There has been a lot of spirited discussions lately – and even controversy – about food logs for nutrition counseling. Do they stir up a reaction in you, either in favor of, or strongly against? Some dietitians are adamant that food logs are an essential tool in nutrition counseling, while others say that they have no place in today’s nutrition counseling, and can even cause harm.
Have no fear dietitians: this article is arming you with facts so that you can determine which tools and strategies best serve your practice and your clients.
The most important consideration is what tool or strategy best serves your client, their lifestyle and their goals. Some considerations for you to keep in mind are: what is the potential benefit of food logging for your client? Will it help your client to manage his or her weight? To improve their iron deficiency or manage blood sugars? Will logging help them develop greater awareness of the connection between emotions and their behaviors?
The best food log (or skipping them altogether) is a match between your client’s needs and goals, and is an authentic fit to your personalized approach to nutrition counseling.
The truth is: there is no one best tool or approach. Different RDs have different approaches and this is a good thing. Not every client needs the same kind of nutrition counseling!
“I think the most important answer is yours. What do you think and how do you want to run your practice? A weight-neutral RD may not focus on tracking. If this is not you, then by all means do what YOU feel is best for YOUR clients. As the owner of a meal planning and tracking software company, I may be biased, but I honestly feel that providing the client a guide along with tracking capabilities can give them a sense of confidence as they build on the new skills that you have taught them.” Suzanne Fisher, MS, RD, LDN, Founder, CEO of Fisher Nutrition Systems
As a registered dietitian, you strive to provide your clients with the best, most effective experience during your nutrition counseling appointments. This requires sifting through the evidence and matching the best tool to the needs of individual clients.
In this blog post, we will discuss some ways you can use food logs to help your clients achieve their goals. We’ll summarize the research in terms of which methods are the most accurate. You’ll also hear from fellow dietitians and their perspectives on why they do – or do not – use food logs with their clients.
For an overview of which specific food logging apps are available and their intended use, be sure to bookmark our previous article: The 28 Best Apps for Dietitians to Use in Their Business.
Overview of types of food log
Apps are here to stay: the use of all kinds of apps (not just food logging apps) increased by an astounding 27% from 2019 to 2020 (1). But, just because an app is on your client’s phone, it doesn’t mean that your client is using it consistently. “Only 3% of 190,000 downloads [of a food-journal app] resulted in a person using the mobile food journal for more than one week (2).
While apps are widely available and widely used, they do have a few limitations for dietitians to consider:
- Security of data
- Availability for use in different languages
- Accuracy of support forums
- Incompatibility with some models of cell phones
In addition to apps, food and lifestyle activity logs can come in many different forms, including:
- a casual 24-hour recall jotted down on paper
- a formal data entry into an app or electronic form
- logging photos of meals and snacks
- Tracking hunger and fullness cues
- logging stress, sleep or physical activity patterns
Some practice management tools allow your clients to track information and securely store it in their personal health record. If you’re using an EHR and plan to have your clients track their data, make sure that the EHR has the ability to easily track data. If you’re new to coaching software or aren’t sure if you’re using the best one for your needs, you’ll want to check out our Best Nutrition Coaching Software and Apps post!
And keep in mind: your client can track far more than just calories or servings as a part of food logging. Health and wellness is complicated and nuanced: being able to track variables such as mood, sleep, stress, physical activity, and hydration may all allow you to better guide your client.
Food logs can have benefits when appropriately used with clients, but it’s important to consider whether or not they’re a good match for you and your work setting before jumping in.
Evidence for food logs: what does the literature say?
What does the research say about food logs? Let’s find out!
As a general rule, all self-reported tracking has some amount of bias compared with compared to more accurate tracking methods, such as weighing portions.
- In a 2021 review of thirty-one research studies regarding food logs, including 24-hour recall and photo tracking methods, found “substantial underestimation of [total energy intake] across a range of dietary assessment methods” that did not vary by gender (3).
- A 2019 review study found that women underreported energy intake to a greater degree than men, “with 24 h recalls having less variation and degree of under-reporting compared to other methods.” (4).
Weighed food logs
The gold standard of accuracy in assessing food intake is weighed food logs: using a scale to precisely measure foods to log what has been consumed. However, this method of tracking can be cumbersome and time-consuming for your client.
- A study from 2000 suggested that dietitians pay particular attention to snacks, sweets, and alcoholic drinks as they’re the most likely components of a day’s intake to be forgotten or missed (5).
Practice pearl: weighted food logs can be the most accurate way to assess food intake. For private practice RDs, this method may feel too cumbersome for your clients and this level of precision is not necessary to provide effective nutrition guidance.
24 hour recalls
24 hours recall – asking your clients what they ate yesterday – can give dietitians a baseline overview of what your client is eating, when they’re eating, as well as habits such as hydration and caffeine intake. This can be a less-formal conversation, or a structured interview, such as The National Cancer Institute’s Automated Self-Administered 24-Hour Dietary Assessment Tool (ASA24).
