Development and qualitative formative assessment of pictorial paper-based and digital carbohydrate-counting educational resources for diabetes management

Abstract

Introduction:

Tailored carbohydrate-counting (CC) resources are helpful for diabetes self-management from an educator and patient perspective. Because these resources are unavailable in Malawi, we developed both pictorial paper-based and mobile app CC resources and explored clinical dietitians’ perceptions of these resources after using them in routine clinical practice.

Methods:

The initial pictorial paper-based CC resource was developed using foods informed by a previous study and input from clinical dietitians.Nutrient composition of foods was determined from the Malawi Food Composition Table and similar sources. We collaborated with clinical dietitians and app developers through a user-centered design/user experience approach, an iterative process to develop the mobile app CC. Five clinical dietitians then integrated both the pictorial paper-based and mobile app CC resources into routine clinical care for patients with diabetes, both inpatient and outpatient, for 10 working days. Subsequently, we conducted in-depth interviews to elicit their perceptions and analyzed the data using thematic analysis.

Results:

Pictures of portioned foods were displayed alongside standardized utensils, food names in English and Chichewa, net weight, carbohydrate content, and the number of carbohydrate counts. The mobile app featured the following tabs: patient profile, carbohydrate information, food comparison, carbohydrate count, and meal planning. Four themes emerged from the in-depth interviews: ease and feasibility of use; benefits to dietetic practice; challenges with using the pictorial paper-based and mobile app; and perceived areas requiring improvement.

Conclusions:

The pictorial paper-based and mobile app CC resources were deemed easy to use and feasible for routine diabetes counseling, hence useful in low-resource settings.

Introduction

Chronic conditions such as type 2 diabetes mellitus (T2DM) are increasing and pose a significant threat to public health and economic development. Globally, according to the International Diabetes Federation, about 589 million adults aged 20–79 years had diabetes in 2024, and this number is expected to rise to 853 million by 2050 [1]. In Africa, diabetes cases are projected to increase by 142%, from 24.6 million in 2024 to 59.5 million by 2050 [1]. In Malawi, the age-adjusted comparative prevalence of diabetes is estimated at 5.7%, and 78.7% are undiagnosed [1]. Among adults with T2DM in Malawi, it is concerning that over 60% have elevated glycosylated hemoglobin (HbA1C > 8%) [2].

In resource-limited settings such as Malawi, the lack of standardized, context-tailored/patient-centered nutrition resources for diabetes management, along with conflicting dietary information, poor diet quality, and food insecurity, affects diabetes self-management [3–5]. A prior study in Malawi found that the diet of adults with T2DM is disproportionately high in carbohydrates, primarily from staple foods such as cereals, roots, and tubers, and was associated with elevated HbA1C, underscoring the need for carbohydrate-counting (CC) resources [6]. CC is an approach to meal planning for diabetes management that focuses on the total carbohydrate content of a meal/food and supports diverse food choices to achieve optimal glycemic targets [7–11]. The concept of CC is that approximately 15 g of carbohydrate is equivalent to one carbohydrate (carb) choice, count, or serving in a meal, food item, or drink, which can raise blood glucose [7–11] unacceptably if not sufficiently balanced across meals and snacks and if disproportionately high in refined carbohydrate foods. For patients with type 1 diabetes, the CC approach helps to match insulin doses to planned meals/food intake, and for those with T2DM or prediabetes, it helps manage blood glucose levels [7–11]. The CC approach allows food substitution within the same food group and improves adherence to dietary recommendations [7–11]. Resources similar to CC have been developed to reflect the foods commonly consumed by specific cultures and ethnic groups and to guide appropriate dietary choices and diabetes self-management [12–15].

The diabetes resources developed to date, unfortunately, do not reflect the traditional foods and dishes commonly consumed in Malawi, posing a challenge for diabetes nutrition education and counseling. Studies have shown that culturally tailored diabetes resources improve glycemic status, diabetes knowledge, uptake, and participation in diabetes education [16–20]. Therefore, we developed CC resources that incorporate foods commonly consumed by patients with diabetes in Malawi, informed by our prior research [6]. Given that there is limited health literacy among patients with diabetes [21–23], a pictorial paper-based approach was first developed to improve the fundamental understanding and readability of patients with diabetes. Subsequently, the advances in technology and the widespread use of mobile phones led to the adaptation of the tool into a mobile application. A user-centered design/user experience design [24–27] was used to tailor to the needs of the primary users, who were clinical dietitians, to enhance the usability and delivery of nutrition and dietetics care. The pictorial paper-based and mobile app prototypes were then tested for feasibility within the existing clinical workflow used by clinical dietitians to provide nutrition education, counseling, and meal planning for inpatient and outpatient adults with diabetes, prior to the effectiveness study involving patients with diabetes.

