Computer Methods and Programs in Biomedicine 192 (2020) 105459

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Computer Methods and Programs in Biomedicine

journal homepage: www.elsevier.com/locate/cmpb

Use of mobile applications to improve nutrition behaviour: A

systematic review
Rathi Paramastri a,1, Satwika Arya Pratama a,1, Dang Khanh Ngan Ho a,
Sintha Dewi Purnamasari a, Afrah Zaki Mohammed a, Cooper J Galvin b, Yi-Hsin Elsa Hsu c,d,
Afifa Tanweer e, Ayesha Humayun f,g, Mowafa Househ h,i, Usman Iqbal b,f,j,∗
a
School of Nutrition and Health Sciences, College of Nutrition, Taipei Medical University, Taipei, Taiwan
b
International Center for Health Information Technology (ICHIT), Taipei Medical University, Taipei, Taiwan
c
School of Health Care Administration, College of Management, Taipei Medical University, Taipei, Taiwan
d
Executive Master Program of Business Administration in Biotechnology, College of Management, Taipei Medical University, Taipei, Taiwan
e
School of Health Sciences, University of Management and Technology, Lahore, Pakistan
f
Department of Public Health and Community Medicine, Shaikh Zayed Medical Complex, Lahore, Pakistan
g
Department of Undergraduate Medical Education (DUME), SKZMDC, Shaikh Khalifa Bin Zayed Al-Nahyan Medical College, Shaikh Zayed Postgraduate
Medical Institute, Shaikh Zayed Medical Complex, Lahore, Pakistan
h
Hamad Bin Khalifa University, College of Science and Engineering, Qatar Foundation, Qatar
i
School of Health Information Science, University of Victoria, Victoria, BC, Canada
j
Master’s Program in Global Health & Development Dept., PhD Program in Global Health & Health Security Dept., College of Public Health, Taipei Medical
University, Taipei, Taiwan

a r t i c l e i n f o a b s t r a c t

Article history: Background and Objective: Mobile applications could be effectively used for dietary intake assessment,
Received 17 July 2019 physical activity monitoring, behavior improvement, and nutrition education. The aim of this review is to
Revised 11 March 2020
determine the effectiveness of mobile applications in improving nutrition behaviors through a systematic
Accepted 17 March 2020
review of literature.
Methods: The review protocol was registered with PROSPERO: registration number CRD42018118809,
Keywords: and followed PRISMA guidelines. We involved original articles including mobile electronic devices for
Mobile application improving dietary intake, physical activity, and weight management in adult populations in this review.
mHealth Data were retrieved from January 2010 to December 2018 with PubMed, Web of Science, Excerpta Med-
Apps
ica Database (Embase), and Cumulative Index to Nursing and Allied Health Literature (CINAHL) as data
Nutrition
sources. Authors individually screened the titles and abstracts, then full articles in order to obtain papers
Dietary behavior
Healthcare technology that met inclusion criteria.
Results: The database search yielded 2962 records. After removing the duplicates and analyzing the full
text papers a total of 8 original articles were reviewed. Two articles showed obvious bias and were not
included in our results or discussion. The remaining six articles with low to moderate bias risk were
included in this systematic review. Three selected studies were randomized control trials (RCTs) with
over 180 participants each. The other three studies were a nested trial, a case-control trial, and a pilot
RCT with 36, 162, and 24 participants respectively. All larger RCTs and the small case control trail showed
significant improvements in some nutritional-health objectives measured. The other two trials showed
insignificant improvements in outcomes measured between groups.

∗
Corresponding author at: Master’s Program in Global Health & Development
Dept., PhD Program in Global Health & Health Security Dept., College of Public
Health, Taipei Medical University, Taipei, Taiwan
E-mail address: usmaniqbal@tmu.edu.tw (U. Iqbal).
1
Equal contribution

