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. Author manuscript; available in PMC: 2025 Feb 10.
Published in final edited form as: J Nutr Gerontol Geriatr. 2024 Feb 10;43(1):1–13. doi: 10.1080/21551197.2024.2302619

Using Voice Assistant Systems to Improve Dietary Recall Among Older Adults: Perspectives of Registered Dietitians

Rahi R Shah 1,2, Claudia C Dixon 2, Michael J Fowler 2, Tiffany M Driesse 1,2, Xiaohui Liang 3, Caroline E Summerour 1, Danae C Gross 2, Hillary B Spangler 1, David H Lynch 1, John A Batsis 1,2
PMCID: PMC10922685  NIHMSID: NIHMS1966186  PMID: 38287658

Abstract

Dietary assessments are important clinical tools used by Registered Dietitians (RDs). Current methods pose barriers to accurately assess the nutritional intake of older adults due to age-related increases in risk for cognitive decline and more complex health histories. Our qualitative study explored whether implementing Voice assistant systems (VAS) could improve current dietary recall from the perspective of 20 RDs. RDs believed the implementing VAS in dietary assessments of older adults could potentially improve patient accuracy in reporting food intake, recalling portion sizes, and increasing patient-provider efficiency during clinic visits. RDs reported that low technology literacy in older adults could be a barrier to implementation. Our study provides a better understanding of how VAS can better meet the needs of both older adults and RDs in managing and assessing dietary intake.

Keywords: voice-assistant systems, dietary recall, older adults, dietitian, technology

INTRODUCTION

Standard practice for Registered Dietitians (RDs) is to collect and document food and nutrition-related history to inform decisions about medical nutrition therapy.1–4 Dietary assessments are important clinical tools for assessing eating habits, disease risk, and health and nutrition status. A variety of methods and media are employed to conduct assessments within clinical settings, including 24-hour dietary recall interviews as well as self-administered paper or web-based food questionnaires, such as the Automated Self-Administered 24-hour dietary assessment tool.5 Specific food recalls are also helpful for managing the imbalances across the nutritional spectrum, from malnutrition due to under or over-consumption, across all agess.6,7 In particular, older adults aged 65+ years can benefit from dietary assessments as they are at increased risk of poor nutrition status, which may increase their risk of developing chronic diseases and that can worsen overall health.8–11

Dietary assessments, while widely used, can be resource-intensive when administered by a trained interviewer and have limitations, such as recall bias.12 Staff often need tro spend a significant length of time administering the assessments, and their success relies on an ability to accurately self-report food intake.12,13 In a 24-hour recall, an individual is typically asked to accurately describe cooking methods, portion sizes, and ingredients, so obtaining accurate dietary data can be difficult with older adults due to age-related changes, such as cognition, vision, and hearing.12,14,15 Hence, the ability to assess adequate intake becomes increasingly important as a result of the increased complexity and heterogeneity observed in older adults and their nutritional needs.16

This critical need provides clinicians and researchers an opportunity to use novel methods to better evaluate dietary habits for older adults. Advancements in technology-based tools have improved the accuracy and ease of use of dietary recalls and self-monitoring through probing questions using smartphone technologies or web-based tools. These have shown to provide more rapid feedback to improve dietary adherence.17,18 Further, the COVID-19 pandemic has led to an improvement in technology literacy in older adults with their adoption of commercial devices continuing to grow, such as wearable activity monitors, wellness applications, and Internet-of-Things devices.19–21

More recently, voice-activated technologies, such as Amazon’s Alexa or Google Home, have seen increased use in the home setting.22 These technologies have the potential to improve the health of older adults. VAS was shown to encourage older adults’ compliance for various behavioral changes, such as taking medications and conducting tasks to self-manage pain, and also help caretakers manage food and nutrition intake of patients with dementia.23–26 Preliminary data showed that patients with diabetes were able to better self-manage their diet with the assistance of VAS.27 With a decreasing gap in the digital divide, our goal is to understand the role of VAS in improving acquisition food intake. It is unknown whether VAS can help RDs in assessing and managing older adults’ nutritional intake. Since perceptions of VAS use may differ between older adults and RDs, our qualitative study explored the perspective of RDs about whether VAS implementation was feasible for dietary recall.

