14. Let Food Be Your Medicine

The majority of interventions to change dietary behaviours are normally applied homogenously across different population groups (e.g. “eat five servings of fruits and vegetables a day”), and, have had limited success (Ordovas et al., 2018[1]; Marsaux et al., 2015[2]; Fallaize et al., 2013[3]). However, in recent years, there has been a growth in personalised nutrition (PN) which uses “individual specific information, founded in evidence-based science, to promote dietary behaviour change resulting in better health outcomes” (Adams et al., 2019[4]). The rise in the use of PN is a result of (Ordovas et al., 2018[1]; Forster et al., 2016[5]):

  • A better understanding of how diets impact overall health, including at the individual level

  • Advances in technology that enable people to record and measure their dietary intake with relative ease

  • Developments in data analytics enabling information to be readily converted into useful information.

Let Food be Your Medicine (hereafter, LFYM) is a privately run mobile- and web-based online tool designed to provide personalised nutritional advice for both prevention and treatment purposes. To operate the tool, users upload information regarding:

  • Diet: information on diet is collected using the Food4Me food frequency questionnaire covering 157 food items divided into 11 groups (e.g. “meat and fish”, “dairy products”, and “sweets and snacks”). Against each food time, users are asked to report how often the item was consumed using a nine-point scale ranging from “never” to “6+ a day”, as well as portion size based on a series of pictures (Forster et al., 2014[6]).

  • Genetic information: participants have the option to purchase a nutrigenetic test, which includes a swab tests. Results from the swab are then analysed with results provide online (Nutricare, 2020[7]). Alternatively, genetic information can be collected from a blood or urine sample.

  • Medical history: users have the opportunity to directly upload information regarding medical conditions.

  • Calories, body composition and physical activity: users have the option of uploading information from wearable and other digital devices to track performance. Key examples including physical activity and calorie trackers, as well data from smart scales.1

Using this information, the tool compares nutritional intake with recommended levels provided by the European Food Safety Agency (see Figure 14.1 for example output). Findings from the comparative assessment are used to develop recommendations on how to address any identified nutritional deficiencies or above standard nutrient amounts through a change in diet (i.e. what foods to eat more/less of) and/or supplements (NutriCare, 2019[8]).2 Recommendations provided by the tool are supported by clinical studies published within the academic literature (NutriCare, 2019[8]). Alternatively, upon receiving results, users can book an appointment with their health care provider or nutritionist to discuss changes to their diet.

LFYM is currently undergoing a testing phase where it has been made available to 300 people in Romania. Once publically available, the standard version will be made available for free and the premium version at a cost between EUR 1-5/month (USD PPP 1.5-7.3) for individuals and EUR 5-10/month (USD PPP 7.3-14.6) for nutritionists (NutriCare, 2019[8]).

Data from the LFYM isn’t available given the intervention is currently in its testing phase. For this reason, the OECD Best Practice Identification Framework (OECD Framework) was used to assess digital PN interventions more broadly (see Box 14.1 for a high-level assessment of digital PN interventions). Consequently, results from the assessment should only be taken as an indication of how LFYM may perform once rolled-out nationally. Further details on the OECD Framework can be found in Annex A.

Smartphone penetration is growing across the world. As of 2017, 80% of the population in high-income countries owned a smartphone with this figure increasing to 82% for low and middle-income countries (Deloitte, 2017[9]). Mobile phone apps therefore present a promising opportunity to promote healthy lifestyles on a large scale. For example, modelling work by OECD estimated mobile apps targeting diet and physical activity over the period 2020-2050 will lead to an additional 3.38 life years gained per 100 000 people in Romania (where LFYM is implemented), which was second highest amongst the 36 countries analysed (OECD, 2019[10]). In terms of specific diseases, over the same time period, the model estimates mobile apps could avoid 760 CVDs and 121 diabetes cases in Romania (OECD, 2019[10]).