https://doi.org/10.1016/j.cmpb.2020.105459
0169-2607/© 2020 Published by Elsevier B.V.
2 R. Paramastri, S.A. Pratama and Dang Khanh Ngan Ho et al. / Computer Methods and Programs in Biomedicine 192 (2020) 105459
Conclusion: This study highlights the potential significant health benefits acquirable through mobile
health application-assisted nutrition interventions. Some of these studies required significant financial
and time input from providers for the application’s utilization. Further studies, perhaps with multiple
intervention arms, are required to compare across programs the elements that are essential for health
benefits observed.
1. Introduction
The introduction of telemedicine services with mobile and per-
sonal computing devices has shown great viability and rapid dis-
semination [1]. Advanced technology has allowed users of these
devices to monitor their health records and to receive medical ad-
vice about healthy lifestyle practices . This has been facilitated by
modular development of application programs and their dissemi-
nation over the years. Today, it is estimated that more than 5 bil-
lion people have mobile devices, and over half of these connec-
tions are smartphones [2]. Smartphone adoption has increased by
almost three-fold in emerging nations from 18% in 2013 to 47% in
2018. Internet usage has also increased from 40% in 2015 to 60% in
2018. Most of the users of smart phone and internet devices have
been reported to be between 18–49 years old [3]. Increasing num-
ber of smartphones users can lead to higher popularity and ac-
cessibility of information through application programs. Therefore,
there are higher potential apps to be developed for lifestyle behav-
ior change in the community. Mobile application for nutrition is
something that many people use to control their diet and maintain
their personal ideal weight. A large number of health and nutri-
tion applications available on Google Play and the Apple App Store
proves the increasing awareness of community regarding adopt-
ing a healthy lifestyle [4]. The effectiveness of nutrition apps in
behavioral change still needs to be rigorously assessed. The latest
review about app nutrition related to the knowledge and behav-
ior was published in 2015 [5]. The current systematic review aims
to provide updated summary on the use of application in altering
the knowledge and health behavior. This study examined the effect
of nutrition mobile applications in stimulating change in eating
behavior and solving nutritional problems. While previous litera-
ture has examined technology as a strategy to provide knowledge
and promote behavior change [5], this review adds to current body
of knowledge by specifically focusing on mobile apps in the con-
text of nutrition to monitor and instruct users in order to choose
healthier food options. The use of learning applications needs ad-
ditional research involving in-application behavior theory.
2. Methods
2.1. Search strategy
We conducted a systematic review of published random-
ized controlled trials (RCTs) on nutrition mobile applications and
its effects on nutrition behavior and disease management ac-
cording to International Prospective Register of Systematic Re-
views (PROSPERO) guidelines. The search strategy was devel-
oped in consultation with senior reviewer (U.I.). We searched
through electronic databases PubMed, Web of Science, Excerpta
Medica Database (Embase), and Cumulative Index to Nursing
and Allied Health Literature (CINAHL) from January 2010 un-
til December 2018 for articles using the following search terms:
mobile nutrition, nutrition applications, e-learning and nutri-
tion, diet applications, telenutrition, ehealth nutrition, enutrition,
weight loss app, calorie control. We searched using the MeSH
terms ((((((((mobile nutrition[Title/Abstract]) OR nutrition appli-
© 2020 Published by Elsevier B.V.
cations[Title/Abstract]) OR e-learning nutrition[Title/Abstract]) OR
diet applications[Title/Abstract]) OR telenutrition[Title/Abstract])
OR ehealth nutrition[Title/Abstract]) OR enutrition [Title/Abstract])
OR weight loss[Title/Abstract]) OR calorie control[Title/Abstract].
2.2. Eligibility criteria
Inclusion criteria were: (1) an original, peer-reviewed published
article (2) written in English (3) with a study population of adults
above 18 years old (4) and conforming to the protocols of either
randomized control trials, cohort study, case-control study, or cross
sectional study. We excluded descriptive studies, review articles
and meta-analyzes.
2.3. Research question development
Derived from the PICOS (Participants, Interventions, Compara-
tors, Outcomes, Study designs) guidelines, we developed the re-
search question for this systematic review. Studies targeting adults,
aged 18 years or above with any health condition, were included to
analyze the change of behavior and knowledge related to nutrition
after using mobile nutrition applications. Children under 18 years
were excluded due to the variations in cognitive and physical de-
velopment through the age span. There was no restriction on race,
ethnicity, geography, and gender to maintain the broadest target
group. The intervention had to include nutrition app developed in
mobile phone. The intervention must involve nutrition education
to change behavior through aiding goal setting, self-monitoring,
and environmental or policy level change [6]. any app that directly
taught users or indirectly changes nutrition-related behavior was
regarded as nutrition education for this review. Desired outcomes
for this study were either nutrition-related behavior (primary out-
come) and nutrition knowledge (secondary outcome) [5].
2.4. Study selection and data extraction
A template was developed to extract relevant data from the
original papers with data extraction completed by all authors. The
process of identification, screening, and eligibility assessment was
applied to ensure that all relevant studies were included. Au-
thors screened the titles and abstracts, then full text publications.
Data extraction was completed separately and any disagreements
were resolved through discussion. A senior reviewer was consulted
when necessary.
2.5. Bias assessment
The quality assessment of studies included in systematic review
is shown in Table 2. The authors (KN, AZ) independently assessed
each included study for quality constructs and risk of bias using
Quality Criteria Checklist: Primary Research Quality Criteria Check-
list for primary Research identified in the AHRQ report on Systems
to Rate the Strength of Scientific Evidence (2002).
The results of the risk of bias assessment were combined into a
single report then exported to the tabular format to create visual
presentation of the publications. All of the studies were deemed to
be of low to moderate risk when assessed using Quality Criteria
Table 1
Characteristics and outcome data of studies
Study population;
Author location Study design Mobile App App purpose App components Intervention and control Nutrition outcomes Results
Partridge et al. 248 young adults at risk Randomized controlled TXT2BFiT • Examine whether • Five personalized • The intervention groups Change in weight and - Weight change at 3 and 9
[7] of weight gain aged 18 - trial (RCT) prevention of weight coaching calls with a participant received the improved eating and physical months remained significant
35 yr; Sydney gain was associated with dietitian 3-month intervention activity behaviors when 3 and 9 months
individual factors • Eight weekly gender with mobile app TXT2BFiT nutrition and physical
• Examine the and stage-of-change • The control group activity were specified as