METHODS

Study design:

We collected data using semi-structured interviews and self-reported demographic surveys between January and March 2022, exploring how VAS could also be considered for use in conducting dietary recalls. All participants provided informed electronic consent that was completed through REDCap, an electronic data capture system.28,29 Following consent, all participants completed a self-reported demographic survey.

Study Site & Recruitment:

A convenience sample of n=20 RDs, from throughout the United States, were recruited and successfully enrolled through multiple platforms including ResearchForMe, institutional and national listservs, and via snowball sampling by local professional networks. ResearchForMe is a secure online tool used to recruit research participants that matched our study criteria and was developed by the North Carolina Translational and Clinical Sciences Institute at UNC.30 Pre-approved recruitment notices were distributed through e-mail listservs through the UNC Department of Nutrition and the Nutrition Interest Groups of The Gerontological Society of America. RDs were also recruited via the team’s interdisciplinary professional network. No relationship was established with research participants prior to the study, but participants were aware that our study’s aim was to understand the perspective of RDs on the current challenges older adults have with dietary recall.

Selection Criteria:

Our inclusion criteria were limited to RDs aged ≥ 22 years as we determined this was the youngest age to receive RD credentials. We excluded non-actively practicing RDs. There were no exclusionary criteria based on the type of institution RDs worked at nor whether they had previous experience with VAS. All RDs were recruited and provided consent to two trained student research assistants under the oversight of the corresponding author and one of the researchers trained in qualitative methods.

Interviews:

RDs completed a one-time 45–60-minute semi-structured interview session. All interviews were conducted virtually and audiorecorded between the research assistants and the participant using Zoom, a secure cloud-based videoconferencing platform.31 Questions were open-ended with clarifying probes (see Appendix 1) focusing on the challenges perceived by RDs that older adults faced with traditional dietary recalls. We gained insights in RD’s thoughts on the design and implementation of a VAS in patients’ homes that would prompt them and capture real-time food intake. All participants were provided a $25 Amazon gift card for their time.

Data Analysis:

All recordings were professionally transcribed through a secure third-party service. Transcripts were not returned to participants for correction. All identifiable information was removed and securely stored. Each transcript was read and analyzed by one researcher with common answers identified and recorded into Microsoft Excel. This was a pre-emptive measure taken prior to importing the data for full qualitative analysis into Dedoose, a qualitative, web-based software package that assists in the analysis and codification of qualitative and mixed methods data.32 The initial screening aided in creating the codebook in Dedoose which informed the demonstrated domains. A codebook was created after a review of all transcripts containing 20 different codes, and were used during inductive thematic analysis. The codes created in Dedoose were intended to mirror the structured questions provided in the qualitative interview guide used during RD interviews. Coding was completed throughout the study by one researcher To maintain trustworthiness and reliability of results, 20% of coded transcripts were reviewed by two other researchers with previous qualitative coding experience coding. No major discrepancies were observed; all minor ones were adjudicated. All qualitative data were discussed among our research team in order to identify common qualitative themes throughout excerpts. No patient feedback was collected regarding qualitative data.

RESULTS

Of the 20 interviewees, ages ranged from 22–65+ years (Table 1). The majority identified as female (95%), white (85%), and not of Hispanic, Latino/a/x, or Spanish origin (90%). Qualitative themes included significance of current methods of dietary recall, barriers, and facilitators, and barriers and facilitators of VAS dietary recall (Table 2). Each RD supported dietary recalls as useful tools for weight management. Common themes mentioned the importance of dietary recalls which included: providing a baseline of a patient’s current diet and nutritional status, helping assess risk factors for nutritional imbalances, and establishing a relationship with the patient. RDs described the ability to adapt and modify current dietary recalls as a positive element that allows RDs to better meet patient needs. Visual aids could be helpful for patients with hearing issues. RDs noted that prompts and personalized follow-up questions could be useful to clarify dietary intake and assist with short-term recall. RDs discussed barriers older adults may have with current dietary recall measures, including web-based self-administered dietary recalls.

Table 1.

Demographic Characteristics of Study Cohort

Demographic Characteristics Participants n = 20
Age range 22–65+
 22–34 years 9 (45)
 35–64 8 (40)
 65+ 3 (15)
Female Sex 19 (95)
Race
 White 17 (85)
 Asian 2 (10)
 Prefer not to say 1 (5)
Ethnicity
 Not Hispanic or Latino/a/x, or Spanish origin 18 (90)
 Yes, Mexican, Mexican American, Chicano/a/x 1 (5)
 Prefer not to say 1 (5)
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All values represented as counts (%).

