A low-glucose eating pattern is associated with improvements in glycemic variability among women at risk for postmenopausal breast cancer: an exploratory analysis.

Background: High glycemic variability (GV) is a biomarker of cancer risk, even in the absence of diabetes. The emerging concept of chrononutrition suggests that modifying meal timing can favorably impact metabolic risk factors linked to diet-related chronic disease, including breast cancer. Here, we examined the potential of eating when glucose levels are near personalized fasting thresholds (low-glucose eating, LGE), a novel form of timed-eating, to reduce GV in women without diabetes, who are at risk for postmenopausal breast cancer. Methods: In this exploratory analysis of our 16-week weight loss randomized controlled trial, we included 17 non-Hispanic, white, postmenopausal women (average age = 60.7 ± 5.8 years, BMI = 34.5 ± 6.1 kg/m2, HbA1c = 5.7 ± 0.3%). Participants were those who, as part of the parent study, provided 3-7 days of blinded, continuous glucose monitoring data and image-assisted, timestamped food records at weeks 0 and 16. Pearson's correlation and multivariate regression were used to assess associations between LGE and GV, controlling for concurrent weight changes. Results: Increases in LGE were associated with multiple unfavorable measures of GV including reductions in CGM glucose mean, CONGA, LI, J-Index, HBGI, ADDR, and time spent in a severe GV pattern (r = -0.81 to -0.49; ps < 0.044) and with increases in favorable measures of GV including M-value and LBGI (r = 0.59, 0.62; ps < 0.013). These associations remained significant after adjusting for weight changes. Conclusion: Low-glucose eating is associated with improvements in glycemic variability, independent of concurrent weight reductions, suggesting it may be beneficial for GV-related disease prevention. Further research in a larger, more diverse sample with poor metabolic health is warranted.Clinical trial registration: ClinicalTrials.gov, NCT03546972.

Use of Biological Feedback as a Health Behavior Change Technique in Adults: Scoping Review.

BACKGROUND: Recent advancements in personal biosensing technology support the shift from standardized to personalized health interventions, whereby biological data are used to motivate health behavior change. However, the implementation of interventions using biological feedback as a behavior change technique has not been comprehensively explored. OBJECTIVE: The purpose of this review was to (1) map the domains of research where biological feedback has been used as a behavior change technique and (2) describe how it is implemented in behavior change interventions for adults. METHODS: A comprehensive systematic search strategy was used to query 5 electronic databases (Ovid MEDLINE, Elsevier Embase, Cochrane Central Register of Controlled Trials, EBSCOhost PsycINFO, and ProQuest Dissertations & Theses Global) in June 2021. Eligible studies were primary analyses of randomized controlled trials (RCTs) in adults that incorporated biological feedback as a behavior change technique. DistillerSR was used to manage the literature search and review. RESULTS: After removing 49,500 duplicates, 50,287 articles were screened and 767 articles were included. The earliest RCT was published in 1972 with a notable increase in publications after 2000. Biological feedback was most used in RCTs aimed at preventing or managing diabetes (n=233, 30.4%), cardiovascular disease (n=175, 22.8%), and obesity (n=115, 15%). Feedback was often given on multiple biomarkers and targeted multiple health behaviors. The most common biomarkers used were anthropometric measures (n=297, 38.7%), blood pressure (n=238, 31%), and glucose (n=227, 29.6%). The most targeted behaviors were diet (n=472, 61.5%), physical activity (n=417, 54.4%), and smoking reduction (n=154, 20.1%). The frequency and type of communication by which biological feedback was provided varied by the method of biomarker measurement. Of the 493 (64.3%) studies where participants self-measured their biomarker, 476 (96.6%) received feedback multiple times over the intervention and 468 (94.9%) received feedback through a biosensing device. CONCLUSIONS: Biological feedback is increasingly being used to motivate behavior change, particularly where relevant biomarkers can be readily assessed. Yet, the methods by which biological feedback is operationalized in intervention research varied, and its effectiveness remains unclear. This scoping review serves as the foundation for developing a guiding framework for effectively implementing biological feedback as a behavior change technique. TRIAL REGISTRATION: Open Science Framework Registries; https://doi.org/10.17605/OSF.IO/YP5WAd. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/32579.

Exploring the Impact of Dawn Phenomenon on Glucose-Guided Eating Thresholds in Individuals With Type 2 Diabetes Using Continuous Glucose Monitoring: Observational Study.