R. Paramastri, S.A. Pratama and Dang Khanh Ngan Ho et al. / Computer Methods and Programs in Biomedicine 192 (2020) 105459
hypothesized mediating specific text messages received a two pages mediators in both groups
effects of healthy eating targeting fruit and handout based on the - Increase in vegetable intake
and physical activity on vegetable consumption, Australian Dietary and decrease
weight change. take-out meal Guidelines and National sugar-sweetened beverages
consumption, Physical Activity in intervention group
sugar-sweetened Guidelines
beverages (SSBs)
consumption and physical
activity levels,
• Weekly emails and
access to smartphone
applications and study
website
Orlemann et al. 186 patients with Randomized controlled OncoFood app • Investigating the • The app contains a Intervention: Nutrition Gaining first insights into - The app group gained
[10] different tumors, mean trial (RCT) feasibility and database of more than counseling, nutritional whether the app may significantly more weight,
age of 58.4 yr; Germany applicability of a novel 1300 nutrition facts for therapy with app contribute to an improved skeletal muscle mass
mobile phone app foods based on the (oncofood) nutritional status in cancer compared with the control
• Evaluating dietary German Nutrition Control: Nutrition patients. group
behaviors in oncologic Society’s nutritional value. counseling, nutritional - No significant difference
patients. • The app reminded therapy without app between groups relating to
patients to enter their the daily protein intake
food intake every day at 9
am, 1 pm, and 7 pm.
Laing et al. [11] 212 adults ≥18 yr; Los Randomized controlled MyFitness Pal (MFP) Social cognitive theory, Real-time user’s weight Intervention group: Change in weight, systolic - No significant difference
Angeles trial (RCT) including trend, caloric intake, and MFP-based programs blood pressure (SBP), between intervention and
self-monitoring, goal nutritional summaries of Control group: text-based behaviors around diet, control group in weight
setting, and feedback their diet programs exercise, and self-efficacy in change, or in SBP
weight loss - The intervention group
exhibited increased use of
personal calorie goal
compared to control group
- Changes in other
self-reported behaviors did
not differ between group
Lee et al. [8] 36 adults with mean age Case-control SmartDiet A diet planner (user Dietary information, Case group: intervention Dietary information, body No significant difference in
(case group was 28.2 yr management, daily weight control with SmartDiet composition (fat mass, lifestyle variables (eating
and control group was calorie intake records, application Control group: weight, body mass index) behavior and exercise
29.5 yr; Seoul meal assessment, without application activity) in both study group
exercise plan) and a diet Body composition (fat mass,
game (game-style weight, and BMI) was
learning tool about how significantly changed in
to control nutritional intervention group
intake and exercise)
Dodd et al. [13] 162 pregnant women Nested randomized trial - Dietary and physical Dietary and physical Intervention group: Change in healthy eating No significant difference
≥30 yr; Adelaide activity change and activity monitoring, and Lifestyle advice plus index, physical activity between intervention and
weight management also weight management smartphone application control group regarding to
during pregnancy group healthy eating index (HEI),
Control group: Lifestyle macronutrient and food
advice group group intake, and physical
activity
Palacios et.al. Overweight and obese Pilot randomized trial MyNutriCart Improving household A healthy grocery list Intervention group: Household food purchase No significant improvements
[12] adults aged 21–45 yr; food purchase behavior based on the daily MyNutriCart app behavior, individual dietary in household food purchase
Puerto Rico and individual dietary nutritional Control group: traditional behaviors, and individual and individual food intake
behaviors recommendations of the nutrition counseling weight control
individuals