Table 2.

Positive and Negative Aspects of Currently Conducted Dietary Recalls

Domain Code Sample Quote
Significance of dietary recall in weight management Importance I think dietary recalls, in relation to weight management, are important to get a starting point for the clients that you’re working with at the beginning of your time working together (RDa #10).
Positive aspects of current dietary recall in older adults Food Visuals Visuals definitely, so I [...] found myself really using [palm sizes to estimate food portions] or [...] if I was doing a home visit going into their kitchen and grabbing like [...] the size of a tablespoon and getting a plate and being like how much of your plate is filled with XYZ [food] (RD #3).
Prompts For my people who have just slight memory issues, they might just need a cue of like say I say, “Okay, well, how have you been eating?” They might just stare me blankly. But if I say, “Okay, how is breakfast?” [...]. That can really jog their memory. Even just a small reminder or cue (RD #8).
Negative aspects of current dietary recall in older adults Barriers Vision issues, hearing issues, recall issues, I guess that could probably happen for anyone, but I’ve seen it a bit in older adults (RD #4).
The barrier would be not knowing serving sizes. A barrier would be not knowing how to use the software that maybe they’re using.
If they do have anxieties around eating behavior, it’s probably more anxiety-provoking to tell me as opposed to telling a technology.
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a

RD = Registered Dietitian

Table 3 summarizes the facilitators of using VAS to address the challenges of current dietary assessments in older adults. RDs voiced support for VAS due to the benefit of real-time data collection to help improve recall and accuracy of portion sizes. If the reliability of self-reported dietary recalls improved through using VAS, RDs stated this would limit repeat of an entire recall assessment, ultimately saving time for RDs to focus on additional interventions during clinic visits. RDs specifically expressed optimism regarding VAS because many individuals already have familiarity with voice-activated technologies, such as Amazon Alexa and Google Home.

Table 3.

Positive and Negative Aspects of Voice-Assistant Systems Dietary Recall

Domain Code Sample Quote
Positive aspects of VASa dietary recall implementation in older adults Positive elements I think real time data collection would be really great, especially for the older folks (RDb #18).
I think it would be just way more detailed [... and] way more accurate than them trying to fill out a webpage, getting frustrated, turning it off, or just on a piece of paper [...]. [RD#8]
Benefits People don’t want to be recorded in their home visually, but most people are comfortable with having audio recording because tons of people already have that in their house (RD #9).
If that audio recording can be transposed and I can get it in writing prior to and then ask questions when I’m with that patient, there’s a lot of merit in that because that focuses my time with them. It makes me more efficient. [RD #1]
Appeal It potentially could be a time saver if I get all that information ahead of time and then you’re just asking for the follow up questions rather than doing the entire recall in the moment (RD #13).
I think [VAS] would make them actually have that human interaction, which per se when doing just a paper or just a web page without a clinician in front of you, they don’t give enough details. [...] if it was Alexa device, I think they would enjoy it because they would feel like a conversation. [RD#6]
Negative aspects of VAS dietary recall implementation in older adults Difficulties I think having access to it. Some folks might have technology literacy issues (RD #6).
Depending on how comfortable [older adults] are with technology, there might be resistance to it. [RD #19]
Downsides The only thing that I worry about is just frustration level for the older adults if they have issues with it (RD #12).
Limitations Perhaps cost. Yes. If it was really expensive and I didn’t have a grant to cover it, I don’t know if I would utilize it (RD #16).
How often did they eat day and night? What are their symptoms and what are their emotions around eating? Did they eat something and have diarrhea? Did they eat something and then don’t go out because they’re going to avoid some urinary incontinence for example? [...] I think emotion around food is also important. [RD #1]
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a

VAS = Voice-Assistant Systems

b

RD = Registered Dietitian

RDs reported that a lack of human interaction was a potential barrier of existing self-administered dietary recalls. It was noted that VAS may be effective in providing a familiar human-like interaction when compared to other methods. RDs primary concern was related to the level of accessibility older adults would have with self-reported recalls with VAS. RDs worried that technology would not be available to patients or themselves, if the cost of VAS was not covered or subsidized by insurance. The comfort level of older adults with using such technology concerned RDs when asked about barriers to using VAS with older adults. However, some RDs reported that they work with a subset of older adults who would be comfortable with VAS technology.