This paper discusses the steps taken to develop pictorial paper-based and mobile app CC materials and to qualitatively elucidate dietitians’ perceived feasibility and usefulness of integrating these resources into their existing clinical workflow.

Materials and methods

The study was conducted between 2021 and 2023 in three phases: (1) developing a pictorial paper-based CC resource, (2) developing a mobile app prototype, and (3) a qualitative feasibility/usefulness assessment among clinical dietitians.

Phase 1: Development of pictorial paper-based resource

We previously conducted a study on the dietary quality among adults with T2DM in Malawi, using 24-hour and typical-day recalls to identify the foods commonly consumed by patients with T2DM [6]. We also collected information on the foods frequently mentioned by patients with diabetes during nutrition education and counseling sessions conducted by clinical dietitians at Kamuzu and Mzuzu Central Hospitals in Malawi. Food items and dishes were prepared and portioned using standardized utensils, such as cups and spoons, and then weighed using a kitchen scale to determine the net weight in grams. We determined the energy and macronutrient content of the foods/dishes mainly from the Malawi Food Composition Table [28]. If foods or dishes were not available in the Malawi Food Composition Tables, the following food databases were consulted based on the best alignment with the food in Malawi: the US Department of Agriculture National Nutrient Database for Standard Reference [29], the Food Composition Tables for South Africa [30], the Kenya Food Composition Table [31], and the Tanzania Food Composition Table [32]. If dishes were not found in the food composition tables, nutrients were determined by summing the nutrient values of the individual food items that comprise them. We purchased the packaged, ready-to-eat foods from grocery stores and local markets and determined their nutrient values from the nutrition facts labels. In some instances, ready-to-eat foods without nutrition facts labels had their nutritional composition determined using food composition tables such as the Malawi Food Composition Table [28]. Throughout the process, we photographed all portioned food items or dishes to guide the visualization of food portion sizes. Clinical dietitians translated food items or dishes into the local Chichewa language. Using the American Diabetes Association guidelines on CC, one carbohydrate (carb) count or choice is equivalent to 15 g of carbohydrate in a meal, a dish, or a food item [10]. Hence, in this study, we presented pictorial representations of food items or dishes, along with the amount of carbohydrate in grams and the number of carb choices or counts. Furthermore, we summarized the energy, macronutrient content, and carb counts/choices of the different food items/dishes in a table.

Figure 1 shows an example of the pictorial paper-based CC resource. Two food items per food group are included for illustration. The food grouping in the CC resource developed in this study aligns with Malawi’s six food groups: staples, fruits, fats and oils, legumes, and vegetables (both starchy and non-starchy) [33], except for animal-source foods. The animal-source food group was separated into meat and meat products and milk and milk products, since the latter contain carbohydrates [10,11]. Additionally, a new food group for beverages, sweets, sugar, and snacks was added, including items consumed outside the traditional six food groups in Malawi. The rationale for the new food group of beverages, sweets, sugar, and snacks was based on our previous study in Malawi, which showed that these foods are consumed by many patients with diabetes [6], and since they contain added sugars and refined carbohydrates, they are more likely to negatively affect blood glucose targets. This was evident in patients with T2DM who had significantly higher HbA1c in our previous studies [2,6]. In addition, it was deemed important to align our CC with existing CC resources developed by the American Diabetes Association, and other resources tailored for the Somali, Malian, and Jamaican communities [10–14].

Figure 1.

Figure 1 long description.

Example of a pictorial paper-based carbohydrate-counting resource per food group.

Photos of the food items were displayed with standardized measuring utensils, net weight in grams, total carbohydrate content, and the number of carb counts or choices. We also presented the food names in English and Chichewa, the common local language in Malawi. We provided a detailed, pictorial paper-based CC resource as a PDF in Supplemental Material 1. To complement the information presented in Figure 1, additional details are provided in Table 1. For all the food items in the pictorial paper-based CC resource, the information includes the food group, food item/dish, serving size, net weight of the edible portion, energy, total carbohydrate, number of carb count/choices, protein, and fat content. This information will guide clinical dietitians and patients in assessing the energy and macronutrient composition of the food items.