24-hour recalls are not perfect, but they may be helpful to estimate adequacy, timing of meals and hydration. 24 hour recalls, can be quick (assuming you can head off long stories and tangents) and give you helpful information to get started with.
- A 2009 review founds that client intakes estimated by 24 hour recalls underestimated total calories by 15% (6).
Practice pearl: when using 24-hour recalls, be sure to ask probing questions about snacks, desserts and drinks for more complete records.
Photo and video food logs
Photo food logs, taking a photo of your meals before (and potentially after) eating are quick, and offer a lot of information both to you and your client.
Here is the most exciting news for dietitians and your clients: photo logs are much more accurate then you might guess. Plus, they’re very quick, and therefore more enjoyable, for your clients to complete.
- A 2020 research study “found a high correlation and small difference between the food-photographic record method and weighed results of a large number of nutrients in many test meals” (7). Which is exciting, because this study is comparing a newer method to the gold standard!
- Similarly, a 2021 study also supports the accuracy of photo and video food logs, as compared to weighted food logs. “In young, educated adults, image-based dietary assessment (IBDA) methods may be useful tools for ranking dietary intake among populations and estimating their group intake, in particular video recording (VR), where the underestimation bias was <5% for energy and all macronutrients and was even lower when only complete data sets were used. In addition, IBDA might remove the burden associated with estimation and recording of food portion sizes by the participants (8).
- This same study found that image-based dietary assessment was more practical and enjoyable than weighted food records (9).
Tech forward companies – that put client ease and experience as a top priority – are weaving this technology into their apps and programs. For example, Rise, a weight loss and healthy eating subscription program that hires RDs as coaches, has clients track each meal and snack with a quick photo.
Practice pearl: photo and video food logs are surprisingly accurate, enjoyable for clients to complete and accessible to use.
Concerns with disordered eating?
Apps may be able to supplement in-person disordered treatment and be a way to increase treatment access to those ED patients who live in a remote setting or have income limitations.
“I work with eating disorders, so weight loss is not part of my practice. Tracking calories can be triggering for most patients, so I use an app called Recovery Record, and it’s wonderful. Can make alerts to remember to eat, place to track hunger/fullness and emotions. You can also take pictures of your meals.” –Jessica Parker, RD, CD
As with any tools, there are risks as well. While there are no studies that support the premise that an app can cause an unhealthy relationship with food, a calorie tracking app might exacerbate those tendencies (9).
- A 2014 study suggested that “ individuals with eating disorders (EDs) might be a patient group that could particularly benefit from smartphone apps as either an adjunct to standard treatment or as a way to receive existing evidence-based treatments” (10).
But we know that there are far greater uses of food logging apps than just calories; food logging may be an effective tool, even with disordered eating clients, to track behaviors or food exchanges. This is a time for the dietitian’s skills and experience to shine!
Who are the experts in disordered eating? RDs who have completed the CEDRD credential. The CEDRD certification training provides a solid framework for certified eating disorder registered dietitians to provide evidence-based care. More on this rigorous program in our article: Everything You Need to Know About Becoming a CEDRD.
Practice pearl: dietitians working in the disordered eating realm may find that certain logging apps are beneficial to their client, such as hunger cues.
Ways to use foods logs in your practice
The old adage is: you can’t manage what you can’t measure. Whether casually on paper or more formally via a phone app, tracking lifestyle data can help you see what adjustments your client can make to work towards their health and wellness goals more effectively.
Having accurate data is important, but even more so, your clinical expertise guiding your client is even more important. You get to help transform the data into an actionable plan.
While we might think of weight loss as the main goal for clients tracking their intake or changing behaviors, there are many important uses of food and lifestyle logs that you may consider for your practice.
Let’s dive in!
One of the basic tenets of nutrition is to make sure that your clients have enough nutrition.
Is your pregnant client getting enough iron to prevent anemia? Is your teenage athlete client eating enough calories to fuel their sports practices as well as their continued growth? Food logs can give RDs an overall picture of adequacy.
One consideration for which food log to use is how detailed the data need to be to serve your client’s goals. A dietitian supporting a child who is following a ketosis diet to manage their epilepsy needs far more accurate data than a client increasing their fiber intake to lower their risk of heart disease. While a tracking app on the phone might be the most accurate, it is also more time consuming for your clients to complete
And not all data has to be about food specifically: many important changes have to do with behavior.
Tracking behavior change
Baby steps add up to big change and being able to track those changes helps your clients to stay motivated through a wellness journey. Remember when going up two flights of stairs made you winded? Now you can go up four!
Timing of meals may also be an important factor to track as you guide your client on their wellness journey. Tracking gratitude, steps, hours slept, minutes meditated or fewer minutes of screen time can all help your clients lead healthier lives.
“I use food records for some clients, but some folks get overwhelmed by tracking foods and I don’t make anyone if it just adds more stress. We can find other ways of making changes. I do have my clients keep a 3-5 day food record before we meet the first time, so that I can get a feel for what they eat, timing of meals, food styles, etc. From the first visit on, it depends on the client. If they track, we focus a LOT on emotions, hunger scale around the meals, other patterns. I also offer them to use just a food photo record, taking the pressure off of evaluating nutrients and calories. Even looking at photos is an excellent way to evaluate and make adjustments.” – Amanda Evans MS, RDN, CDCES founder of Amanda Evans Nutrition Consulting, LLC
Logging emotions and stress
Your clients may have been at a high state of stress for so long that they don’t even remember what it felt like to not be anxious and overwhelmed: it is their normal!