Advances in technology (e.g. machine learning) partnered with the growing use of smartphone has led to a growth in the use of PN advice. The evidence on PN dates back many years with Kroeze et al., in (2006[11]), summarising key findings from a systematic review of computer-tailored interventions targeted physical activity and dietary behaviour. Their analysis revealed that of the 26 randomised control trials (RCTs) regarding PN, 20 showed statistically significant, positive effects, in particular regarding a reduction in fat intake (Kroeze, Werkman and Brug, 2006[11]). More recently, Forster and colleagues (2016[5]) reviewed the evidence on the impact of PN tools delivered online (web-based), via mobiles as well as through wearable sensor technologies. In total, results from seven RCTs were summarised, four of which recorded significant effects associated with PN:

  • Sternfeld et al. (2009[12]) found individuals participating in a 16-week tailored healthy eating and physical exercise plan offered online led to a reduction in consumption of trans-fats and saturated fats, and an increase in fruit and vegetable consumption, when compared to the control group. Specifically, four-months post the intervention, the intervention group consumed 0.29 and 0.75 grammes less of trans-fats and saturated fats, and 0.35 additional cups of fruits and vegetables per day (Sternfeld et al., 2009[12]). Individuals, who, at baseline, did not meet recommended dietary targets, saw the greatest improvement.

  • Springvloet et al. (2015[13]) evaluated the short- and medium-term efficacy of a web-based programme offering tailored nutrition education based on self-reported consumption of fruits, vegetables, high-energy snacks and fat intake. Results from the study found when compared to the provision of generic nutrition information, those who received PN reduced their fat intake and high-energy snacks by more (-0.28 fat points and -0.20 high-energy snacks per day, four-months post the intervention) (Springvloet et al., 2015[13]).

  • Maes et al. (2011[14]) evaluated the impact of Food-O-Meter, an online tool offering tailored nutritional advice to those aged between 12-17 years. The study reported modest findings, with fat intake falling for those who are overweight in the intervention group compared to those in the control group.

  • Ambeba et al. (2015[15]) examined the impact of daily-feedback-messages (DFM) to changes in dietary intake using a two-year RCT involving obese participants. Findings from the RCT indicate those who receive DFM, compared to those who do not, reduce their mean percentage energy intake (-22.8% versus -14%, respectively) and fat intake (-10.4% versus -4.7%, respectively) after 24-months.

Forster et al. (2016[5]) also included the Food4Me study, which represents the most comprehensive PN RCT, to date (Celis-Morales et al., 2017[16]). The Food4Me “proof of principle” study was an internet-based 6-month RCT to assess the impact of PN compared to standard population advice. Participants in the study were divided into one of four groups: group 1) general dietary advice based on European population guidelines; group 2) PN based on individual dietary intake data; group 3) PN based on individual dietary intake and phenotypic data;3 and group 4) PN based on individual dietary intake, and phenotypic and genotypic data (Celis-Morales et al., 2017[16]).

Results from the study found those who received PN (i.e. groups 2-4) saw improvements in salt and folate intake when compared to group 1. Specifically, the difference in mean change of salt intake for group 2-4 and group 1 was 0.65 grammes/day, and 29.6µg/day regarding folate consumption (Celis-Morales et al., 2017[16]). The impact of the intervention on other indicators such as fruit and vegetable consumption, waist circumference and BMI also showed positive effects, however, these were not statistically significant (Celis-Morales et al., 2017[16]).

Effectiveness information outlined in this section is largely based on interventions offering PN using self-reported food frequency questionnaires (FFQs). Conversely, LFYM uses genetic information as well as FFQs, therefore, the effectiveness of the LFYM may differ.

The economic impact of mobile apps promoting healthy lifestyles (through improved diet and physical activity) was recently modelled by OECD (2019[10]). Overall, the analysis concluded mHealth apps are efficient given they reduce labour costs such as absenteeism and presenteeism. For example, in Romania, it is estimated mHealth apps will lead to labour cost savings of USD 4 PPP per capita (EUR 3.64) annually (OECD, 2019[10]).