Table 1.

Summary of energy, macronutrients, and carbohydrate count/choice per serving of the food item based on the pictorial paper-based resource

Table 1 long description.

Food group	Food item/dish	Serving size	Net weight (g, edible portion)	Energy (Kcal)	Total carbohydrates (g)	Fiber (g)	No. carbohydrates count/choice	Protein (g)	Fat (g)
Staples	Cassava, fermented, thick porridge (Nsima ya kondowole)	1/3 cup	104	67	15	1	1	0	0
	Maize, thick porridge, degermed-dehulled flour (Nsima ya galamilu)	1/2 cup	123	89	17	0	1	3	1
Vegetables: starchy and non-starchy	Peas, cooked, oil added (Nsawawa zokazingila)	1/2 cup	93	95	14	5	1	5	8
	Pumpkin, boiled (Dzungu lowiritsa)	1 small piece. 5.5 cm long and 7.5 cm in diameter	110	66	14	2	1	2	0
	Okra, stew (Therere lokupa)	1/2 cup	114	44	7	3	0	2	0
	Pumpkin, leaves, cooked, groundnut flour added (Nkhwani otendera)	1/2 cup	118	97	6	2	0	5	6
Fruits	Tangerine, peeled (Nachesi)	1 small	86	42	11	2	1	1	0
	Pawpaw (Papaya)	1 cup	142	68	15	3	1	1	0
Legumes	Cowpeas, dry, cooked, oil added (Cowpeas stew) (Khobwe okazingila)	1 cup	225	90	14	3	1	1	2
	Beans, dry, boiled, oil added (beans stew) (Nyemba zouma zokazingila)	1 cup	220	108	17	7	1	6	2
Milk and milk products	Milk, full cream, powder (Mkaka wa ufa osawenga mafuta)	4 tablespoon	30	152	12	0	1	7	8
	Milk, fermented/cultured (Chambiko)	1 cup	250 ml	160	11	0	1	8	9
Meat and meat products	Fish, whole, roasted (Utaka owotcha)	4 small	42	147	0	0	0	21	7
	Beef, lean steak, stew ((Mnofu wa nyama ya ng’ombe yokazingila)	3 small pieces	86	105	0	0	0	15	5
Fats and oils	Margarine (blue band), (Majarine	1 tablespoon	12	54	0	0	0	0	6
	Peanut butter, no sugar added (Pinati/chiponde chosathira shuga)	1 tablespoon	15	96	4	3	0	2	3
Beverages, sugar, sweets, and snacks	Black tea with one tablespoon of sugar added (Tiyi wamasmaba othira shuga)	1 cup	250 ml	52	13	0	1	0	0
	Honey (Uchi)	1 tablespoon	20	61	17	0	1	0	0

Phase 2: Mobile app prototype development

We used a user-centered/user experience approaches [24] to develop a mobile app prototype. This approach is iterative and involves the main users, in our case, clinical dietitians, in the development and testing process by focusing on their needs and experiences to ensure usability and easy adoption in practice [24–27]. Multiple virtual meetings and two in-person workshops were held with five clinical dietitians from Kamuzu and Mzuzu Central Hospitals, as well as two expert app developers. Prior to the workshops, Zoom meetings were held with the clinical dietitians to introduce the pictorial paper-based CC resource, to gather feedback on whether the food items or dishes reflected what patients with diabetes frequently mentioned during nutrition education and counseling sessions, and to discuss which features the app should include to improve dietetic services. At the first in-person workshop, the primary researcher presented a draft pictorial paper-based CC resource to gather input from clinical dietitians and to discuss the initial prototype of the mobile app, to guide the app developers. Clinical dietitians and app developers drew on their prior experience with various nutrition apps to brainstorm the key features for the CC mobile app. The goal was to develop an app with features that would be simple and easy to navigate, considering the demographics of patients with diabetes in Malawi. Then, the clinical dietitians drew the desired app features on paper for visualization and shared them with the app developers. More specifically, the researchers wanted to establish high-fidelity prototypes, similar to those in Bonet-Olivencia et al. (2023), that would be viable and user-friendly for the user testing phase [24]. Feature finalization was based on a literature review and consensus among the clinical dietitians, primary researchers, and app developers. The app developers received a pictorial paper-based CC resource to incorporate into the app, aligned with the agreed-upon features. Regular Zoom meetings were held among the primary researchers, app developers, and clinical dietitians to ensure that prototype development met the end users’ needs. During the second workshop, app developers presented the prototype, and clinical dietitians tested it by entering data and navigating its features to inform and refine the prototype. Clinical dietitians provided feedback on the content, layout, navigation, and areas needing improvement. The revised prototype was subsequently tested in the third phase of the formative feasibility assessment in a clinical setting by the clinical dietitians.