BACKGROUND: Glucose-guided eating (GGE) improves metabolic markers of chronic disease risk, including insulin resistance, in adults without diabetes. GGE is a timed eating paradigm that relies on experiencing feelings of hunger and having a preprandial glucose level below a personalized threshold computed from 2 consecutive morning fasting glucose levels. The dawn phenomenon (DP), which results in elevated morning preprandial glucose levels, could cause typically derived GGE thresholds to be unacceptable or ineffective among people with type 2 diabetes (T2DM). OBJECTIVE: The aim of this study is to quantify the incidence and day-to-day variability in the magnitude of DP and examine its effect on morning preprandial glucose levels as a preliminary test of the feasibility of GGE in adults with T2DM. METHODS: Study participants wore a single-blinded Dexcom G6 Pro continuous glucose monitoring (CGM) system for up to 10 days. First and last eating times and any overnight eating were reported using daily surveys over the study duration. DP was expressed as a dichotomous variable at the day level (DP day vs non-DP day) and as a continuous variable reflecting the percent of days DP was experienced on a valid day. A valid day was defined as having no reported overnight eating (between midnight and 6 AM). ∂ Glucose was computed as the difference in nocturnal glucose nadir (between midnight and 6 AM) to morning preprandial glucose levels. ∂ Glucose ≥20 mg/dL constituted a DP day. Using multilevel modeling, we examined the between- and within-person effects of DP on morning preprandial glucose and the effect of evening eating times on DP. RESULTS: In total, 21 adults (59% female; 13/21, 62%) with non-insulin-treated T2DM wore a CGM for an average of 10.5 (SD 1.1) days. Twenty out of 21 participants (95%) experienced DP for at least 1 day, with an average of 51% of days (SD 27.2; range 0%-100%). The mean ∂ glucose was 23.7 (SD 13.2) mg/dL. People who experience DP more frequently had a morning preprandial glucose level that was 54.1 (95% CI 17.0-83.9; P<.001) mg/dL higher than those who experienced DP less frequently. For within-person effect, morning preprandial glucose levels were 12.1 (95% CI 6.3-17.8; P=.008) mg/dL higher on a DP day than on a non-DP day. The association between ∂ glucose and preprandial glucose levels was 0.50 (95% CI 0.37-0.60; P<.001). There was no effect of the last eating time on DP. CONCLUSIONS: DP was experienced by most study participants regardless of last eating times. The magnitude of the within-person effect of DP on morning preprandial glucose levels was meaningful in the context of GGE. Alternative approaches for determining acceptable and effective GGE thresholds for people with T2DM should be explored and evaluated.

Using Biological Feedback to Promote Health Behavior Change in Adults: Protocol for a Scoping Review.

BACKGROUND: Many health conditions can be prevented, managed, or improved through behavioral interventions. As a component of health behavior change interventions, biological feedback is of particular interest given recent advances in wearable biosensing technology, digital health apps, and personalized health and wellness. Nevertheless, there is a paucity of literature to guide the design and implementation of interventions that incorporate biological feedback to motivate health behavior change. OBJECTIVE: The goal of this scoping review is to deeply explore the use of biological feedback as a component of health behavior change interventions that target adults. The objectives of the review include (1) mapping the domains of research that incorporate biological feedback and (2) describing the operational characteristics of using biological feedback in the context of health behavior change. METHODS: A comprehensive list of search terms was developed to capture studies from a wide range of domains. The studies to be included are randomized controlled trials published as primary research articles, theses, or dissertations targeting adults 18 years and older, who use biological feedback to change a health-related behavior. The following electronic databases were searched: Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, EBSCOhost, PsycINFO, and ProQuest Dissertations & Theses Global. The screening and data extraction process will be guided by the Joanna Briggs Institute Manual for Evidence Synthesis and conducted by trained reviewers. RESULTS: Database searches were completed in June 2021. A total of 50,459 unique records were returned after the removal of 48,634 duplicate records. The scoping review is planned for completion in 2022. CONCLUSIONS: To our knowledge, this will be the first scoping review to map the literature that uses biological feedback as a component of health behavior change interventions targeting adults. The findings will be used to develop a framework to guide the design and implementation of future health behavior change interventions that incorporate biological feedback. TRIAL REGISTRATION: OSF Registries OSF.IO/YP5WA; https://osf.io/yp5wa. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/32579.

Hunger Training as a Self-regulation Strategy in a Comprehensive Weight Loss Program for Breast Cancer Prevention: A Randomized Feasibility Study.

