THE EFFECT OF AN IPAD APPLICATION ON THE QUALITY OF LUNCHES BROUGHT FROM HOME BY MIDDLE SCHOOL CHILDREN

Objective: To evaluate the mobile application, LaLa Lunchbox, on improving the dietary quality of lunches brought from home. Design: Quasi-experimental design. Setting: Middle school in East, Greenwich, RI. Participants: 25 students in the 6 grade who were predominately white (72%) females (76%) with an average age of 11.2 years. Intervention: For 4 weeks, LaLa Lunchbox app was used to create virtual lunchbox for each school day of the following week. Main Outcome Measure: Lunch Quality Index (LQI) scores calculated based on the presence or absence of fruit, vegetables, protein, or empty calorie snack with a maximum score of 4 points based on four lunch observations at baseline, week 2 and 4 of intervention, and 1 week follow-up. Analysis: A repeated-measures analysis of variance (ANOVA) measured the LQI score over time between the 2 groups. Results: Although there were no differences between groups, there was an effect of time on LQI score (p<.05). Overall fruit (67.4%) and protein (80.4%) were included in most lunches but a high calorie snack was also frequently included (52.2%) and vegetables rarely included (21.7%). Conclusions and Implications: The mobile application, LaLa Lunchbox was not effective in improving dietary quality as a stand-alone intervention, but could be useful as a tool in combination with nutrition education focusing on increasing vegetables and reducing empty calorie snacks.

iv ACKNOWLEDGEMENTS I would like to thank each of my committee members. Dr. Geoffrey Greene, thank you for all your patience and support throughout this MS/DI journey. Your help has truly been invaluable in getting me here today. Linda, I am so grateful for the opportunity you gave me to work at SNAP-Ed this year. I have learned so much and this experience definitely will stick with me the rest of my life. Dr. Furong Xu, thank you for your guidance and willingness to help during this thesis writing process.
To my fellow grad students/dietetic interns: Vicki, Jim, Dara, Patrick, and Noereem, thank you all for your constant encouragement during these two years. I can't believe we're done! It's been a long road and I couldn't have done it without you guys.

INTRODUCTION
Childhood obesity has more than doubled in children and tripled in adolescents in the past 30 years (1). Risk factors for coronary heart disease (CHD), such as hypertension, dyslipidemia, impaired glucose tolerance, and vascular abnormalities, once thought to be only experienced in adulthood are already present in overweight children (2). Additionally, children and adolescents who are obese are more likely to be obese as adults (3,4).
According to the National Health and Nutrition Examination Survey (NHANES), the majority of 2-17 year olds are consuming excessive amounts of empty calories, which is associated with excess weight gain (5,6). Children are also are not meeting dietary recommendations for nutrient-dense, highfiber foods (5,6).
Because children consume more than one-third (35%) of their daily calories at school, food served by the National School Lunch Program (NSLP) has become an important area of research and intervention (7). As of March 2012, new standards for the NSLP were adopted which more closely aligned them to the 2010 Dietary Guidelines for Americans (8). Although the 62% of students in the U.S. that participate in the NSLP are now receiving more nutritious lunches, it can be assumed that the remaining students bring a lunch from home (9). Research has found that the lunches children bring from home are lower in nutrition quality than the foods offered at school (7,10,11).
Several studies have found that lunches brought from home include fruits, vegetables, and dairy at significantly lower percentages than school lunches, and are more likely to contain foods high in sugar and/or fat and a non-100% juice fruit juice drink (11). One study found that packed lunches contained a mean 21.3 grams of sugar, which is well above the 12-20 grams/day recommendation of the American Heart Association for this age group (12).
Mobile technology has created a new medium for intervention that can reach and affect a vast amount people across the globe. Throughout the world, the number of smartphone users exceeded one billion in the fall of 2012 (13). The usage of mobile apps is likewise increasing rapidly, and grew at a rate of 115% in the year 2013 (14). Today, the U.S. consumer spends an average of 2 hours and 38 minutes per day on smartphones and tablets (15).
Out of that time, 80% (2 hours and 7 minutes) is spent using apps and 20% (31 minutes) is spent on the mobile web (15). Approximately half (49%) of middle-school children use a smartphone at home and 39% use a smartphone to complete homework assignments (16). Furthermore, more than one in three (36%) use a tablet at home and 31% of middle school students use a tablet to complete homework (16).
Health smartphone applications (apps) are on the cutting edge of pediatric nutrition practice (17). In 2011, there were more than 40,000 mobile health apps, contributing to the $718 million global industry, according to Research2Guidance, an international market research firm (18). Although consumers are using them, there are few studies to support the effectiveness of smartphones in improving health.
Research on computer-based interventions has generally shown success in improving health behaviors of children and adolescents. A webbased program called Teen Choice: Food & Fitness resulted in a significant increase in adolescents who reported eating three or more serving of vegetables per day in the past week compared with the control group (19).
Additionally, after using the 10-session multimedia intervention, Squire's Quest!, there was a significant increase in fruit, 100% juice, and vegetable intake (1.0 serving) compared to the control for elementary students (20).
Research has yet to evaluate the effectiveness of mobile applications (apps) for improving the dietary quality of children. Lunches from home have been shown to be less healthy than lunches provided at school, and although web-based and multimedia interventions have been found to be effective in promoting behavior change, no one has evaluated the ability of a mobile app to motivate the user (parent or child) to change the nutritional value of lunches from home. The objective of this study was to assess whether the use of a nutrition mobile app will increase the dietary quality of lunches brought from home. We hypothesized that the group receiving the 4-week intervention with the LaLa Lunchbox iPad app will have a higher Lunch Quality Index (LQI) score than participants in the control group. A secondary objective of this study was to explore the contents of middle school lunches brought from home.