Regarding PN interventions specifically, a number of studies evaluated efficiency exist, however, few specifically refer to interventions offering tailored dietary advice based on genetic information (Laddu and Hauser, 2019[17]). Dalziel and Segal (2007[18]) evaluated the economic performance of 10 nutrition interventions, two of which offered PN advice (“Intensive Lifestyle Change to Prevent Diabetes”, considered to have “high-quality evidence” and “Nurse Counselling in GP [General Practice]” with “intermediate quality evidence”). Results from their analysis found both interventions were cost-effective, specifically, Intensive Lifestyle Change to Prevent Diabetes was highly cost-effective with a cost per QALY of USD 1 410 (or EUR 1 2834). Results for Nurse Counselling in GP were expressed as an incremental cost-effectiveness ratio with one additional percentage point of participants eating more than five servings of fruits and vegetables per day costing USD 4 300 (or EUR 3 914). More recently, a systematic review of the cost-effectiveness of personalised interventions with a nutrition component found of the 49 studies analysed, over 70% were cost-effective (Milanne Galekop, 2019[19]).

LFYM is offered online or via a mobile-based app at a cost of between EUR 1-5 (USD PPP 1.5-7.3) per month (a pared-down version offering standard as opposed to personalised advice is available for free). When the programme is rolled-out nationally, it will be available to everyone with access to a smartphone or the internet.

Previous analyses of mHealth users indicate they are popular among younger, higher-educated populations (Bol, Helberger and Weert, 2018[20]; Azzopardi-Muscat and Sørensen, 2019[21]), therefore, they potentially exacerbate existing health inequities by restricting access to groups in society that would benefit most (Oliveira Hashiguchi, 2020[22]; Jarke, 2018[23]). For example, research undertaken by OECD estimated adults in the highest income quartile are 50% more likely to use the internet to research health information, compared to adults in the lowest income quartile (OECD, 2019[24]). Other groups less likely to use digital health interventions include older populations and those living in rural areas due to factors such as cost (e.g. pay for a smartphone), lower e-health literacy skills and limited broadband access (Bol, Helberger and Weert, 2018[20]; Azzopardi-Muscat and Sørensen, 2019[21]; Oliveira Hashiguchi, 2020[22]).

The impact of LFYM has not been evaluated as the intervention is in its infancy. Therefore an assessment of the quality of evidence used to evaluate LFYM is not possible. Instead, the evidence-based section assesses the quality of the Food4Me Study, which represents the most comprehensive research into PN to date (see Table 14.2) (Celis-Morales et al., 2017[16]).

The Food4Me proof-of-principle study utilised a four-arm, web-based RCT across seven European countries to evaluate the impact of different levels of PN on a range of health outcomes. Specifically, the 1 607 eligible participants were randomly allocated into one of the four groups: 1) general dietary advice based on European population guidelines; 2) PN based on individual dietary intake data; 3) PN based on individual dietary intake and phenotypic data;5 or 4) PN based on individual dietary intake, and phenotypic and genotypic data (Celis-Morales et al., 2017[16]).

Using the Quality Assessment Tool for Quantitative Studies, the Food4Me study is rated as having a strong study design (i.e. RCT) and data collection methods (i.e. the Food Frequency Questionnaire was used to measure to dietary intake which was the primary outcome). However, the study was not blinded and seemingly did not adequately control for potential confounders (e.g. socio-economic status), therefore the study was rated as “weak” in these areas (Effective Public Health Practice Project, 1998[25]).

At this stage, the extent of coverage of LFYM is unknown. Estimates of potential participation and dropout rates therefore rely on previous studies of similar interventions.

Research undertaken by OECD revealed around 2.2% of the adult population (15-64 years) use mobile apps to improve their health (Goryakin et al., 2017[26]). Regarding dropout rates, previous research from the Food4Me study in Europe revealed a dropout rate of approximately 20%, depending on user demographics (e.g. the Food4Me study reported female and participants with obesity were 38% and 125% more likely to dropout, respectively) (Livingstone et al., 2017[27]).

Based on the research summarised above, LFYM could expect a participation rate of approximately 2% and a dropout rate of 20%, depending on the population group.

LFYM is an evidence-based PN intervention aimed at preventing as well as addressing current health problems using latest available technology. The intervention is in its infancy having only been trialled with 300 participants based in Romania. Therefore, data on best practice indicators such as effectiveness, efficiency and equity are not yet available. For this reason, policy options to enhance implementation have been developed based on a “gap analysis” comparing facilitators and barriers to success of similar interventions compared to the design of LFYM.