Weight losses >10% favorably modulate biomarkers of breast cancer risk but are not typically achieved by comprehensive weight loss programs, including the Diabetes Prevention Program (DPP). Combining the DPP with hunger training (HT), an evidence-based self-regulation strategy that uses self-monitored glucose levels to guide meal timing, has potential to enhance weight losses and cancer-related biomarkers, if proven feasible. This two-arm randomized controlled trial examined the feasibility of adding HT to the DPP and explored effects on weight and metabolic and breast cancer risk biomarkers. Fifty postmenopausal women [body mass index (BMI) >27 kg/m2)] at risk of breast cancer were randomized to the DPP+HT or DPP-only arm. Both arms followed a 16-week version of the DPP delivered weekly by a trained registered dietitian. Those in the DPP+HT also wore a continuous glucose monitor during weeks 4-6 of the program. Feasibility criteria were accrual rates >50%, retention rates >80%, and adherence to the HT protocol >75%. All a priori feasibility criteria were achieved. The accrual rate was 67%, retention rate was 81%, and adherence to HT was 90%. Weight losses and BMI reductions were significant over time as were changes in metabolic and breast cancer risk biomarkers but did not vary by group. This trial demonstrated that HT was feasible to add to comprehensive weight management program targeted toward postmenopausal women at high risk of breast cancer, though upon preliminary examination it does not appear to enhance weight loss or metabolic changes. PREVENTION RELEVANCE: This study found that it was feasible to add a short glucose-guided eating intervention to a comprehensive weight management program targeting postmenopausal women at high risk of breast cancer. However, further development of this novel intervention as a cancer prevention strategy is needed.

A Low-Glucose Eating Pattern Improves Biomarkers of Postmenopausal Breast Cancer Risk: An Exploratory Secondary Analysis of a Randomized Feasibility Trial.

Postmenopausal breast cancer is the most common obesity-related cancer death among women in the U.S. Insulin resistance, which worsens in the setting of obesity, is associated with higher breast cancer incidence and mortality. Maladaptive eating patterns driving insulin resistance represent a key modifiable risk factor for breast cancer. Emerging evidence suggests that time-restricted feeding paradigms (TRF) improve cancer-related metabolic risk factors; however, more flexible approaches could be more feasible and effective. In this exploratory, secondary analysis, we identified participants following a low-glucose eating pattern (LGEP), defined as consuming energy when glucose levels are at or below average fasting levels, as an alternative to TRF. Results show that following an LGEP regimen for at least 40% of reported eating events improves insulin resistance (HOMA-IR) and other cancer-related serum biomarkers. The magnitude of serum biomarkers changes observed here has previously been shown to favorably modulate benign breast tissue in women with overweight and obesity who are at risk for postmenopausal breast cancer. By comparison, the observed effects of LGEP were similar to results from previously published TRF studies in similar populations. These preliminary findings support further testing of LGEP as an alternative to TRF and a postmenopausal breast cancer prevention strategy. However, results should be interpreted with caution, given the exploratory nature of analyses.

Teaching people to eat according to appetite - Does the method of glucose measurement matter?

BACKGROUND: Hunger training teaches people to eat according to their appetite using pre-prandial glucose measurement. Previous hunger training interventions used fingerprick blood glucose, however continuous glucose monitoring (CGM) offers a painless and convenient form of glucose monitoring. The aim of this randomised feasibility trial was to compare hunger training using CGM with fingerprick glucose monitoring in terms of adherence to the protocol, acceptability, weight, body composition, HbA1c, psychosocial variables, and the relationship between adherence measures and weight loss. METHODS: 40 adults with obesity were randomised to either fingerpricking or scanning with a CGM and followed identical interventions for 6 months, which included 1 month of only eating when glucose was under their individualised glucose cut-off. For months 2-6 participants relied on their sensations of hunger to guide their eating and filled in a booklet. RESULTS: 90% of the fingerpricking group and 85% of the scanning group completed the study. Those using the scanner measured their glucose an extra 1.9 times per day (95% CI 0.9, 2.8, p < 0.001) compared with those testing by fingerprick. Both groups lost similar amounts of weight over 6 months (on average 4 kg), were satisfied with the hunger training program and wanted to measure their glucose again within the next year. There were no differences between groups in terms of intervention acceptability, weight, body composition, HbA1c, eating behaviours, or psychological health. Frequency of glucose testing and booklet entry both predicted a clinically meaningful amount of weight loss. CONCLUSIONS: Either method of measuring glucose is effective for learning to eat according to hunger using the hunger training program. As scanning with a CGM encouraged better adherence to the protocol without sacrificing outcome results, future interventions should consider using this new technology in hunger training programs.

