longevity and multiple health benefits. High adherence to the MedDiet has been related to a decreased risk of overall mortality, cardiovascular disease, overall cancer incidence, neurodegenerative disease and diabetes1. In particular, the MedDiet, based on seasonal and local products, is characterized by a high intake of plant-based food (fruit, vegetables, legumes, nuts, and unrefined cereals) and a moderate intake of fish, eggs, dairy, and poultry. Olive oil represents the main source of fat. The consumption of saturated fatty acids is low, with very low consumption of red and processed meats, sweets, and processed foods. The MedDiet is also characterized by a moderate intake of ethanol, mostly in the form of wine consumed during meals2.
The evaluation of diet is complex and challenging. The correct evaluation of dietary practices and MedDiet adherence in the study of nutrition is the key in attempting to find associations between this dietary pattern and its health outcomes. The traditional methods used to assess diet are food frequency questionnaires, food diaries and 24-h dietary recall. They have been broadly used in nutrition epidemiology and in clinical nutrition, however, they are highly subjected to misreporting, recall bias and depend on the participant's capacity to estimate food content and portion size. These traditional dietary assessment methods are time-consuming, expensive and represent an important burden for both participant and researcher3,4. To overcome these limitations, there is a need to reformulate traditional dietary assessment. The goal of the dietary assessment is to achieve a balance between the collection of accurate and reliable data with the resources consumed and the burden for the participant3. Several researchers have developed complementary approaches to evaluate adherence to the MedDiet. These approaches calculate composite dietary scores that result from the combination of different dietary characteristics associated with the MedDiet2. The first MedDiet score was created in 1995 by Trichoupoulou et al. (1995)5 and includes a total of 8 components. The score assessed the frequency of consumption of 7 food groups: vegetables, fruits and nuts, legumes, cereals, meat and meat products, milk and dairy products and alcohol intake. The eighth component was a fat quality measurement; the ratio between monounsaturated and saturated fatty acid (MUFA/SFA)5. One of the most used MedDiet assessment questionnaires, the MEDAS (Mediterranean Diet Adherence Screener) was developed during the PREDIMED study (Prevención con Dieta Mediterránea) with the aim of controlling dietary intervention compliance6. The MEDAS is a validated 14 item dietary screener which considers additional items compared to the first MedDiet score such as the type of oil used in cooking, consumption of sugar in drinks and sweets and the consumption of the typical Spanish spiced tomato sauce known as "sofrito". The questionnaire was found to be useful in evaluating the adherence to the MedDiet especially in time-limited settings such as large epidemiological studies and general clinical practice6.
The widespread availability of new technologies and the changes in how people use them have created the opportunity to incorporate these innovations into dietary assessment. They offer the chance to capture the complexity of food intake while overcoming the aforementioned limitations of traditional methods. In this context, ecological momentary assessments (EMAs) have been developed as a tool to use new technologies in performing repeated sampling of an individual's current behavior and experience7. The introduction of EMAs into dietary assessment can improve accuracy, ecological validity, and data robustness while minimizing reporting and recall bias and decreasing participant and research burdens. Additionally, the use of EMAs allows for the continuous assessment of diet; through the observation of fluctuations across time, observation of within-person changes, and the modeling of these variations. EMAs have the potential to minimize the reactivity bias, yield higher rates of compliance and lower the occurrence of missing data4,7,8. In summary, the major advantages associated with the use of EMAs are: (1) the collection of data as it occurs in the natural environment, (2) real time or near real time data collection rather than retrospective survey, thereby avoiding recall bias, and (3) repeated sampling, which allows for the study of behaviors and experiences over a given time period4,9. The use of EMAs to assess dietary intake is increasing and several clinical trials have used them to collect dietary information. The type of data collected in these studies include: the frequency of meals and snacks, the consumption of predefined food groups and beverages, and the recording of food images4,7.
To the best of our knowledge, the EMA approach has never been used to study the adherence to the MedDiet. The aim of the present study was to develop a set of mobile device assisted EMAs to continuously assess the adherence to the MedDiet. To do so, we developed a set of 8 mobile device-assisted EMAs to measure the consumption of 11 food groups, including the assessment of those typical of the MedDiet (olive oil, fruit, vegetables, etc.) along with the intake of food groups that represent a typically low consumption in the MedDiet (processed and red meat, sugary drinks, etc.).
Protocol
Representative Results
Discussion
Here we describe a protocol to assess an individual's adherence to the MedDiet via a mobile-based application. This method uses daily EMAs to capture the dietary pattern and by means of an algorithm, calculates a weekly score representing the degree of adherence to the MedDiet. A positive score is given to the high intake of healthy food items which are characteristic of the MedDiet. Conversely, a negative score is given to the intake of unhealthy food groups, in accordance with the recommendations given for the Span…
Divulgations
The authors have nothing to disclose.
Acknowledgements
This work was supported by grants from Alzheimer Association (18PTC-R-592192; The PART THE CLOUD to RESCUE (REverse, reStore, Cease and UndErstand) Brain Cell Degeneration in Alzheimer's disease Program), Instituto de Salud Carlos III (FEDERPI17/00223), CIBER de Fisiopatología de la Obesidad y Nutrición (CIBEROBN) and DIUE de la Generalitat de Catalunya (2017 SGR 138) from Agència de Gestió d'Ajuts Universitaris i de Recerca (AGAUR).
Materials
| Data processing software (excel) | MS Office | – | Others suitable options like R studio |
| Google forms | – | Free online software that allows the creation of surveys and questionnaires to be delivered. It's part of Google's web-based apps sui | |
| Limesurvey platofrm (https://www.limesurvey.org/) | Limesurvey | – | A free software application for conducting online surveys |
References
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