Study Design
This study used a quasi-experimental design to explore the effect of an iPad app on the dietary quality of lunches brought from home by middle school children. This 6-week study compared children's lunches of an experimental group that received an app-based intervention with a delay-treatment control group that did not have access to the app until after completion of the study.

Subjects
Intervention and control group participants were 6 th grade students at week 2, data from week 2 was imputed for weeks 3 and 4.

Demographics and Baseline LQI
Twenty-seven students returned completed parental consent and child assent form and were present for the baseline observation. The intervention classroom had 14 participants and the control classroom had 13 participants.
During the study, 2 participants in the intervention classroom dropped out of the study due to other academic responsibilities. Twelve participants in the experimental group and 13 participants in the control group finished the study.
The overall attrition rate was 7.4%. There were no statistically significant differences between the intervention and control groups for any of the baseline demographic or primary outcome variables. The characteristics of the sample are shown in Table 1. Overall, participants were predominately white (72%), female (76%), with an average age of 11.2 years. Over 65% of the parents had a postgraduate degree and all of the participants reported that one of their parents achieved at least a college degree. Approximately 76% were at a healthy weight (5 th -85 th BMI percentile) and only about 14% were overweight or obese (> 85 th percentile). There was also no statistically significant difference between the intervention and control groups for baseline LQI.

Lunch Quality Index (LQI) Score
There was no significant difference in LQI score between the two groups over the 4 time points in the completers analysis (p=.13), but there was a statistically significant effect of time (p=.047) (  Figure 2).

Individual Food Components
In total, 92 lunches were observed during this study. Overall in both groups, fruit was included in 67.4% of the lunches, and vegetables were present in only 21.7%. A protein food item was found in 80.4% of lunches and an empty calorie snack was included in 52.2% of all lunches.

App Usage
Due to school absences and other obligations during the "study hall" period, some participants were unable to use the app during the allotted time.
The children who did not attend the study visit were asked to use the iPad app at some point before Thursday of that week. The first week, 11 out of the 12 students (92%) in the experimental group used the app to create their lunchboxes. During the second week, 11 of the students used the app. In the last two weeks of the intervention, 100% of the students used the app.
Overall, the 12 participants completed the lunchboxes on the app 46 out of an intended 48 times (96%) throughout the 4-week intervention.

a. Student Evaluation
Ten of the 12 (83.3%) experimental group completers responded to the LaLa Lunchbox evaluation survey after the intervention ended. Thirty-percent of these students liked and 40% felt neutral about using the app. When asked why they liked or disliked using the app, the responses varied. Some were positive about the app with comments such as, it gave me "the chance to see and try different varieties of foods that I did not know about" and "it is good for my parents to know what I want to eat". Others found the app a little restrictive. One student was dismayed with the lack of choices stating they did not like the app because it "didn't have pickles!" Another student suggested allowing the app user to type in their desired food choices. Sixty-percent reported that their parents were neutral about the weekly emails detailing their lunchbox choices, while 30% reported that their parents found the emails helpful. The majority (90%) of the students said their parents tried to purchase and pack the foods they selected for their lunchbox. More students (40%) agreed or strongly agreed that their lunches were healthier after using the app, whereas only 20% disagreed or strongly disagreed. However, none of the students responded that they would use the app in the future.

b. Parent Evaluation
Only 5 of 12 (41.7%) parents of intervention program completers responded to the study evaluation that was sent by email after completing the study. Four parents (80%) responding that they used the app every week while 1 said they never used the app. When asked what they liked about the app, one parent expressed that the weekly emails of the lunchbox choices "made it easier to shop" and that "the suggestions were very helpful". Another parent thought the app was an "interesting concept," but was concerned how practical it would be in reality. Two parents said they would not use the app in the future, 1 parent said they would use it again, and 2 said they might. The final question asked for some ideas or recommendations (including educational material, recipes, or another app) that they think might be helpful to other parents in packing healthy lunches for their children. One suggestion was to have "a newsletter or app for unique kid friendly lunchbox ideas/recipes to try". Another parent recommended encouraging exercise in addition to healthy lunches and they felt that high school students are in greater need of a healthy lunch intervention because they are probably "making poorer choices than 6 th graders". One parent ended the survey with an encouragement to "please keep doing this" because it "made me and my daughter more aware of what she eats."

c. Teacher Evaluation
The teacher of the homeroom used for the experimental group was also asked a few evaluative questions through email. Overall, she felt the app was easy to use by the students since "the reporting was completed in just a few minutes" and commented saying, "the kids love any technology." She thought the app "was great" but wished we would have been able to teach the students more about nutrition. She felt the study could have been improved by higher student participation. She also expressed doubt that Archie R. Cole Middle School's population accurately represents "most of the nations eating habits". She thought, "the study would have been more useful if it were done in Providence, RI [school district with a predominantly minority population]."