Translating hunger training research to primary health: a qualitative study of nurse attitudes towards a novel weight management intervention.

INTRODUCTION Practice nurses in general practice are ideally placed to deliver weight management treatments. Teaching people to eat according to their appetite, based on measurements of blood glucose ('hunger training'), is known to lead to weight loss and improved eating behaviour. To effectively translate this research to primary care requires understanding of key stakeholder perspectives. AIM The aim of this study was to explore the perspectives of practice nurses on the suitability of using hunger training as a weight management intervention in general practice. METHODS Ten nurses trialled hunger training for 1 week, followed by a semi-structured interview where they were asked about their experience; perceived patient interest; enablers and barriers; and suggested changes to hunger training. RESULTS All nurses were positive about hunger training and wanted to use it with their patients. They thought it was a useful method for teaching patients about eating according to their appetite, and the impact of food choices on glucose. Motivation was seen to be both an important potential barrier and enabler for patients. Other anticipated patient enablers included the educational value of hunger training and ease of the programme. Other barriers included lack of time and cost of equipment and appointments. For most nurses, 1 week of following hunger training was sufficient training to deliver the intervention. Suggested refinements included adding nutrition advice to the booklet, incorporating other health goals and enabling social support. DISCUSSION These findings suggest that hunger training could be translated to primary care with minor modifications.

Intermittent fasting, Paleolithic, or Mediterranean diets in the real world: exploratory secondary analyses of a weight-loss trial that included choice of diet and exercise.

BACKGROUND: Intermittent fasting (IF) and Paleolithic (Paleo) diets produce weight loss in controlled trials, but minimal evidence exists regarding long-term efficacy under free-living conditions without intense dietetic support. OBJECTIVES: This exploratory, observational analysis examined adherence, dietary intake, weight loss, and metabolic outcomes in overweight adults who could choose to follow Mediterranean, IF, or Paleo diets, and standard exercise or high-intensity interval training (HIIT) programs, as part of a 12-mo randomized controlled trial investigating how different monitoring strategies influenced weight loss (control, daily self-weighing, hunger training, diet/exercise app, brief support). METHODS: A total of 250 overweight [BMI (in kg/m2) ≥27] healthy adults attended an individualized dietary education session (30 min) relevant to their self-selected diet. Dietary intake (3-d weighed diet records), weight, body composition, blood pressure, physical activity (0, 6, and 12 mo), and blood indexes (0 and 12 mo) were assessed. Mean (95% CI) changes from baseline were estimated using regression models. No correction was made for multiple tests. RESULTS: Although 54.4% chose IF, 27.2% Mediterranean, and 18.4% Paleo diets originally, only 54% (IF), 57% (Mediterranean), and 35% (Paleo) participants were still following their chosen diet at 12 mo (self-reported). At 12 mo, weight loss was -4.0 kg (95% CI: -5.1, -2.8 kg) in IF, -2.8 kg (-4.4, -1.2 kg) in Mediterranean, and -1.8 kg (-4.0, 0.5 kg) in Paleo participants. Sensitivity analyses showed that, due to substantial dropout, these may be overestimated by ≤1.2 kg, whereas diet adherence increased mean weight loss by 1.1, 1.8, and 0.3 kg, respectively. Reduced systolic blood pressure was observed with IF (-4.9 mm Hg;  -7.2, -2.6 mm Hg) and Mediterranean (-5.9 mm Hg; -9.0, -2.7 mm Hg) diets, and reduced glycated hemoglobin with the Mediterranean diet (-0.8 mmol/mol; -1.2, -0.4 mmol/mol). However, the between-group differences in most outcomes were not significant and these comparisons may be confounded due to the nonrandomized design. CONCLUSIONS: Small differences in metabolic outcomes were apparent in participants following self-selected diets without intensive ongoing dietary support, even though dietary adherence declined rapidly. However, results should be interpreted with caution given the exploratory nature of analyses. This trial was registered with the Australian New Zealand Clinical Trials Registry as ACTRN12615000010594 at https://www.anzctr.org.au.

A tool for assessing the satisfaction of a diet: Development and preliminary validation of the Diet Satisfaction Score.