The mobile app features (Figure 2) include:

Figure 2.

Figure 2 long description.

Mobile app carbohydrate-counting resource features.

1. A profile tab, which encompasses age in years, height in meters, and weight in kilograms, and then calculates the body mass index. The information provided in the profile was used to estimate the individual’s total energy needs using 25–30 kilocalories per kilogram of body weight, based on European Society for Parenteral and Enteral Nutrition guidelines on hospital nutrition [34], focusing on the standard and hospital diets as typically used in Malawi. We used the estimated energy to estimate Acceptable Macronutrient Distribution Ranges based on dietary reference intakes for healthy adults of 45–55% for carbohydrates, 10–35% for protein, and 20–35% for fat [35–37].

2. Carbohydrate (carb) information tab, providing details on all the foods included in the app, the food groups, and for each selected food, it displays its total carbohydrate content and the number of carb counts.

3. Food comparison tab: which allows users to choose foods within the same food group and compare their energy, total carbohydrate, fiber, carb count, protein, and fat content.

4. The CC tab allows users to add different types of foods, and it will display the total energy, total carbohydrates, carb count, fiber, protein, and fat content of all the food items added.

5. Meal planning tab: users can plan meals for breakfast, lunch, dinner, and snacks for a specific number of days. Based on the meal plan, the app calculates energy and macronutrient intake and displays the percentage of estimated requirements, thereby indicating the extent to which normal ranges are met.

Phase 3: Qualitative formative feasibility study

The five clinical dietitians from the two referral hospitals (Kamuzu and Mzuzu Central Hospitals) volunteered to use the mobile app and pictorial paper-based CC resources for 10 working days as part of their routine clinical nutrition workflow. The resources were used for dietary education, counseling, and meal planning for both inpatient and outpatient adults with diabetes. Subsequently, in-depth individual interviews with each clinical dietitian were conducted via Zoom to elucidate their perceptions of the tool(s) and to elicit experiences, challenges, and potential areas for improvement for both the mobile app and the pictorial paper-based CC resources. Two researchers (moderator and note taker) conducted the interviews, which were audio-recorded. Each interview lasted an average of 50–65 minutes, after which the moderator and the note taker debriefed and shared the notes. More specifically, the moderator summarized the main points, and each participant was asked to confirm the content and to identify any additional points or areas requiring clarification. The following questions guided the interview:

Interview guide for the in-depth interviews

1. What are your experiences with the CC resources (mobile app and pictorial paper-based) after using them for ten working days in your daily clinical workflow?

2. What are your general thoughts about these tools?

   • Probe: How acceptable and feasible do you find these tools for dietetics counseling, education, and meal planning, especially for patients with diabetes?
3. How user-friendly are these tools to use for dietary education and counseling, especially for patients with diabetes?

   • Probe: How easy would these tools be for patients with diabetes to understand?

4. What are some advantages of incorporating these tools into your daily routine when providing dietary diabetes education and counseling sessions?

5. What challenges did you face while using the tools during dietary education and counseling sessions with patients with diabetes?

6. What are your suggestions for improving these tools, that is, the mobile app, and the pictorial paper-based version?

   • Probe: What are some examples of things that might be helpful a) to you as a professional, and b) to the patient with diabetes?

Data analysis

The audio recordings were transcribed verbatim by a trained graduate research assistant and the primary researcher. Transcriptions were compared with the interview notes to ensure data accuracy, and a brief discussion was held between the research assistant and the primary researcher to further validate the data. Using the six steps of thematic analysis and following an inductive approach [38,39], the qualitative data were coded line-by-line in two phases by four trained research assistants. During the first phase of data analysis, two research assistants independently coded the data manually and then met to discuss the emerging codes and any discrepancies until consensus was reached. Furthermore, to establish credibility and rigor, two additional research assistants also independently coded the data and met to discuss the emerging codes, thereby confirming the codes identified in the first phase of coding and ensuring alignment. We compared two sets of the coded data to identify common codes which were then summarized into the emerging theme, subthemes, and matched with supporting direct quotes [38,39].