3
4 R. Paramastri, S.A. Pratama and Dang Khanh Ngan Ho et al. / Computer Methods and Programs in Biomedicine 192 (2020) 105459

Table 2
Quality assessment of studies

Partridge Orlemann Laing Lee et al. Dodd Palaciaos

et al. [7] et al. [10] et al. [11] [8] et al. [13] et al. [12]

Overall quality rating

Relevance questions
1- Would implementing the studied interventions or procedure (if found YES YES YES YES YES YES
successful) result improved outcomes for the patients/clients/population
group? (NA for some Epi studies)
2- Did the authors study an outcome (dependent variable) or topic of study YES YES YES YES YES YES
a common issue of concern to dietetics practice?
3- Is the focus of the intervention or procedure (independent variable) or YES YES YES YES YES YES
topic of study a common issue of concern to dietetics practice?
4- Is the intervention or procedure feasible? (NA for some epidemiological YES YES NO YES YES YES
studies)
Validity Questions
1- Was the research question clearly stated YES Not clear YES YES YES YES
2- Was the selection of study subjects/patients free from bias? YES NO YES YES YES YES
3- Were study groups comparable NO YES YES YES YES YES
4- Was method of handling withdrawals described? NO YES YES YES YES YES
5-Was blinding used to prevent introduction of bias? YES YES YES YES YES YES
6- Were intervention/therapeutic regimens/exposure factor or procedure and YES YES YES YES YES YES
any comparison(s) described in detail? Were intervening factors described?
7- Were outcomes clearly defined and the measurements valid and reliable? YES YES YES YES YES YES
8- Was the statistical analysis appropriate for the study design and type of YES YES NO YES YES YES
outcome indicators?
9- Are conclusions supported by results with biases and limitations taken YES YES NO YES NO YES
into consideration?
10- Is bias due to study’s funding or sponsorship unlikely? YES YES Neutral NO YES Neutral