DISCUSSION
This study evaluated the effectiveness of a mobile nutrition app for improving dietary quality of home-provided lunches for middle school students.
The iPad application, LaLa Lunchbox was found to be ineffective for improving the dietary quality of lunches brought from home.
Although there was no difference in change in LQI score between groups, there was an effect of time. There was a non-significant trend between baseline and time 2. The LQI score of the lunches from home decreased after the intervention began in the experimental group and increased in the control group. These results are inconsistent with other studies that had interventions to improve lunches brought from home. Many of these other studies found more favorable results (24)(25)(26). The Healthy Lunchbox Challenge intervention, which found significant increases of fruits, vegetables, and water in lunches from home, used both an incentive program and direct education for parents (24). Incentives were provided if participants brought fruits, vegetables, and water in their lunches, so these participants were likely motivated to increase the dietary quality of their lunch based on the promise of a reward (24). In the current study, incentives were provided regardless of lunch content to both control and experimental groups so that they would not be an influencing factor to the provision of healthier lunches in the intervention group versus the control group.
There was, however, another lunch intervention study that found similar results to the current study for primary school children aged 4-11 (27). This study had a 16-day intervention with a program called Food Dudes that consists of a series of DVD episodes promoting fruit and vegetables. The Food Dudes program had previously been effective in improving fruit and vegetable consumption for lunches provided by the school (28), but for lunches brought from home it was found to be limited in its effect on both short-term and long-term fruit and vegetable consumption (27). There were no significant increases in fruits and vegetables in the experimental group, but a significant increase was found in the control group.
These conflicting results are likely related to the complexity of the problem of altering lunches brought from home. In order to change lunches brought from home it is necessary to change the home environment. If the home environment does not have healthy foods available, healthy foods cannot be packed in lunches. Likewise, for these types of interventions to be successful they need to affect parent behavior. Parental involvement was critical to the execution of this study, so their level of involvement likely had an impact on the extent of behavior change in the children. Since only 5 out of 12 parents responded to the study evaluation, we can likely conclude that this study suffered from a lack of parent involvement. We may have found more success if we had elicited a direct engagement with the parents such as face-to-face meetings rather than merely weekly emails. These interactions could have provided accountability and led to greater adherence to each child's lunchbox choices especially if parents were anticipating a follow-up meeting after the intervention.
There is evidence that interventions that exclusively use technology are less effective than face-to-face interaction. For example, Harvey-Berino et al.
compared the effectiveness of a weight maintenance program administered through 3 different modes (29). They found the internet program to be less effective than either dose of face-to-face contact as the internet group It has also been shown that print media is more effective at promoting behavior change in children than computer-based media. One study investigated the effect of a web-based physical activity intervention versus a print-based physical activity workbook in adolescent girls. Although the content of the two interventions methods were kept constant, the print-based intervention was found to increase physical activity intention and behavior significantly more than the web-based intervention (30). The researchers suggested a potential explanation for this difference could be a difference in the way information is processed on paper versus on a screen. Print media may elicit greater attention to and processing of messages than Web media (30). Since school-age children still primarily learn from textbooks and printed materials, learning using computers or mobile technology may not be deemed as credible and could possibly be perceived as a mode used solely for entertainment.
Computer-based interventions, including web-based or multimedia interventions, have been successful in changing dietary behavior in children. The study demonstrated a need for dietary intervention with lunches brought from home. In both groups overall, only 22% of lunches included a vegetable and more than half included an empty calorie snack. Even with our homogeneous and well-educated population with high socioeconomic status, the lunches children are bringing from home are not meeting the recommendations for a healthy diet (6).
There were several limitations in this study. The first limitation was that there was a very small sample size, but it was designed as a pilot study to provide a protocol and direction for future research. The sample was restricted due to the requirement that children had to bring a lunch from home for all 6 weeks of the study. Another limitation was that we did not measure consumption of the lunches, so we cannot draw any conclusions on whether or not the app affected what the students actually ate from their lunches.
However, previous research has found that the availability and accessibility of foods often predicts consumption (31,32). Additionally, portion size was not assessed in the observation, so we cannot determine the total amount of calories or nutrients provided in the lunches. Furthermore, while the "What's in Your Lunch?" recording forms proved to be helpful in identifying the ingredients in sandwiches and salads which we would be unable to obtain through only the observation photographs, we could not identify the ingredients in other types of food such as pasta or soup that were contained in enclosed containers. Therefore, it is probable that some food items, especially vegetables within entrées were present but not counted. Lastly, due to the high socioeconomic status and ethnically uniform of the population at Archie R. Cole Middle School, the results of this study cannot be generalized to the population at large.
The nature of the app itself is another issue with promoting generalized use of this intervention. First, the app not applicable to most low-income households whose children receive free/reduced lunches through the NSLP.
Second, the collection of food choices in the app assumes access to and availability of a variety of food, which is an unreasonable assumption for many households. Third, choices may be expensive especially "out of season" fruits and vegetables.
One of the strengths of this study was that it was not reliant on selfreport, which is susceptible to reporter error and bias. There was a very high (98%) inter-observer reliability. The study was intentionally designed to focus exclusively on the mobile app intervention; therefore, we avoided additional methods that could have influenced behavior change such as nutrition education or incentives. This allowed for results to reflect the impact of the app alone. This strengthens confidence in the finding that the app was not effective. Nevertheless, since most of the children and responding parents enjoyed using it, this study does suggest that mobile health apps hold promise.