Ethical consideration

The National Health Sciences Research Committee in the Ministry of Health in Malawi approved the study (protocol number 23/03/4017). Permission to conduct the study at two hospitals, Kamuzu and Mzuzu Central Hospitals, was sought. Each clinical dietitian provided written informed consent to participate in the study.

Results

Emerging themes from qualitative formative feasibility study

The clinical dietitians involved in the feasibility study comprised of two males and three females, all having a Master of Science in Clinical Dietetics and with more than three years of clinical practice. As presented in Table 2, four main themes and subthemes, with supporting direct quotations, emerged after the clinical dietitians piloted both the pictorial paper-based and the mobile app CC resources. These include:

Table 2.

Emerging themes, subthemes, and direct quotes

Table 2 long description.

Emerged themes	Subthemes	Direct quotes
Easy and feasible to use	It is easy to navigate from one tab to another. Easy to teach patients about portion sizes using graphics. The presence of pictures of local foods and measuring utensils. The tools are viable for meal planning and controlling portion sizes.	“The tabs on the mobile app are easy to navigate. There was no challenge in moving from one tab to the other; it’s straightforward. You click the food, and it gives you the nutrients it has.” “The presence of pictures makes it easy to provide counseling and estimate portion sizes since dietitians do not have food models in our offices and we do not have to Google all the time.” “…I feel like this app is easy to use, it’s good, it’s something that I should always have… and I think every dietitian in Malawi should have this app because to me, as I’ve used it, I think it makes work easier.”
Beneficial to dietetic practice	It is easier to estimate portion sizes and calculate carbohydrate and energy intake using local specifications than by searching online. The app helps to reduce carb-counting errors and guesswork. The tools facilitated dietary assessment of the patients. The mobile app supported one-on-one counseling, and pictorial paper-based materials supported group education. Paper-based made it easy for patients to visualize and understand portion sizes and food choices.	“… [Without the tool], we were just writing down the meals and then calculating them manually. But with this app, we can just point out, and it will calculate meals and nutrients. So, it’s a bit timesaving, not even a bit, it’s timesaving.” “…This will be beneficial to our profession, because if we look at the number of dietitians [compared to] clients that we serve, the ratio is just too small; we are very few. So, with the use of this app, which is time-saving and easy, it will help us to serve more clients within a short period of time.” “I’m at the bedside. I want to develop a diet plan for the patient. I’ll have to Google food items and estimate the nutrient content. So, I may develop a diet plan using uncommon foods. But when I’m using this app on the bedside or not, I can come up with the meal plan, and I know exactly what food items the patient eats, the amount, and their kilocalories, and macronutrients provided.”
Challenges with using the pictorial paper-based and mobile app	The app requires a smartphone and a higher level of literacy. It might take some time for the patient to get used to navigation (2–3 days) when using the app. The paper-based method is time-consuming and requires manual nutrient calculations.	“The mobile app requires a smartphone, and those with low literacy levels find it hard to use, but we have a paper-based carb-counting resource, though it is time-consuming for us dietitians.” “Using the paper-based method, you had to manually calculate all the nutrients, like the carbs they ate, unlike the mobile one, which did it automatically.”
Perceived areas requiring improvement	Improve quality of some pictures Add more local foods and translate them into local language. Add a notification feature.	“For the paper-based, improve the quality of some pictures and make them big because most patients with diabetes have eye problems—for example, some clients were not able to detect the differences in different sizes of some foods, yet the writing indicated that they were different in terms of grams, so I think it was the angling issues.” “It would be helpful to have notifications for the patients. I feel like the patients can easily forget to use the app because [it’s new to them] and we need to have a notification feature to remind the patients.”

Theme 1: Ease and feasibility of use

Clinical dietitians found that both tools were practical and compatible with current clinical workflows, owing to the inclusion of food portion images, representation of local foods, and the mobile app’s simple, easy-to-understand, and user-friendly tab navigation. One clinical dietitian stated, “…I feel like this app is easy to use, it’s good, it’s something that I should always have… and I think every dietitian in Malawi should have this app because to me, as I’ve used it, I think it makes work easier.” Displaying local foods in various portion sizes aided dietary counseling for patients with diabetes. Another clinical dietitian added, “The presence of pictures makes it easy to provide counseling and estimate portion sizes since dietitians do not have food models in our offices and we do not have to Google all the time.”