healthy eating behavior or weight change status. The other three

Fig. 1. Flow chart of study selection process
Checklist. However, there were some studies that had elements of
risk. Some RCT studies failed to report their method of assigning
subjects to groups and clearly exhibited bias. All studies did not
include the sources of bias as well as limitations in their conclu-
sons
3. Results
The study selection process is illustrated in Fig. 1. The database
search yielded 2962 records. After removing the duplicates, the ti-
tle and abstracts were screened for 2850 records. Full text was
reviewed for 15 manuscripts. Of these, six articles were included
in final systematic review. We identified studies from Europe,
United States, and Asia. The key characteristics are described in
Table 1. Among six studies, three were randomized control trials
(RCTs) with over 180 participants (listed first). These three larger
RCT studies showed significant improvement in the context either
studies had smaller patient participant populations and were a
nested trial, a case-control trial, and a pilot RCT. The small case
control trail showed significant improvements in some nutritional-
health objectives measured. The other two trials showed insignif-
icant improvements in outcomes measured between groups. In
study conducted by Partridge et al. [7], increased vegetable intake
and reduced sugar-sweetened beverages, accompanied by physi-
cal activity had reported as mediators that considerably improve
weight status in participants. Similar result also found in study by
Lee et al. [8], usage of mobile app increased the outcome of body
composition.The quality assessment of studies included in system-
atic review is shown in Table 2. In total, two reviewers (KN, AZ)
independently assessed each included study for quality constructs
and risk of bias using Quality Criteria Checklist: Primary Research
identified in the AHRQ report on Systems to Rate the Strength of
Scientific Evidence [9]. This checklist was used to evaluate the risk
of bias within the studied papers. All of the studies were deemed
to be of low to moderate risk when assessed using Quality Crite-
ria Checklist. However, there was study that had elements of risk.
RCT study failed to report their method of assigning subjects to
groups and clearly exhibited bias [10]. This study did not include
the sources of bias as well as limitations in their conclusions.
Table 3. shows the characteristics of the studies included in this
systematic review. The goals were similar among these six stud-
ies, for instance, Partridge et al. [7], Orlemann et al. [10] and Laing
et al. [11] aimed to prevent weight gain. Another goal of these
studies were related to dietary intake and physical activity behav-
ior. Five of six studies used self-assessment for feedback and moni-
toring [7,8,10–12], while Dodd et al. used interview methods to ob-
tain variables data [13]. Social support appears to be an important
determinant of success in changing habits [14], meanwhile this fac-
tor was only be included in two studies [10,11].
This systematic review also aimed at finding out the role of
apps on increasing knowledge related nutrition. We discovered
that 3 of 6 studies provided feature to enhance nutrition knowl-
edge through the apps [7,8,11]. None of the studies used threat for
behavior change however reward was used as a method to encour-
age subjects to change their behavior in two studies [11,15].
 R. Paramastri, S.A. Pratama and Dang Khanh Ngan Ho et al. / Computer Methods and Programs in Biomedicine 192 (2020) 105459 5

Table 3
Taxonomy of behavior change techniques utilized by nutrition interventions involving apps.

Partridge et al. [7] Orlemann et al. [10] Laing et al. [11] Lee et al. [8] Dodd et al. [13] Palacios et al. [12]

Goals and planning Prevention of weight Change in food Weight loss Dietary intake and Dietary and physical Individual dietary
gain mediated by intake and prevent weight loss activity change behaviors and
healthy eating and weight gain weight control
physical activity
Feedback and monitoring Self-reported body Self-assessment for Self-assessment of Diet, weight, and Research assistant Diet and weight
weight, diet, and energy and nutrient body weight, dietary physical activity made three self-assessment
physical activity supply intake, and physical self-assessment telephone calls and
activity face to face
interview
Social support Personalized Professional Phone call from Display calories N/A Household food
coaching calls nutritional advices to research assistant intake and purchase
achieve determined and social expenditure self-assessment
energy and nutrient networking feature
requirements
Shaping knowledge N/A Use traffic light color Real-time showing N/A The healthy food and N/A
and symbol to user’s weight trend balanced diet
interpret daily goal suggestion
achievement
Natural consequences N/A N/A N/A Nutrition game as N/A List of healthy food
simple quiz provided and
unhealthy food
included only weekly
Comparison and behavior N/A N/A N/A N/A N/A N/A
Associations Coaching calls, N/A N/A N/A N/A N/A
monthly text
messages and email
Repetition and substitution N/A N/A N/A N/A N/A N/A
Comparison of outcomes Compare result of Compare result of Compare result of N/A N/A Instructed to use the
using mobile apps using mobile apps using mobile apps app every grocery
and handout and standardized and short text shopping or at least
protocol paper record message (SMS) once per week for
intervention group
and keep the grocery
receipt for control
group
Reward and threat N/A N/A Received a $20 gift N/A N/A N/A
card for attending
each follow-up visit
Regulation N/A N/A N/A N/A N/A N/A
Antecedents Suggest to decrease N/A Suggest to choose N/A N/A N/A
sedentary lifestyle any kind of activity
and unstructured to lose weight
physical activity
Identity Self-reflection N/A Self-reflection Self-reflection Self-reflection Minimizing the
unhealthy food
suggestion
Scheduled consequences N/A N/A N/A N/A N/A Self-reflection
Self-brief N/A N/A N/A N/A Set self-achievable N/A
goals and identify
potential barriers, to
use these perceived
barriers to solve
problems, and
develop
individualized
strategies
Covert learning N/A N/A N/A N/A N/A N/A