Assessments can be difficult to conduct, and current methods present challenges in different age groups. RDs noted that recalls can be complex, particularly in older adults, due to issues with hearing and memory (65% of participants) and accurately reporting serving sizes (45% of participants), which is summarized in Appendix 2. RDs expressed support for considering using VAS in dietary assessments compared to interview or self-administered recalls. RDs reported that VAS implementation could increase the ease of older adults conducting recalls that may increase efficiency during visits (reported by 65% of participants). RDs expressed two key types of data they would like to see: measurements of times of day the patient is eating and subjective measurements of emotions surrounding dietary intake (e.g., mood, satiety, food-related symptoms). Though RDs expressed support for implementing VAS, there was an overall sense of reservations surrounding the level of technological comfort needed.

DISCUSSION

RDs highlighted that current dietary recall methods do not fully address provider and patient needs. The results revealed that RDs believe implementation of VAS-based dietary recalls have the potential to improve patient convenience of reporting food intake, improved recall of portion sizes via real-time data collection, and increasing patient-provider efficiency during clinic visits.

The potential of using VAS supports the likelihood that it can improve older adult health through refining current dietary recalls to develop more individualized nutrition plans. We recognize other technologies that may improve current dietary recall methods. Multimodal sensors that monitor swallowing, image-based dietary recalls using wearable or handheld cameras, and mobile applications have all been studied to measure food intake.33–35 VAS has the ability to mirror human interaction through vocal communication and feedback, which is a benefit that it may have over other technologies. One study demonstrated how older adults can communicate with an Alexa-like VAS to have human-like conversations and interactions, which significantly reduced loneliness.36 This an important consideration as RDs i reported that lack of human interaction was a concern with implementating this technology. RDs also mentioned that the large-scale commercial availability of voice-assistants, such as Amazon Alexa and Google Home, will make older adults more comfortable with VAS-based dietary recalls. Therefore, VAS may feel less burdensome and less intrusive for patients than sensor, camera, and mobile application-based technologies.

RDs expressed concern that low technology literacy in older adults was a possible barrier to the use of VAS. Some other common issues that older adults may have with VAS include problems that may arise with voice recognition and ability to recall voice commands.24 Given the potential of technology, such as VAS, increasing the comfort level older adults have with technology in general could enhance their quality of life.35 Improving technology literacy can be a complex process. Older adults are a heterogenous population with different needs and varying levels of technology exposure, so there is no one size fits all solution to tackling the technology barrier to VAS. RDs that expressed concern over technology barriers may have been working with a majority of adults that were much older, 80+, but we cannot say for certain as we did not explore the average age of their patient population.

We wish to highlight that overcoming low levels of technology literacy should not be understated. VAS can be more accessible for older adults than other technologies. Some older adults find voice technologies easier to learn and navigate than computers and smartphones.37 Due to less reliance on visual and physical feedback, VAS can improve food reporting and can lead to better usability in older adults relative to app-based food reporting.38 With the increasing adoption of technology by older adults,20 we expect technology literacy issues to decrease as adults continue to become more comfortable with technology over time. This is supported by our findings that show RDs work with a subset of older adults that are becoming increasingly more technologically savvy. Age-related decreases in hearing may affect VAS accessibility. Older adults with hearing impairment may find challenges with VAS interfering with hearing aids or difficulty using VAS around noisy environments.39 Studies have emphasized the importance of voice interface customization including the ability to change the pitch, when developing VAS.39

Our study is, to the best of our knowledge, the first VAS-based study involving healthcare providers. Our interviews with RDs, a group whose perspective has not been frequently studied, will be useful in informing future studies both on how to improve current methods of dietary recall and how to implement VAS in dietary recalls. Our systematic coding was a strength of the study’s methodology. All coding was adjudicated with two other researchers that were trained in qualitative methods, which helped strengthen our results and analysis. Other study limitations were due to sampling bias. Most recruited participants were from North Carolina and worked at, or near, academic centers. RDs that work in community clinics or private practices or are from different geographic regions may have different perspectives than the cohort recruited in this study. Our small sample size and most participants being primarily white and female, further reinforces that our results may not be generalizable to the perspective of all RDs. There is a possibility that social conformity of responses may have occurred, but we tried to limit this by asking participants to be as candid and genuine as possible prior to each interview. Two different research assistants interviewed participants, potentially impacting the consistency of the interview and responses but we had a standardized structured training and overseen by staff with experience in qualitative methods.