Theme 2: Beneficial to dietetic practice

The clinical dietitians reported that the pictorial paper-based CC was preferred by patients and made it easier for them to see portion sizes, take notes, and choose foods. However, the clinical dietitians liked the mobile app and found both tools helpful for dietary assessment and for communicating with patients with diabetes about their diet. They found that the resources saved time, allowing them to see more patients with diabetes, reduced errors and guesswork in dietary assessments, and supported dietary counseling and nutrition education. For example, one clinical dietitian said, “…This will be beneficial to our profession, because if we look at the number of dietitians [compared to] clients that we serve, the ratio is just too small; we are very few. So, with the use of this app, which is time-saving and easy, it will help us to serve more clients within a short period of time.” The CC resources also helped with meal planning for both inpatient and outpatient adults with diabetes. One dietitian explained, “I’m at the bedside. I want to develop a diet plan for the patient. I’ll have to Google food items and estimate the nutrient content. So, I might develop a diet plan using uncommon foods. But when I’m using this app on the bedside or not, I can come up with the meal plan, and I know exactly what food items the patient eats, the amount, and their kilocalories, and macronutrients provided.”

Theme 3: Challenges with using the pictorial paper-based and mobile app

Challenges with the CC resources included the need for smartphones and a certain level of literacy to use the mobile app, which can create barriers for patients from diverse sociodemographic backgrounds, as well as the need for more time to learn how to use the app. Clinical dietitians also reported that using pictorial paper-based CC increased the time spent with patients, thus not time-saving. For example, one clinical dietitian said, “The mobile app requires a smartphone, and those with low literacy levels find it hard to use, but we have a paper-based carb-counting resource, though it is time-consuming for us dietitians.”

Theme 4: Perceived areas requiring improvement

Clinical dietitians suggested ways to improve both the pictorial paper-based and mobile app CC resources. They recommended clearer images to help patients with vision impairments, particularly for distinguishing food portion sizes in the pictorial paper-based version. It was mentioned that, “For the paper-based, improve the quality of some pictures and make them big because most patients with diabetes have eye problems—for example, some clients were not able to detect the differences in different sizes of some foods, yet the writing indicated that they were different in terms of grams, so I think it was the angling issues.” They also proposed adding a notification feature in the mobile app to allow users to receive individualized alerts.

Discussion

Studies show that adherence to diabetes self-management education support (DSMES) is low when not tailored to patients’ needs, especially in low-resource settings and among those with low literacy [3,4,20,21,40]. To address this, we developed a pictorial paper-based CC tool for clinical dietitians to use during counseling to help low-literacy patients better understand suggested portion sizes of local foods. We then adapted the tool into a mobile app for clinical dietitians and higher-literacy smartphone users. The context-tailored CC materials align with DSMES recommendations by providing culturally tailored diabetes education resources that promote patients’ self-care, informed decision-making, and healthy eating, with the goal of optimizing health outcomes [41]. Clinical dietitians used both CC resources in routine clinical care and found them user-friendly, which helped in dietary assessment, counseling, education, and meal planning. As a result, clinical dietitians were able to serve more patients with diabetes. These findings suggest that both culturally tailored CC resources could be a helpful means of providing diabetes education/interventions, either alone or together, depending on patient ability, thereby reducing barriers to accessing evidence-based nutrition information for optimal diabetes care.

Context-specific diabetes education programs and interventions that address the needs of patients with diabetes have been shown to improve patients’ nutrition behaviors, diabetes knowledge, self-monitoring of blood glucose, confidence, patient empowerment, participation in diabetes education, and clinical outcomes, particularly HbA1C [17,18,20,42–44]. Therefore, developing a pictorial paper-based and mobile app CC that incorporates foods commonly consumed by patients with diabetes in Malawi provides an easy-to-interpret, reliable source of dietary information for patients, which can improve dietary knowledge and adherence and ultimately help achieve glycemic targets when used as a guidance tool. Furthermore, a simplified pictorial paper-based and mobile app CC addresses challenges identified in our previous studies, specifically conflicting dietary information sources, high-carbohydrate diets, and the associated difficulty in achieving optimal glycemic targets [3,6].