A review of digital PN and other lifestyle interventions revealed a number of key success factors for enhancing effectiveness, many of which are already adopted by LFYM. These include a range of behavioural change techniques and social support mechanisms (see Box 14.2 for further details). Based on a gap analysis comparing these factors against the design of LFYM, several options to enhance effectiveness could be considered:

  • A new feature being launched in 2021 allowing users to interact with one another online6 is highly encouraged given the proven benefits associated with people feeling supported and part of a community (Hwang et al., 2010[28]). Since a wide range of users will access the online forum (i.e. with different health issues and goals), to maximise the potential of an forum/discussion group, a feature allowing users to more readily connect with others “in the same boat” may be beneficial (e.g. a filtering system allowing users to identify others aiming to lose weight).

  • The types of information uploaded by participants into the app/web-based portal could be extended to include other risk factors such as alcohol and tobacco consumption (data on physical activity is already allowed through wearable technologies). By self-monitoring consumption of alcohol and tobacco, participants may be more motivated to reduce consumption. However, there are risks associated with uploading personal information, which must be considered. This topic is discussed in further detail under “Enhancing extent of coverage”.

  • Users who upload information from their wearable device (e.g. smart scales, and calorie and physical activity trackers) can track their performance in meeting specific goals on a frequent basis. To further motivate users, consideration could be given to providing users with either tailored or generic messages to maintain motivation, including to those who do not have access to wearable devices. For example, providing email or text messages to users when they reach a milestone towards achieving their set goal or when they have recorded improvement in their behaviour such as a consistent increase in daily physical activity. The literature indicates messaging should be frequent and be updated regularly, however, it is important that users have the option to reduce messaging as it may cause fatigue (Livingstone et al., 2017[27]).

Higher levels of population health literacy (HL) will enhance the effectiveness of mHealth apps, such as LFYM. HL refers to an “individual’s knowledge, motivation and skills to access, understand, evaluate and apply health information” (Moreira, 2018[35]). When people are health literate they are more likely to act on health information they receive, take greater responsibility for their own health, as well as engage in shared decision-making. Example strategies to boost HL have been outlined in a recent OECD report and include specific actions such as encouraging HL in schools and workplaces, as well as broader efforts to better measure and monitor changes in HL levels (Moreira, 2018[35]).

Improving digital HL, for users and health professionals, will also enhance the effectiveness of LFYM. For health professionals, this can be achieved by: developing digital health competency frameworks; developing concrete guidelines on how to integrate digital health topics into educational and training; and integrating digital skills into continuous professional development programs (OECD, 2019[24]).

Efficiency is calculated by obtaining information on effectiveness and expressing it in relation to inputs used. Therefore policies to boost effectiveness without significant increases in costs will have a positive impact on efficiency.

Overarching policies aimed at reducing barriers to access for disadvantaged groups, such as improving access to broadband, fall outside the scope of responsibilities of LFYM administrators. Nevertheless, policies that could be considered include: targeted promotion campaigns; provision of detailed, tailored, advice on how to use the app and its benefits to disadvantaged groups; as well as piloting LFYM in low-SES communities.

Given NCDs disproportionality affect lower-SES groups, ensuring access to digital PN interventions should be of interest to relevant policy makers given this group stands to benefit most.

Studies to evaluate the impact of digital PN interventions, to date, have largely relied on intermediate outcomes7 such as changes in fruit and vegetable consumption and fat intake (see assessment of “Effectiveness”). Given LFYM plans to collect data on a final outcome measure – specifically, objective measures of BMI using smart scales – findings from a future evaluation of the intervention should be of high interest to policy makers. However, it is important when evaluating BMI data (and any other outcomes) to control for a range of socio-economic demographic variables such as education, employment and income, given users of PN are typically wealthier (for example, only a small subset of the population can afford to purchase a smart scale) (Adams et al., 2019[4]). Controlling for gender, age and ethnicity will also be of high interest. Failing to control for individual characteristics may lead to bias results by presenting findings for a specific group as opposed to the wider population.