IMPLICATIONS FOR RESEARCH AND PRACTICE
This pilot study was one of the first of its kind to examine the efficacy of a stand-alone mobile app that is currently on the market in promoting behavior Obese children and adolescents are more likely to be obese as adults, and therefore, are at an increased risk for coronary heart disease, type II diabetes, stroke, many types of cancer, and osteoarthritis in adulthood (3,4).
However, risk factors for coronary heart disease, such as hypertension, dyslipidemia, impaired glucose tolerance, and vascular abnormalities, were once thought to be only experienced by adults, but are now present in many overweight children (5,6).
A 55-year follow-up study demonstrated that adults who were overweight in adolescence had an increased risk of morbidity and mortality from cardiovascular diseases, independently of adult weight (7). This suggests that there are permanent metabolic and physical changes that lay the foundation for cardiovascular disease later in life (8). There is evidence that the physical progression of atherosclerosis begins during childhood in severely obese children. An investigation that performed non-invasive ultrasonographic measurements on 48 severely obese children and 27 healthy children discovered that severely obese children showed clear signs of early progression of atherosclerosis through increased likelihood of early endothelial dysfunction and increased stiffness of elastic arteries (8). Therefore, severe childhood obesity not only is a risk factor for later cardiovascular disease, but also is associated with current impairment of vascular function.

Diet related etiology
Low nutrient-dense and high energy-dense foods are associated with excess weight gain in children and adults (9,10). The quality of children's and adolescent's diets (2-18 years old) was assessed using the Healthy Eating Index, estimated from NHANES (2009-2010) (10). They found that children are consuming on average 33% of their total calories (798 kcal/day of 2027 kcal) in the form of empty calories, defined as the sum of solid fat and added sugars (10,11), considerably exceeding the recommended discretionary calorie allowances for this age group, which range from 8% to 19% of total calories (11). The sources of these empty calories are sugar-sweetened beverages, grain desserts, and pizza (11).
Furthermore, on average, children and adolescents are failing to meet recommendations (10). Scores for greens and beans and whole grains were the farthest from the standards since average consumption was only 14-18% and 16-18% of the recommended amount per day, respectively (10).

School lunches
Since children consume more than one-third of their total calories at school, food provided through the NSLP has become an important area of intervention (12). As of March 2012, new standards for the NSLP became effective to align them with the 2010 Dietary Guidelines for Americans (13).
School lunches must provide one-third of the daily requirements for energy and macronutrients through a balanced meal that includes all five food groups: fruits, vegetables, grains, meat/meat alternative, and milk (14). The NSLP now considers fruit and vegetables two separate components and children must select either ½ cup of a fruit or vegetable or ¼ cup of a vegetable and ¼ cup of fruit to place on their lunch tray (15). The schools also must serve a greater variety of fruits and vegetables with weekly requirements for dark green, red/orange, beans/peas (legumes), starches, and other vegetables (15). In addition, at least 50% of the grains products served must be whole grain, and only low-fat 1% or skim milk is provided (15).
While the 62% of students in the U.S. that participate in the NSLP are now receiving more nutritious lunches (14), there is no regulation on the quality of lunches brought from home and evidence shows that these packed lunches are failing to meet the recommendations for a healthy diet. Two studies conducted in the United Kingdom (UK) compared the food and nutrient intakes of primary school children consuming school meals and packed lunches (16). One of the studies visually observed a total of 120 lunches at a single time point, 62 school meals and 58 packed lunches at a single time point (16). The other study examined the diets of 311 children from low-income households using 24-hour recalls (17). The children in both studies were 6-11 years old (16). On average, children that brought a lunch from home consumed more sugar, sodium, saturated fat in their lunches than children who ate a school lunch (16). Children with lunches brought from home had higher daily consumption of white bread, fats and oils, chips and savory snacks, and preserves and sweets, which were likely the sources of the excessive amounts of sodium, fat, and added sugar (17).
Therefore, these studies suggests that lunches brought to school from home are less likely to contribute to a healthy diet than school provided lunches (17). technique, but this study also analyzed the sugar content of the lunches (20).
Similar to Johnston and colleagues, they found lunches brought from home were low in fruits and vegetables (20). They also found that these bag lunches contained a mean 21.3 grams of sugar, which is above the 12-20 grams per day Since lunches are providing approximately one-third of the total daily kilocalories, according to the American Heart Association, they should contain no more than 4-6.7 grams of sugar, which is much less than the average bag lunch in this study (20).
A cross-sectional study using 24-hour dietary recall data from the 2004-2005 third School Nutrition Dietary Assessment Study found that on average children consume 35% of their daily calories at school (12). The study compared the consumption of National School Lunch Program (NSLP) participants and non-participants (12). Low nutrient, energy-dense foods were classified into five mutually exclusive categories: higher fat baked goods, candy and sweetened gum, dairy-based desserts, french fries and similar potato products, and chips and salty snacks (12). Throughout the day, all children consumed on average 527 kcal from low nutrient, energy-dense foods (12).
The review of the literature shows that school lunches are on average healthier than lunches brought from home. In general, packed lunches contain more sodium, saturated fat, and added sugar than lunches provided by the school (17,18). They also tend to contain less vegetables and whole grains (19,21,22). It is important to address poor quality packed lunches through interventions targeted specifically to induce healthy changes in the types of foods being brought to school for lunch.