Ways in which your clients might benefit from logging emotions and stress:
- Identifying times that they are using food as a coping mechanism
- Learn how dinner choices change after an extra-long day at work
- If drinking alcohol influences eating patterns
Tracking stress and being able to link those levels to your client’s ability to make thoughtful decisions around mealtime may be illuminating for your clients if they’re able to approach tracking with curiosity instead of judgment.
“The only time I have folks track is if it’s clear they will not use it to judge themselves. That’s rare – it’s almost always a control and/or shaming exercise, but there are very rare patients who can do it objectively and with curiosity. And if I do have them track, it’s very (very) short-term, and I do the nutrient analysis. It’s never in an effort to control or limit but to instead balance nutrient needs. Instead of food tracking, I instead like to focus on behavior, mood, and emotion tracking. But again, only if they’re able to do it in a curious way and it’s not perpetuating/reinforcing negative views of themselves” – Rebecca Toutant, MA, RD, LDN, CDCES, CPT and founder of Nourishing Bits & Bites.
Promoting weight loss
Creating a calorie deficit may help your clients to lose weight. Tracking intake can help to adjust nutrition planning to support their weight loss goals while staying motivated. Clients can focus on portions, calories, exchanges as well as exercise amount, sleep and other factors for weight management.
Food logs can also help you find trouble areas that are holding back the client’s progress. Is the client tracking caloric beverages? Eating off of their child’s plate? Did one snack portion turn into two? Food logs help you to create a fuller picture of what the current habits are, and what changes will further their journey.
Food logs may be an important tool as your clients learn to manage a new or existing disease diagnosis. Tracking carbohydrate exchanges may be the first step for your client who is newly diagnosed with diabetes, in addition to tracking how high-fiber meals influence blood sugars, or how stress and sleep affect blood sugars.
Clients can use food logs to learn about chronic kidney disease (CKD), with regards to tracking protein, fluid intake, phosphorus and other kidney-specific nutrients.
“I have many of my CKD patients track [their intake] because it helps with their kidney function. Sometimes weight loss is a side effect of that. If someone comes to me for the main goal of weight loss, I ask them why? I believe HAES and intuitive eating is a key to a healthy relationship with food but it’s not the only way.” –Greta Hensler RD, LN, CSO, founder of Lorelei Nutrition.
Connecting with your client
At the end of the day, food logs are simply tools. For best results, and to best support your clients, ask yourself a few questions:
- Which type of logging is appropriate for the types of clients that I work with?
- Which food logging approach is practical for my client’s lifestyle, health and wellness goals?
- Which approach to food logging will balance collecting the intended results while being enjoyable for my client, and minimizing client dissatisfaction or shame?
“I think it really depends on the client. While tracking food might lend to unhealthy thoughts, behaviors for one, it may be perfectly healthy and even helpful for another individual. I use my clinical judgment on a case-by-case basis for food diaries: A good fit for some and not for others.” –Michelle Tiburzio, RDN, CLC
If honoring hunger, letting go of dieting and connecting with your body resonate with you as your approach to eating and nutrition, gentle nutrition may be the best fit for your practice. Good news: there are food logs to consider with this approach, too!
If your client gets hyper-focused on tracking data, or becomes tired of logging their daily breakfast, lunch, and dinner intake on a food diary page, then it might be time to rethink what healthy eating really means.
If you haven’t explored gentle nutrition, our blog post, How to Embrace Gentle Nutrition in Your Practice, is a great resource to get to know this approach to nutrition counseling. The foundation of gentle nutrition is to cultivate a more constructive and compassionate relationship with food and eating.
Practicing gentle nutrition does not exclude using a logging system of some kind. Olivia Cupido explains:
“As a weight neutral RD who practices Intuitive Eating (IE) principles, I do use tracking for some of my clients (not appropriate for all) but we don’t necessarily look at calories or macros but more eating patterns, how and why etc. The platform I use (Practice Better) allows me to hide the nutrient information from the client, so they don’t know any numbers. There is also an area to note mood, stressors, symptoms (I have many digestive health clients for whom this is really helpful for). I find this information is much more eye-opening than calories and macros.” –Olivia Cupido, RD, MHSc, founder of OG Nutrition
Food logging – is it right for your client?
At the end of the day, different clients are best supported in different ways, and by using different tools. For some of your clients, they may benefit from using a food logging tool to track their health data and move towards their wellness goals. For others,
As a registered dietitian, you are an excellent advocate for your clients. Think about each client’s personal goals and consider if a food logging tool will help them to best achieve them. The best tool will be user-friendly, as accurate as needed to track those goals and provide minimal frustration. Ultimately the right tool is the one that is best for your client.