European Journal of Clinical Nutrition (2018) 72:879–887
Using digital photography in a clinical setting: a valid, accurate, and
applicable method to assess food intake
Received: 2 August 2017 / Revised: 23 January 2018 / Accepted: 7 February 2018 / Published online: 21 March 2018
© Macmillan Publishers Limited, part of Springer Nature 2018
Background/objectives Regular monitoring of food intake is hardly integrated in clinical routine. Therefore, the aim was to
examine the validity, accuracy, and applicability of an appropriate and also quick and easy-to-use tool for recording food
intake in a clinical setting.
Subjects/methods Two digital photography methods, the postMeal method with a picture after the meal, the pre–postMeal
method with a picture before and after the meal, and the visual estimation method (plate diagram; PD) were compared
against the reference method (weighed food records; WFR). A total of 420 dishes from lunch (7 weeks) were estimated with
both photography methods and the visual method. Validity, applicability, accuracy, and precision of the estimation methods,
and additionally food waste, macronutrient composition, and energy content were examined.
Results Tests of validity revealed stronger correlations for photography methods (postMeal: r = 0.971, p < 0.001;
pre–postMeal: r = 0.995, p < 0.001) compared to the visual estimation method (r = 0.810; p < 0.001). The pre–postMeal
method showed smaller variability (bias < 1 g) and also smaller overestimation and underestimation. This method accurately
and precisely estimated portion sizes in all food items. Furthermore, the total food waste was 22% for lunch over the study
period. The highest food waste was observed in salads and the lowest in desserts.
Conclusions The pre–postMeal digital photography method is valid, accurate, and applicable in monitoring food intake in
clinical setting, which enables a quantitative and qualitative dietary assessment. Thus, nutritional care might be initiated
earlier. This method might be also advantageous for quantitative and qualitative evaluation of food waste, with a resultantly
reduction in costs.
About 20–60 % of hospitalized patients are affected by
malnutrition [1, 2]. Guidelines recommend screening all
patients for malnutrition. If nutritional risk or malnutrition
exist, a nutritional assessment, nutrition care plan, and
monitoring of food intake should follow thereafter .
Nutritional monitoring is an extensive evaluation of food
intake and has the potential to identify patients who do not
meet their nutritional requirements in an early stage [4, 5].
Regarding hospitalized patients, food intake is often
suboptimal [6, 7] and, however, nutritional monitoring is
rarely integrated in clinical routine . Major barriers,
besides the lack of knowledge and poor awareness of
caregivers, might be the absence of a quick and easy-to-
use monitoring tool which is also at the same time accu-
rate and precise. Traditional dietary assessment methods,
such as weighed food records (WFR) aretime-
consuming and disturbing for the clinical setting and
therefore not implementable .
Various research groups have used digital photography
for recording food intake in different collectives such as in
cafeteria or free-living conditions [11–17]. It might be
advantageous in numerous aspects, as digital photography
offers information about the meal components eaten and
* Maria Luger
Center for Public Health, Department of Social and Preventive
Medicine, Medical University of Vienna, Kinderspitalgasse 15/1,
1090 Vienna, Austria
Special Institute for Preventive Cardiology And Nutrition –
SIPCAN, Rabenﬂeckweg 8, 5061 Elsbethen, Salzburg, Austria
Department of Internal Medicine III, Division of Endocrinology &
Metabolism, Medical University of Vienna, Währinger Gürtel 18-
20, 1090 Vienna, Austria
Electronic supplementary material The online version of this article
(https://doi.org/10.1038/s41430-018-0126-x) contains supplementary
material, which is available to authorized users.