Previous interventions to improve lunches from home
This section will review intervention studies designed to improve lunches from home.
Lunch is in the Bag is a childcare center-based nutrition education program for parents of preschool-aged children and is aimed at increasing fruits, vegetables, and whole grains in lunches brought from home (21). Using a quasiexperimental design, six centers were randomly assigned to either an experimental group or comparison group that received no intervention (21). The intervention included parent handouts and behaviorally-based activities for parents and children, in addition to teacher training (21). Following the 5-week intervention, observations of lunches showed a significant increase of fruits and vegetables from 0.41 servings at baseline to 0.65 servings at post and whole grains from 0.54 to 1.06 servings (21).
Another intervention called the "SMART" lunch box was focused on 8-9 year old students in 89 schools in the United Kingdom (UK) (22). This intervention was aimed at improving the contents of packed lunches to better align them with the governmental nutrition standards for school provided lunches (22). Each participating school was randomly assigned to two groups: the full experimental group and the minimal intervention (control) group (22). In the experimental group, parents received supplies for packing a healthy lunch, which included: a lunch bag, a plastic container for a sandwich or alternative entrée, a container for fruit or vegetables, and a water bottle (22). Parents and children in the experimental group also received nutrition education materials and games encouraging families to pack balanced meals that include all five food groups with water to drink (22). In the minimal experimental group, parents received a leaflet with information on improving lunches brought from home (22). Lunches from parents in the experimental group had moderately but significantly greater amounts of fruit and vegetables and dairy foods following the intervention when compared to the control group (22). The amount of fruits and vegetables combined increased by ⅓ of a serving in the experimental group, but there was no effect on the amount of fat, sugar, and sodium (22).

Tilley and colleagues evaluated a summer camp intervention called the
Healthy Lunchbox Challenge and found it to be successful in improving both staff and child lunches brought from home (23). The intervention included a parent and staff education program on "Building a Better Lunchbox" and a child and staff incentive program for bringing fruits, vegetables, and water to drink in their lunches (23). Foods and beverages were assessed through direct observation.
This large study with 1,977 children found an significant increase in the percentage of children bringing fruits (31% to 42%), vegetables (5% to 16%), and water (47% to 60%) from baseline to post-assessment (23). The percentage of 241 staff members who brought fruits and vegetables significantly increased from 30% to 47% and 9% to 22% respectively (23). There were also observed decreases in low-nutrient-dense foods and beverages such as chips and non-100% juice fruit drinks in both children and staff (23).
In the UK, the 16-day Food Dudes program was designed to improve lunchtime consumption in primary school children aged 4-11 (24). The Food Dudes program consists of a series of DVD episodes using peer-modeling to promote eating fruit and vegetables (24). This program had previously been successful in improving fruit and vegetable consumption when the fruits and vegetables were provided and offered by the school during lunchtime (25), but it had not been tested on improving lunches brought from home. In both the control group who did not receive any intervention and the intervention group, consumption of lunches brought from home was measured using before and after photographs (24). The observations took place at baseline measurement, at 3-month follow-up, and after 12 months following the intervention. There was not a significant change in fruits and vegetables consumption in the intervention group at 3 months and a non-significant decrease in fruit and vegetable consumption at 12 months (30 g vs. 30 g vs. 25 g respectively). However, in the control group fruit and vegetable consumption significantly increased at 3 months compared to baseline but the change was not sustained at 12 months (29 g vs. 36 g vs. 30 g respectively) (24). This study found that the Food Dudes program was limited in its effect on both short-term and long-term fruit and vegetable consumption.