This preliminary data provides data that can be used to design future studies and inform the design of VAS technologies and to understand how to implement these devices into dietary recall assessments. Prospective studies should specifically focus on feedback obtained from RDs in our study to develop VAS that include the following: probing cues and follow up questions to enhance real-time data collection, ability for RDs to access patients’ responses to VAS dietary recall, and questions that enable collection of emotional and timing data associated with food intake. We recommend reproducing this study with a more diverse array of RDs in order to qualify the results of our study. While the perspective of RDs is important, we also need to consider the direct perspective of patients and caretakers. Future qualitative studies that interview older adults, 65 and older, and dyads will refine our understanding on how to improve accessibility of VAS and technology literacy in general.

Acknowledgements:

We thank Quirina Merced Vallejos for their help reviewing coded transcripts.

Funding:

The research reported in this publication was supported in part by the National Institute on Aging and Office of Dietary Supplements of the National Institutes of Health [grant number K23AG051681, R01AG067416]; the The North Carolina Translational and Clinical Sciences Institute (NC TraCS) [grant number UL1TR002489]; the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health and the University of North Carolina Nutrition Obesity Research Center (NORC) [grant number DK056350]; and the University of North Carolina at Chapel Hill Medical Students Training in Aging Research (MSTAR) program from the National Institute On Aging of the National Institutes of Health [grant number T35AG038047].

Appendix 1: Interview Questions

A. INTRODUCTIONS AND OPENING QUESTIONS:

  1. Describe the importance of conducting dietary recalls in obesity management.
    1. What are some impacts you believe dietary recalls have on weight management?
      1. Probe: how can they be helpful, what do they do

B. BARRIERS TO CONDUCTING EXISTING DIETARY RECALLS:

  1. What elements of conducting dietary recall measures work well for an older adult population?
    1. Why do you think those elements work well?
  2. What barriers exist in conducting dietary recall measures in older adults?
    1. How do you think older adults can overcome some of these barriers?
  3. What opportunities exist to improve dietary recall in older adults?
    1. Which opportunities do you believe would be most helpful to you?
  4. What features are missing in paper-based versions of dietary recall assessments?
    1. How do you think they should be addressed?
    2. What features could be specifically helpful for use in older adults?
  5. What features are missing in web-based versions of dietary recall assessments?
    1. How do you think they should be addressed?
    2. What features could be specifically helpful for use in older adults?

C. TECHNOLOGY:

  1. How do you think technology can be helpful in improving dietary recall assessments?

  2. What experience do you have with using technology to track and monitor dietary recall?

    • Probe: What has worked?

    • Probe: What hasn’t worked?

D. VOICE ASSISTANT DEVICES

We are hoping to design a voice assistant device (think Amazon Alexa) that captures dietary recall data in patient’s homes.

  1. In an ideal ‘dream big’ world:
    1. What specific types of information would you want this device to collect related to dietary recall?
    2. What type of data would you like from the device to inform your practice as a result of this data collection?
  2. What elements of collecting voice-related diet data do you think:
    1. Could work well?
    2. Could be hard to measure?

  3. As compared to a conventional in-person, self-administered 24-hour dietary recall,

    1. What type of information could we collect using this method?

    2. What benefits would this have over a traditional recall?

    3. What are some pros of a voice-based data collection approach?

    4. What are some cons of a voice-based data collection approach?

    5. What would be the appeal of using a voice-based device in lieu of a 24-hour recall?

      1. To you as a clinician?

      2. To your patients?

  4. For older adults,

    1. What difficulties do you think older adults would have in using this technology?

    2. What do you think might get in the way of older adults using this device?

      Probe: Any foreseeable problems with the program (i.e. time, etc)?

  5. Do you see any downsides to using such a device? If so, what are they?

    • Probe: Do you see any potentially negative side effects or other concerns?

    • Probe: What would get in your way of using this technology?

    • Probe: Are there any physical, psychological, or other challenges for you or for your patients if they were to use this device?

Footnotes

Conflict of Interest Disclosure:

There are no conflict of interest pertaining to this manuscript or authors of this manuscript.

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