AIM: Adherence to dietary change is crucial for long-term benefit and a key element of adherence is the satisfaction of a given diet. We aimed to develop a brief questionnaire, suitable for use in clinical practice that can assess satisfaction with a diet, and to conduct preliminary evaluation of its reliability and validity. METHODS: The questionnaire was developed and drafts were sent to two expert panels for content review. The final questionnaire was assessed for internal consistency, face and construct validity, and test-retest reliability. Expert feedback was provided by nine clinicians/researchers. The tool was assessed in three phases in different international populations who were recruited using social media. It included adults who were currently following a diet (total n = 1604), and those who had recently abandoned their diet (phase 3 only). RESULTS: The Diet Satisfaction Score consisted of 10 items measuring one dimension (Cronbach's alpha = 0.85), and participants had a mean total Diet Satisfaction Score of 3.7 (SD = 0.50) from a possible range of 1 to 5. Test-retest reliability was good as indicated by an intraclass correlation coefficient of 0.64 and a mean difference (95% confidence interval, CI) between repeated test scores of 0.03 (-0.02, 0.09). Each 1-point increase in Diet Satisfaction Score was associated with longer diet duration by 1.7 weeks (95% CI = 1.5, 2.0, P < .001). CONCLUSIONS: The Diet Satisfaction Score showed good reliability and preliminary validity and may be a useful clinical tool for assessing diet satisfaction and has the potential to predict adherence.

'Am I really hungry?' A qualitative exploration of patients' experience, adherence and behaviour change during hunger training: a pilot study.

OBJECTIVES: Hunger training (HT) is an intervention designed to teach people to eat according to their hunger by connecting physical symptoms of appetite with glucose levels. HT is most effective for weight loss, and improving eating behaviours when adherence is high. However, adherence is a challenge that should be explored prior to wider dissemination. The aim of this study was to explore participants' experience and self-reported adherence and behaviour change related to HT. DESIGN: A qualitative study, nested within a randomised controlled pilot study of two different methods of monitoring glucose during HT. Semistructured interviews were audio-recorded, transcribed verbatim and analysed thematically using a phenomenological approach. SETTING: Single-centre study with participants recruited from the local area. PARTICIPANTS: 40 participants began the pilot study and 38 participants (52.6% women) remained at 1 month and completed interviews. RESULTS: Most participants felt they were able to match their hunger to their glucose levels by the end of the intervention. The main adherence barriers were the social pressure to eat, lack of time and lack of flexibility in participants' meal schedules. Common adherence enablers were having a set routine, social support and accountability. Participants described increased awareness of hungry versus non-hungry eating and better cognition of feelings of hunger and satiety as a result of the intervention, which in turn led to changes of food choice, portion size and adjusted meal timing and frequency. CONCLUSIONS: Findings show that HT is acceptable from a patient perspective, and results can be used to inform the translation of HT programme to healthcare settings. TRIAL REGISTRATION NUMBER: ACTRN12618001257257.

Adherence to Hunger Training over 6 Months and the Effect on Weight and Eating Behaviour: Secondary Analysis of a Randomised Controlled Trial.

Monitoring blood glucose prior to eating can teach individuals to eat only when truly hungry, but how adherence to 'hunger training' influences weight loss and eating behaviour is uncertain. This exploratory, secondary analysis from a larger randomized controlled trial examined five indices of adherence to 'hunger training', chosen a priori, to examine which adherence measure best predicted weight loss over 6 months. We subsequently explored how the best measure of adherence influenced eating behavior in terms of intuitive and emotional eating. Retention was 72% (n = 36/50) at 6 months. Frequency of hunger training booklet entry most strongly predicted weight loss, followed by frequency of blood glucose measurements. Participants who completed at least 60 days of booklet entry (of recommended 63 days) lost 6.8 kg (95% CI: 2.6, 11.0; p < 0.001) more weight than those who completed fewer days. They also had significantly higher intuitive eating scores than those who completed 30 days or less of booklet entry; a difference (95% CI) of 0.73 (0.12, 1.35) in body-food choice congruence and 0.79 (0.06, 1.51) for eating for physical rather than emotional reasons. Adherent participants also reported significantly lower scores for emotional eating of -0.70 (-1.13, -0.27). Following hunger training and focusing on simply recording ratings of hunger on a regular basis can produce clinically significant weight loss and clinically relevant improvements in eating behaviour.

The Effect of Different Types of Monitoring Strategies on Weight Loss: A Randomized Controlled Trial.