4. Discussion
Results of the review indicate that nutrition knowledge can
impart favorable dietary and health behavioral changes in app
users through short-term nutrition education, health coaching, re-
minders, and/or diet tracking tools. Four of six studies have re-
ported positive impact for supporting user to increase a healthy
diet, to enhance their self-efficacy, and their desire to obtain
healthy dietary goals [7,8,11,15]. In many studies, the interven-
tion involved multiple modalities of patient contact including app,
email, and/or calls from a health coach. In these instances, it is im-
possible to determine if it was the mobile app alone that yielded
the significant health benefits. The studies included in this review
also span large differences in patient population sizes, health indi-
cations, and desired outcomes. In some studies, the objective was
for weight gain, in others it was weight loss, and in another it was
to get patients to actively monitor their calorie intake. To be able
to definitively compare across methodologies and determine effec-
tive strategies for intervention coordinated objectives, standardiza-
tion of methodology, and/or implementation of multiple interven-
tion arms in the same large RCT would be the most scientific ap-
proach.
Several systematic reviews have been conducted to examine
the use of smartphone applications for the dietary and lifestyle
interventions weight loss [5,16,17]. A study by DiFilippo [5] con-
cluded that the smartphone apps are associated with increased
6 R. Paramastri, S.A. Pratama and Dang Khanh Ngan Ho et al. / Computer Methods and Programs in Biomedicine 192 (2020) 105459
nutrition knowledge. Stephens et al. [17] assessed the impact on
reduced weight and increased physical activity. Previous system-
atic review and meta-analysis conducted by Hutchesson et al.
[16] showed that use of several media platforms such as inter-
net, computer, mobile, and smartphone technologies intervention
can promote weight loss. Apparent result was shown in Partridge
et al. [7] study. The 3-month intervention plus 6-month mainte-
nance program was proven successful to reduce weight gain with
weekly personalized calls, text messages and emails. The partic-
ipant was also facilitated by not only smartphone apps, website,
community blog and guideline booklet, so they can remain achieve
their goal to obtain ideal body weight. Personalized calls were also
proven to be effective way as direct way to communicate the mo-
tivational support, provide feedback and also discuss the potential
obstacle during intervention.
Dodd et al. [13] study was specified in pregnant women and
showed significant difference of increase in the Healthy Eat-
ing Index during pregnancy. Although several weaknesses in this
study was low response rate in participant which impact on non-
response bias and also potential recall bias during 24 hour dietary
recall. Nevertheless, this study had no strong evidence to prove the
effect of the nutrition app on participants in pregnant women. Or-
lemann et al. [10] study specifically targeted the tumor patients to
use the four-week OncoFood app. The study finding demonstrated
significant weight and muscle mass increase. However, the analy-
sis failed to explain the insignificant result in reduced of protein
and macronutrients. These papers had some drawbacks, including
lack of participants, unspecific tumor disease, and involvement in
the short period. Nonetheless, the current studies still suggest little
evidence about the effectiveness of nutrition apps usage. Nutrition
apps may be effective and should be further evaluated in more rig-
orous studies with standardized outcomes.
To execute and interpret the good systematic reviews of litera-
ture, a risk of bias assessment needed to be performed as a pre-
dominant step. Risk of bias has been defined as “the likelihood of
inaccuracy in the estimate of causal effect in that study” [18]. Fur-
thermore, conducting risk of bias assessment in the included pri-
mary studies imparts an indication of the quality of available evi-
dence. The tool used in recent review was Quality Criteria Check-
list: Primary Research. It provides a domain-based qualitative de-
scription of critical areas of potential bias in primary studies. Most
studies were considered to be of low to moderate risk when as-
sessed using this tool. In spite of that, a clinical study by Orlemann
et al. [10] failed to provide method to obtain study participants.
Thus, it might incorporate study quality and strength of the evi-
dence [19].
Nevertheless, smartphone apps have several advantages. Cough-
lin et al. [20] discovered that smartphone technologies consider-
ably reduced the burden of using paper-based form to record daily
intake of nutrition. Study by Hebden et al. [21] supported this
finding, smartphone apps found to have the potential to improve
population health, because of their widespread and increasing use,
