Validity and Usability of a Smartphone Image-Based Dietary Assessment App Compared to 3-Day Food Diaries in Assessing Dietary Intake Among Canadian Adults: Randomized Controlled Trial
Authors: Ji Yuwei , Plourde Hugues , Bouzo Valerie , Kilgour Robert D , Cohen Tamara R 
Published: June 2020

Background
Accurate dietary assessment is needed in studies that include analysis of nutritional intake. Image-based dietary assessment apps have gained in popularity for assessing diet, which may ease researcher and participant burden compared to traditional pen-to-paper methods. However, few studies report the validity of these apps for use in research. Keenoa is a smartphone image-based dietary assessment app that recognizes and identifies food items using artificial intelligence and permits real-time editing of food journals.

Objective
This study aimed to assess the relative validity of an image-based dietary assessment app — Keenoa — against a 3-day food diary (3DFD) and to test its usability in a sample of healthy Canadian adults.

Methods
We recruited 102 participants to complete two 3-day food records. For 2 weeks, on 2 non-consecutive days and 1 weekend day, in random order, participants completed a traditional pen-to-paper 3DFD and the Keenoa app. At the end of the study, participants completed the System Usability Scale. The nutrient analyses of the 3DFD and Keenoa data before (Keenoa-participant) and after they were reviewed by dietitians (Keenoa-dietitian) were analyzed using analysis of variance. Multiple tests, including the Pearson coefficient, cross-classification, kappa score, % difference, paired t test, and Bland-Altman test, were performed to analyze the validity of Keenoa (Keenoa-dietitian).

Results
The study was completed by 72 subjects. Most variables were significantly different between Keenoa-participant and Keenoa-dietitian (P<.05) except for energy, protein, carbohydrates, fiber, vitamin B1, vitamin B12, vitamin C, vitamin D, and potassium. Significant differences in total energy, protein, carbohydrates, % fat, saturated fatty acids, iron, and potassium were found between the 3DFD and Keenoa-dietitian data (P<.05). The Pearson correlation coefficients between the Keenoa-dietitian and 3DFD ranged from .04 to .51. Differences between the mean intakes assessed by the 3DFD and Keenoa-dietitian were within 10% except for vitamin D (misclassification rate=33.8%). The majority of nutrients were within an acceptable range of agreement in the Bland-Altman analysis; no agreements were seen for total energy, protein, carbohydrates, fat (%), saturated fatty acids, iron, potassium, and sodium (P<.05). According to the System Usability Scale, 34.2% of the participants preferred using Keenoa, while 9.6% preferred the 3DFD.

Conclusions
The Keenoa app provides acceptable relative validity for some nutrients compared to the 3DFD. However, the average intake of some nutrients, including energy, protein, carbohydrates, % fat, saturated fatty acids, and iron, differed from the average obtained using the 3DFD. These findings highlight the importance of verifying data entries of participants before proceeding with nutrient analysis. Overall, Keenoa showed better validity at the group level than the individual level, suggesting it can be used when focusing on the dietary intake of the general population. Further research is recommended with larger sample sizes and objective dietary assessment approaches.