The ability to control for individual characterises will ultimately depend on the data collection process. For this reason, LFYM administrators could consider additional socio-demographic and health-related questions when signing up to the intervention.

Details on outcome indicators of interest to LFYM and how to collect this data is provided in Box 14.3.

Further details on how to undertake an evaluation can be found in OECD’s Guidebook on Best Practices in Public Health (OECD, 2022[36]).

Policies to enhance the extent of coverage are outlined according to individuals and health professionals.

A key component of the LFYM intervention is the use of genetic testing to provide tailored nutritional advice. However, potential participants may be wary of uploading genetic information to a digital device operated by a private company due to potential risks (for example, concerns regarding how data may “be used and abused” by different stakeholders such as insurers and employers) (see Box 14.4 for further details) (Stewart-Knox et al., 2009[38]). A survey of 6 000 individuals across eight European countries found just 28% of participants were willing to undertake genetic testing for PN purposes, with rates lower for younger, healthier individuals (Stewart-Knox et al., 2009[38]). Further, less than a quarter (22%) of participants would not be willing to have a genetic test. For this reason, it is recommended that LFYM administrators provide extensive information and actively promote how genetic data is used and stored in order to alleviate concerns (e.g. keeping abreast of developments in the standard required to collect, protect, share and use genetic data will be important – such as the Future of Privacy Forum) (Adams et al., 2019[4]).

Once the intervention is rolled-out and sufficient data on participant demographics is available, an analysis of participation rates across population groups is encouraged to identify key trends (e.g. higher dropout in certain population groups). Further analysis into key participation trends may be necessary, for example, through stakeholder interviews and surveys, to identify why certain groups are less engaged than others.

A recent study by Chen et al. (2017[40]) examining the use of mHealth apps amongst dieticians in Australia, New Zealand and the United Kingdom revealed 62% of respondents use mHealth apps within their practice. Dieticians not using mHealth apps highlighted the following factors for this choice: 1) no access to a smartphone at work (51% indicated this as a barrier); lack of infrastructure in their practice, such as poor Wi-Fi (42%); and lack of time with patients to recommend apps (26%) (Chen et al., 2017[40]).

Responsibility for addressing these barriers lies with higher-level policy makers (e.g. state/national level), however, barriers that could be addressed by LFYM include “lack of awareness of the best apps to recommend” and “apps [being] too hard to use” (Chen et al., 2017[40]). For example, LFYM administrators could engage with dietetic associations in countries it hopes to launch in as a way to promote the app and its uses. LFYM could also use this opportunity to offer dieticians a free trial in which to get used to the app, which would also provide an opportunity for LFYM administrators to gather feedback on the app’s usability.

This section explores the transferability of LFYM from Romania to other OECD and non-OECD EU countries and is broken into three components: 1) an examination of previous transfers; 2) a transferability assessment using publically available data; and 3) additional considerations for policy makers interested in transferring LFYM.

The LFYM mHealth intervention has, to date, not been transferred to other countries or regions outside Romania, however, mHealth healthy lifestyle apps are common in most developed countries. For example, the WHO as part of its “Be He@althy, Be Mobile” initiative has developed a series of handbooks to help policy makers implement mHealth interventions (WHO, 2021[41]).

The following section outlines the methodological framework to assess transferability and results from the assessment.

Details on the methodological framework to assess transferability can be found in Annex A.

Indicators from publically available datasets to assess the transferability of LFYM are listed in Table 14.4. Please note, the assessment is intentionally high level given the availability of public data covering OECD and non-OECD European countries.

LFYM is broadly transferable across OECD and non-OECD European countries based on publically available data (Table 14.5). Compared to Romania (the owner setting), most countries have higher internet use and access as measured by the proportion of people accessing health information online, eHealth adoption amongst GPs and the ICT development index – for example, 33% of people in Romania seek health information online compared to an average of 54% in other countries. Further, most countries have legislation to protect digital patient data, as well as eHealth and unhealthy eating plans indicating political support for the intervention (64% and 90%, respectively).