Technology use and health apps
According to a study from Pew Internet & American Life Project, nearly half of American adults own a smartphone (26). Throughout the world, the It is not just adults who are making use of this technology. TRU research group conducted a study for the Verizon foundation with 1,000 online surveys to children aged 11-14 years. They found that approximately half (49%) of middleschool children use a smartphone at home and 39% use a smartphone to complete homework assignments (31). Furthermore, more than one in three (36%) use a tablet at home and 31% of middle school students use a tablet to complete homework (31). However, only 18% use a tablet in the classroom (31).
Research has found out of students who use tablets in the classroom, two in three (67%) report that using this technology makes them want to learn more, and the majority claim using some form of technology in the classroom makes them feel smart (61%), excited (54%), and happy (52%) (31).
"There's an app for that", the famous Apple advertisement slogan rings true even in regards to the healthcare industry. Health mobile applications (apps) are on the cutting edge of pediatric nutrition practice (32). In 2011, there were more than 40,000 mobile health apps, contributing to the $718 million global industry, according to Research2Guidance, an international market research firm (33). Many consumers are using mobile health apps; however, there is limited research to support the effectiveness of these apps in improving health.

Nutrition software for improving health
Although the literature on mobile technology is limited, the literature on mobile interventions is ever growing. However, the research on computer-based software is more comprehensive and previous studies have demonstrated that computer-based interventions can favorably affect many different health behaviors including dietary quality.

Multimedia
Web-based and multimedia software provides a platform for reaching large groups of people without expending huge sums of money. Interventions through the internet have produced positive results for many different health outcomes eDiets.com (35). A sample of 124 overweight or obese adults were randomly assigned to 12-months using VTrim or 12-months using eDiets.com. For the first 6 months, the VTrim website included specific weekly lessons. Weekly meetings were held on-line with the therapist to reinforce the lesson topics. The participants were instructed to reduce their caloric intake by up to 1000 calories/day and were encouraged to gradually increase their energy expenditure. The participants self-reported their weight and dietary intake weekly and the therapist provided weekly feedback. There was also a discussion board to encourage peer-to-peer and group support on VTrim's website. On eDiets.com, participants were given a caloric goal based on a reduction of approximately 1000 calories per day based on their calculated metabolic rate and the website provided tailored meal plans and fitness programs (35). Weight was self-reported weekly and automated feedback messages were received (35).
There was an interactive forum where participants could receive online support from both peers and experts (35). This study found that the VTrim group lost significantly more weight at 6 months than the eDiets.com group ( The average number of hours viewing television was not significantly different at any time point (39). Interactive multimedia interventions such as Health in Motion that deliver tailored feedback demonstrate a potential to initiate behavior change for several energy balance promoting behaviors.
Research on multimedia games to promote health in children appears to be promising. Baranowski  To investigate whether web-based interventions are more effective than more traditional methods, Marks and colleagues examined the effect of a webbased physical activity intervention versus a print-based physical activity workbook (42). After recruiting in four middle schools in North Carolina, 359 girls in 6 th -8 th grades were randomized to either a web-based intervention or a printbased intervention. The print workbook was identical in content to the information on the website. Self-reported physical activity was collected through phone calls at baseline and at 2 weeks. Both groups increased their physical activity intentions, but the print-based intervention was found to increase physical activity intention significantly more than the web-based intervention.
Furthermore, the print-based intervention group reported increases in physical activity behavior and there was no change in physical activity behavior with the web-based intervention (42). This study suggests that a print-based workbook is more effective at increasing physical activity intention and behavior than a webbased intervention.

Mobile communication
Text messaging also has been found to be effective at improving health.
Patrick et al. evaluated the effect of a text message-based intervention on weight loss for overweight adults. Seventy-five overweight adults were randomly assigned to one of two groups (43). The first group only received printed materials about weight control and the second received the intervention, which included personalized text messages sent 2-5 times dairy, printed materials, and brief phone calls from a health counselor every month (43). These personally tailored and interactive text messages were a means for behavioral prompting, support, and self-monitoring. Subjects who received the text-messaging intervention lost significantly more weight (-2.88kg or 3.16% body weight) than the print materials group. Moreover, subjects were highly satisfied, with 22 out of 24 (92%) participants stating that they would recommend the intervention to friends and family (43). This study demonstrates the potential of mobile communication to effective promote weight loss in overweight adults (43).