The use of mobile applications in dietetics practice as a source of nutrition information for patient nutrition education and counseling, patient communication, and patient self-monitoring is increasingly common [45–48]. Clinical dietitians are uniquely positioned to provide expert dietary education to patients with diabetes [49–51]. Therefore, in this study, clinical dietitians were involved in the development and testing of the mobile app and pictorial paper-based CC to support its implementation in dietetic practice. The mobile app and pictorial paper-based CC resources were perceived as beneficial for dietitians, as they facilitated dietary assessment and meal planning, were easy to use and feasible, and helped dietitians to assist more patients with diabetes. Previous studies showed that involving dietitians in app development and in educational and skills-building sessions on integrating apps into dietetic practice provided evidence-based dietary information, facilitated familiarity and usability with the app, and improved dietitians’ self-efficacy in incorporating the app into their existing workflow, thereby enhancing the quality of patient care [46,52].

Strengths and limitations

A primary strength of the study was the development of a pictorial paper-based CC that incorporated traditional foods, which will help patients with diabetes and those with limited literacy to recognize familiar foods and better visualize portion sizes. In addition, the clinical dietitian’s involvement in developing and pilot testing, in a clinical setting, both the mobile app and the pictorial paper-based CC, authenticated the process. Limitations include the use of only two clinical sites and the lack of qualitative data from patients to close the loop on the user-centered/user experience designs; however, the forthcoming results on the effectiveness of using both pictorial paper-based and mobile app CC in nutrition education and counseling on patients’ CC knowledge and glycemic status will help to offset this limitation. Future efforts to further develop and expand feasibility testing should also involve patients with diabetes, caregivers, and other healthcare providers, such as nurses, and clinicians. Furthermore, it would be helpful to extend sites to community settings to test sustained/extended application and use. Since the qualitative data focused on integrating CC materials into existing clinical workflows, even though not used formally, the general principles associated with the Consolidated Framework for Implementation Research [53,54] guided the feasibility assessment component of this study. More specifically, we considered barriers and facilitators to provide insights into the factors influencing implementation processes from the clinical dietitian’s perspective [53,54].

Conclusions

The context-specific CC materials developed were considered easy to use and practical, with the potential to benefit both dietitians and patients with diabetes. However, results on the effectiveness of materials aimed at patients diagnosed with both type 1 and type 2 diabetes delivered through nutrition education and counseling will further validate the tools.

Supporting information

Mphwanthe et al. supplementary material

Mphwanthe et al. supplementary material

Figure 1. Long description

An example of the pictorial paper-based CC resource, showing two food items per food group. The food groups are: staples, fruits, fats and oils, legumes, and vegetables (both starchy and non-starchy), meat and meat products, milk and milk products, and beverages, sweets, sugar, and snacks.

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Table 1. Long description

Table 1 complements the information presented in Figure 1. For all the food items in the pictorial-paper-based CC resource, the information includes the food group, food item/dish, serving size, net weight of the edible portion, energy, total carbohydrate, number of carb count/choices, protein, and fat content.

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Figure 2. Long description

An example of a mobile app with its features. The features include: 1) A profile, 2) carbohydrate (carb) information, 3) food comparison, and 4) meal planning.

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Table 2. Long description

Table 2, represents four main themes and subthemes, with supporting direct quotations, emerged after the clinical dietitians piloted both the pictorial paper-based and the mobile app CC resources.

Navigate back to Table 2..

Supplementary material

The supplementary material for this article can be found at https://doi.org/10.1017/cts.2026.10787.

Data availability statement

Data will be made available upon reasonable request to the corresponding author.

Author contributions

Getrude Mphwanthe: Conceptualization, Funding acquisition, Investigation, Methodology, Supervision, Visualization, Writing – original draft, Writing – review & editing; Bridget Mkama: Formal analysis, Investigation, Visualization, Writing – review & editing; Humphrey Chatenga: Formal analysis, Visualization, Writing – review & editing; Lydia Lowe: Formal analysis, Visualization, Writing – original draft, Writing – review & editing; Lorraine Weatherspoon: Conceptualization, Funding acquisition, Methodology, Writing – original draft, Writing – review & editing.

Funding statement

This research was supported by UNESCO-The World Academy of Sciences, Seed Grant for New African Principal Investigators (SG-NAPI). SG-NAPI Agreement No. 4500454080.

Competing interests

Authors declare no potential conflict of interest.