OBJECTIVE: To determine the effectiveness of various monitoring strategies on weight loss, body composition, blood markers, exercise, and psychosocial indices in adults with overweight and obesity following a 12-month weight loss program. METHODS: Two hundred fifty adults with BMI ≥ 27 were randomized to brief, monthly, individual consults, daily self-monitoring of weight, self-monitoring of diet using MyFitnessPal, self-monitoring of hunger, or control over 12 months. All groups received diet and exercise advice, and 171 participants (68.4%) remained at 12 months. RESULTS: No significant differences in weight, body composition, blood markers, exercise, or eating behavior were apparent between those in the four monitoring groups and the control condition at 12 months (all P ≥ 0.053). Weight differences between groups ranged from -1.1 kg (-3.8 to 1.6) to 2.2 kg (-1.0 to 5.3). However, brief support and hunger training groups reported significantly lower scores for depression (difference [95% CI]: -3.16 [-5.70 to -0.62] and -3.05 [-5.61 to -0.50], respectively) and anxiety (-1.84, [-3.67 to -0.02]) scores than control participants. CONCLUSIONS: Although adding a monitoring strategy to diet and exercise advice did not further increase weight loss, no adverse effects on eating behavior were observed, and some monitoring strategies may even benefit mental health.

Determining how best to support overweight adults to adhere to lifestyle change: protocol for the SWIFT study.

BACKGROUND: Physical activity plays a critical role in health, including for effective weight maintenance, but adherence to guidelines is often poor. Similarly, although debate continues over whether a "best" diet exists for weight control, meta-analyses suggest little difference in outcomes between diets differing markedly in macronutrient composition, particularly over the longer-term. Thus a more important question is how best to encourage adherence to appropriate lifestyle change. While brief support is effective, it has on-going cost implications. While self-monitoring (weight, diet, physical activity) is a cornerstone of effective weight management, little formal evaluation of the role that self-monitoring technology can play in enhancing adherence to change has occurred to date. People who eat in response to hunger have improved weight control, yet how best to train individuals to recognise when true physical hunger occurs and to limit consumption to those times, requires further study. METHODS/DESIGN: SWIFT (Support strategies for Whole-food diets, Intermittent Fasting, and Training) is a two-year randomised controlled trial in 250 overweight (body mass index of 27 or greater) adults that will examine different ways of supporting people to make appropriate changes to diet and exercise habits for long-term weight control. Participants will be randomised to one of five intervention groups: control, brief support (monthly weigh-ins and meeting), app (use of MyFitnessPal with limited support), daily self-weighing (with brief monthly feedback), or hunger training (four-week programme which trains individuals to only eat when physically hungry) for 24 months. Outcome assessments include weight, waist circumference, body composition (dual-energy x-ray absorptiometry), inflammatory markers, blood lipids, adiponectin and ghrelin, blood pressure, diet (3-day diet records), physical activity (accelerometry) and aerobic fitness, and eating behaviour. SWIFT is powered to detect clinically important differences of 4 kg in body weight and 5 cm in waist circumference. Our pragmatic trial also allows participants to choose one of several dietary (Mediterranean, modified Paleo, intermittent fasting) and exercise (current recommendations, high-intensity interval training) approaches before being randomised to a support strategy. DISCUSSION: SWIFT will compare four different ways of supporting overweight adults to lose weight while following a diet and exercise plan of their choice, an aspect we believe will enhance adherence and thus success with weight management. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12615000010594. Registered 8th January 2015.

Diet app use by sports dietitians: a survey in five countries.

BACKGROUND: Despite the hundreds of diet apps available for use on smartphones (mobile phones), no studies have examined their use as tools for dietary assessment and tracking in sports nutrition. OBJECTIVE: The aim is to examine the prevalence and perceptions of using smartphone diet apps for dietary assessment and tracking among sports dietitians. METHODS: A cross-sectional online survey to examine the use and perception of diet apps was developed and distributed to sports dietitians in Australia, Canada, New Zealand, the United Kingdom, and the United States (US). RESULTS: The overall response rate from the 1709 sports dietitians invited to participate was 10.3% (n=180). diet apps were used by 32.4% (57/176) of sports dietitians to assess and track the dietary intake of athletes. Sports dietitians from the US were more likely to use smartphone diet apps than sports dietitians from other countries (OR=5.61, 95% CI 1.84-17.08, P=.002). Sports dietitians used 28 different diet apps, with 56% (32/57) choosing MyFitnessPal. Overall, sports dietitians held a positive perception of smartphone diet apps, with the majority of respondents viewing diet apps as "better" (25/53, 47%) or "equivalent" (22/53, 41%) when compared with traditional dietary assessment methods. CONCLUSIONS: Nearly one-third of sports dietitians used mobile phone diet apps in sports nutrition practice, and viewed them as useful in helping to assess and track the dietary intake of athletes.