Mobile apps
The research base on mobile app-based interventions is considerably lacking difference between groups (44). There were also no differences between energy intake or energy expenditure between the groups (44). This study shows that the mobile-based interventions can produce a modest, short-term weight loss, but the addition of a diet tracking app and social networking did not have a substantial impact on additional weight loss in overweight adults.
Hebden et al. conducted at a large Australian university measured the effect of a mobile health intervention on weight management among young adults (45).
Fifty-one participants were randomized to either an intervention or a control group. Both groups received a printed diet booklet and one session with a registered dietitian (45). In addition, the intervention group received text messages, emails, and had access to smartphone applications and internet forums (45). The four smartphone apps were developed by researchers and each addressed one of the lifestyle behaviors: physical activity and sedentary behavior, intake of fruits and vegetables, energy-dense "takeaway" food, and sugar-sweetened beverages (45). These apps allowed users to record their behavior (e.g. amount of physical activity performed, servings of fruits and vegetables eaten, etc.). Then they received immediate tailored motivational advice, as well as feedback on the health guidelines for that specific behavior (45). This study found that after 12 weeks, body weight decreased in both the intervention (-1.60 kg) and the control (-1.41 kg groups), but there was no significant difference between the groups (45). This study demonstrates that a mobile health intervention can have short-term positive effects on weight but it is not any more effective than more traditional intervention methods such as faceto-face counseling and print materials.
Another study conducted in Australia by Kirwan  randomized to either record their daily dietary intake using the Lose it iPhone app, using the "notes" function on their smartphones, or using traditional pen and paper methods (47). After the 8-week intervention, both groups lost weight but there were no significant differences in the amount of weight loss between groups. This suggests that self-monitoring of diet and exercise, regardless of method, can result in successful weight loss. There is still a need for more research, but this study demonstrates that smartphone applications have the potential to be an easy, cost-effective way to promote healthy behavior changes.
There is limited research on mobile apps in improving health. A few previous studies on found a positive impact of health apps on adults. Although mobile technology is widely used by school-age children, research has yet to evaluate the effectiveness of mobile apps in improving the dietary intake of children.
Other technology-based interventions demonstrated a favorable effect on dietary quality and studies using mobile apps with adults found them feasible and enjoyable to use, but the results in promoting behavior change are inconclusive.
Studies have also shown that lunches brought from home are less healthy than lunches provided at school. However, to our knowledge, there have been no published interventions testing the ability of an app to motivate the parents of a child or the child themselves to increase the nutritional value of lunches brought from home.

APPENDIX E -Percentage of Food Components Charts
Week 1 and Week 2

Student Evaluation of the LaLa Lunchbox App
Thank you for participating!
Please circle the answer that best represents how you feel about each statement below.
I liked using the iPad app, LaLa Lunchbox.

PARENTAL PERMISSION FORM FOR RESEARCH
My name is Christina Pryor and I am a graduate student in nutrition at the University of Rhode Island. Linda Sebelia MS RD is running a research study this fall at Archie R Cole Middle School to learn more about the lunches that 6 th graders bring to school every day and to see if the app La La Lunchbox is a useful tool for young people. We are inviting you be a part of this project. The details of the project are written below. You should feel free to ask questions.

Description of the project:
This 6-week long study is being conducted in an effort to evaluate the effectiveness of the smartphone application LaLa Lunchbox. The app allows children to personalize their lunchbox, which is divided into four quadrants: vegetables, fruit, protein, and snacks. Your child is able to choose between four and six items from a variety of pictorial representations for each category. All the foods that are available on the app are minimally processed and are low in fat, sugar, and sodium. The selections are then formatted into a grocery list to make it easier for you to purchase the preferred lunchtime food items. A copy of the grocery list will be sent to you in an email for the following week. Furthermore, you will be provided with your child's username and password which you can use to log into the account if you have a personal iPhone or iPad to view the lunchboxes and the grocery list. Your child will change the password at the end of the study to protect confidentiality.
In order to be eligible for the study your child must bring their own lunch to school for the duration of the 6-week study.
What will be done: If you allow your child to participate, here is what will happen: Before the start of the first lesson the student will complete a demographic survey to obtain information regarding their age, gender, race/ethnicity, height, weight, and the parent's (your) education level. Your child will then use the app once a week in their homeroom classrooms to plan their lunches for the following week. There will also be four observations of the lunches the children bring to school. During these observations a photograph will be taken of each lunch next to a number identifying the student of whom it belongs. A photograph will also be taken of any nutrient facts labels on the food products within the lunch. In addition, your child will fill out a form in which they record the contents of their lunch. Once the sixth week is completed, your child will complete another survey to determine if his or her overall dietary intake has been affected.

Risk or discomfort:
There are no risks or discomforts recognized in this research study.

Benefits of this study:
Through this study, your child may gain positive lifelong healthy eating behaviors and skills in using smartphone applications to improve health. Your child will also receive a small gift at the start and end of the study.

Confidentiality:
Your child's part in this study is confidential. Any identifiable information will be stored in secured electronic files and in a locked file cabinet.

Decision to quit at any time:
Since the intervention is being conducted during the homeroom class time, your child is encouraged to participate. However, if your child does not wish to participate, myself, their teacher, and your child will discuss other options available. You also have the right to withdraw your child from participating at any time.  Description of the project: This 6-week long study evaluates the nutritional quality of lunches brought from home through direct observation. The observations include taking a photograph of the lunch your child has brought to school which will be evaluated later to determine the nutritional value. There will be a total of 4 observations over the length of the study.