To help consolidate findings from the transferability assessment above, countries have been clustered into one of four groups, based on indicators reported in Table 14.4. Countries in clusters with more positive values have the greatest transfer potential. For further details on the methodological approach used, please refer to Annex A.

Key findings from each of the clusters are below with further details in Figure 14.2 and Table 14.6:

  • Countries in cluster one have population, political, economic and sector specific arrangements in place to transfer LFYM. Countries in this cluster are therefore less likely to experience issues associated with implementing and operating LFYM in their local context.

  • Countries in cluster two have population, political and economic arrangements in place to transfer LFYM, but may wish to introduce policies that ensure the sector is ready for LFYM.

  • Countries in cluster three have a sector that supports LFYM. However, before transferring LFYM, countries in this cluster may want to consider increasing uptake of digital health technologies among the population, ensure LFYM aligns with political priorities and undertake further analysis to assess if LFYM is affordable among the population.

  • Countries in cluster four would likely support LFYM as it aligns with overarching political priorities. However, before transferring LFYM, countries in this cluster may also want to increase uptake of digital technologies, implement policies to ensure the sector is ready for this type of intervention, and assess overall affordability. It is important to note that Romania, which currently operates LFYM, is in this cluster, indicating although ideal, such conditions are not necessarily pre-requisites for transferring LFYM.

Data from publically available datasets is not ideal to assess the transferability of LFYM, for example, there is no publically available data set on whether a country has regulations in place that forbid direct-to-consumer genetic testing. Therefore, Box 14.5 outlines several new indicators policy makers should consider before transferring LFYM.

LFYM is a promising mobile and web-based PN intervention with the potential to prevent as well as treat existing health care conditions. Given the intervention is currently in its infancy, data to evaluate the intervention against the OECD Framework was not available. Instead, this case study reviewed similar digital PN interventions which revealed many meet best practice criteria, for example, a recent systematic review found over 70% of studies conclude PN is cost-effective (Milanne Galekop, 2019[19]). However, similar to other digital health interventions, LFYM has the potential to widen social inequalities given mHealth apps are less accessible to certain priority population groups (e.g. lower SES).

A review of the literature highlighted several high-level policy options LFYM administrators could consider to enhance effectiveness, the evidence-based, equity and extent of coverage. These include, but are not limited to, offering users targeted social support and motivational messages; additional promotion of the service to disadvantaged groups such as those with a lower socio-economic status; as well as boosting public acceptability by ensuring transparency in regard to how data, genetic data in particular, is used and stored.

A transferability assessment comparing Romania, where LFYM is being piloted, and OECD and non-OECD European countries indicates the intervention is broadly transferable. For example, compared to Romania, most countries have higher levels of internet use and access among the public and health profession. However, before determining transferability, it is important to collect new types of information including regulation regarding the collection and use of genetic information.

Box 14.6 outlines next steps for policy makers and funding agencies regarding the LFYM intervention.


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← 1. A smart scale measures weight and other body composition metrics and automatically records and uploads this information to an app or other online service.

← 2. The dietary assessment covers: Carbohydrates, Fibre, Protein, Omega 3, Omega 6, Calcium, Chloride, Copper, Iron, Iodine, Potassium, Magnesium, Manganese, Sodium, Phosphorus, Selenium, Zinc, Vitamin A, Vitamin B1, Vitamin B2, Vitamin B3, Vitamin B5, Vitamin B6, Vitamin B7, Folate, Vitamin B12, Vitamin C, Vitamin D, Vitamin E, and Vitamin K.

← 3. Phenotypic data includes information such as age, sex, ethnicity and disease profile,

← 4. For contextual purposes, the National Institute of Heath and Care Excellence (NICE) applies a cost per QALY threshold of between GBP 20 000-30 000 (EUR 24 010-36 016) when developing advice on which health interventions to fund or not.

← 5. Phenotypic data includes information such as age, sex, ethnicity and disease profile,

← 6. A forum allowing users to interact with one another is planned for Q1 of 2021.

← 7. Intermediate outcomes that are known to relate directly to the final outcome – for example HbA1c levels to diabetes prevalence, cholesterol levels to heart attacks, or calorie intake to obesity prevalence.

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