dynamic technological advancements, and use of existing features
(e.g. internet access, geopositioning technology, as well as photo,
video, and voice recording capabilities), and the potential for re-
ducing intervention delivery costs. Furthermore, although there are
often similarities between apps, particularly focusing on tracking,
there are often key differences, including the ways in which nutri-
tion information is presented and when, whether, and how feed-
back is delivered to the user.
This review has several strengths, including an inclusive search
strategy and using the most recent of Behavior Change Technique
(BCT) taxonomy to evaluate the feasibility, acceptability, and effi-
cacy of behavioral intervention delivered by smartphone technol-
ogy. A recent systematic review examined goal setting as a com-
ponent of behavior strategies specific to weight management, diet,
and physical activity. The use of BCT allows future scientists and
clinicians to review which mobile apps have useful features for be-
havioral changing. In addition, BCT also commonly used in study
aiming to evaluate the change of behavior, including physical ac-
tivity and sedentary behavior, as well as nutrition behavior. Conroy
et al. [22] reported that the information provided in BCT could be
utilized for developing apps to optimize lifestyle health behavior
modification. Thus, incorporating BCT features could lead to bet-
ter engagement and long-term use. Meanwhile, in developing apps,
researchers need to give consideration to the target population in
terms of their access, ability to adopt this form of intervention, and
preferences regarding the design [21].
5. Limitations
The small number of large RCTs was our main limitation in this
systematic review. Another limitation is that studies used multi-
ple objectives as their outcome including knowledge acquisition,
weight loss/gain, and/or app usage (or other arbitrary behavior
changes). Future research should emphasize more in specific pop-
ulation such as cancer patient or pregnant women for clearer ev-
idence. Limited number of participants and participants’ diversity
needs to be considered in the future studies. Future studies also
should include head-to-head comparisons of app versus traditional
method such as counseling rather than mixing the two into single
intervention group.
6. Conclusion
Since mobile app usage becomes increasingly common in gen-
eral population, the potential for improving healthy behavior via
this medium needs exploration to optimize outcomes. This study
showed that mobile app-based interventions can promote various
healthy behaviors including diet and physical activity. Most of the
app interventions reviewed focused on monitoring health status
and behavior change, as well as provide feedback or health-related
information. App programs may be more effective when social sup-
port is advocated and when entertainment functions or visualiza-
tion features are included. Future research should address mobile
app efficacy for health promotion in developing countries and bet-
ter assess what features of app design yield significant healthy be-
havior changes.
Declaration of Competing Interest
The authors declare no conflict of interest.
CRediT authorship contribution statement
Rathi Paramastri: Conceptualization, Data curation, For-
mal analysis, Writing - original draft, Validation, Visualization.
Satwika Arya Pratama: Conceptualization, Data curation, For-
mal analysis, Writing - original draft, Validation, Visualization.
Dang Khanh Ngan Ho: Conceptualization, Writing - review &
editing, Validation, Visualization. Sintha Dewi Purnamasari: Con-
ceptualization, Data curation, Formal analysis, Writing - original
draft, Validation, Visualization. Afrah Zaki Mohammed: Concep-
tualization, Writing - review & editing, Validation, Visualization.
Cooper J Galvin: Validation, Visualization, Writing - review & edit-
ing, Supervision, Resources. Yi-Hsin Elsa Hsu: Conceptualization,
Validation, Visualization, Writing - review & editing, Supervision,
Resources. Afifa Tanweer: Conceptualization, Writing - review
& editing, Validation, Visualization. Ayesha Humayun: Concep-
tualization, Validation, Visualization, Writing - review & editing,
Supervision, Resources. Mowafa Househ: Conceptualization, Val-
idation, Visualization, Writing - review & editing, Supervision,
 R. Paramastri, S.A. Pratama and Dang Khanh Ngan Ho et al. / Computer Methods and Programs in Biomedicine 192 (2020) 105459
Resources. Usman Iqbal: Conceptualization, Validation, Visualiza-
tion, Writing - review & editing, Supervision, Resources.
Acknowledgments
This work was supported by Ministry of Science of Technology
project number MOST107-2218-E-038-004-MY2.
Supplementary materials
Supplementary material associated with this article can be
found, in the online version, at doi:10.1016/j.cmpb.2020.105459.
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