Rights and Complaints
In order to be eligible for the study your child must bring their own lunch to school for the duration of the 6-week study.
What will be done: If you allow your child to participate, here is what will happen: Before the start of the first lesson the student will complete a demographic survey to obtain information regarding their age, gender, race/ethnicity, height, weight, and the parent's (your) education level. There will also be four observations of the lunches your child brings to school. During these observations a photograph will be taken of each lunch next to a number identifying the student of whom it belongs. A photograph will also be taken of any nutrient facts labels on the food products within the lunch. In addition, your child will fill out a form in which they record the contents of their lunch. Once the sixth week is completed, your child will complete another survey to determine if his or her overall dietary intake has been affected.

Risk or discomfort:
There are no risks or discomforts recognized in this research study.

Benefits of this study:
Your child will receive a small gift at the start and end of the study. Also, through this study, we will be able to assess the nutritional quality of lunches brought to school by 6 th graders. This information will be compared with an experimental group that is taking part in an iPad nutrition app intervention with the goal of improving nutritional quality of lunches. Your child will have the opportunity to use this app once the 6week study is over.

Confidentiality:
Your child's part in this study is confidential. Any identifiable information will be stored in secured electronic files and in a locked file cabinet.

Decision to quit at any time:
Since the intervention is being conducted during homeroom class time, your child is encouraged to participate. However, if your child does not wish to participate, myself, their teacher, and your child will discuss other options available. You also have the right to withdraw your child from participating at any time.

Rights and Complaints:
If you are not satisfied with the way this study is performed, you may discuss your complaints with Linda Sebelia: (401)

CHILD ASSENT FORM FOR RESEARCH
My name is Christina Pryor and I am a graduate student in nutrition at the University of Rhode Island. Linda Sebelia MS RD is running a research study this fall at Archie R Cole Middle School to learn more about the lunches that 6 th graders bring to school every day and to discover if the app LaLa Lunchbox is a useful tool for young people. We are inviting you be a part of this project. The details of the project are written below. You should feel free to ask questions.
What will be done: You and your parent or guardian will fill out forms, including a demographic survey. After you bring back this form and the permission form from your parent or guardian with your signatures, you will start a 6-week program playing with an iPad app called LaLa Lunchbox for about a half an hour once a week in your homeroom. This app lets you pick food you would want your parents or guardian to put in your lunchbox for the next week. We will also be taking some pictures of the lunches you bring to school. At the end of the program you will fill out the food frequency questionnaire again.

Risks or discomfort:
This study has no known risks or discomfort.

Benefits of this study:
You may start choosing healthier food to have in your lunches and end up eating better and feeling better. You will receive a small gift at the start and end of the study.

Confidentiality:
No one else will know if you were in the study and no one will find out what answers you gave. We will store all the information about you in a locked file cabinet.

Decision to quit at any time:
You may want to talk this over with your parents or guardian before you decide. The decision to be part of this study is up to you. You can still be part of the program even if you are not part of the study. We will also ask your parents to give their permission for you to take part in this study, but even if your parents say "yes", you can still decide not to do this. If you do decide to participate, you can always drop out of the study at any time. Just let your teacher know or ask one of your parents to call us.

CHILD ASSENT FORM FOR RESEARCH
My name is Christina Pryor and I am a graduate student in nutrition at the University of Rhode Island. Linda Sebelia MS RD is running a research study this fall at Archie R Cole Middle School to learn more about the lunches that 6 th graders bring to school every day, and we are inviting you be a part of this project. The details of the project are written below. You should feel free to ask questions.
What will be done: You and your parent or guardian will fill out forms, including a demographic survey. After you bring back this form and the permission form from your parent or guardian with your signatures, we will take some pictures of the lunches you bring to school. After 6-weeks, you will fill out the food frequency questionnaire again.

Risks or discomfort:
This study has no known risks or discomfort.

Benefits of this study:
You will receive a small gift at the start and end of the study, and you will be helping us determine what 6 th graders are bringing to school in their lunches so we can figure out if a specific nutrition program is effective or not.

Confidentiality:
No one else will know if you were in the study and no one will find out what answers you gave. We will store all the information about you in a locked file cabinet.
Decision to quit at any time: You may want to talk this over with your parents or guardian before you decide. The decision to be part of this study is up to you. You can still be part of the program even if you are not part of the study. We will also ask your parents to give their permission for you to take part in this study, but even if your parents say "yes", you can still decide not to do this. If you do decide to participate, you can always drop out of the study at any time. Just let your teacher know or ask your parents to call us.
Feel free to ask questions. If you have a question later that you didn't think of now, you can ask your homeroom teacher. If you have questions you or parents may call us at (916) 316-2257 or call the person in charge of the study, Linda Sebelia at (401) 874-4024.
Signing your name at the bottom of this form means that you have read or listened to what it says and you understand it. Signing this form also means that you agree to participate in this study and your questions have been answered. You and your parents will be given a copy of this form after you have signed it.