Formative Research to Develop a Prototype of Sugar-sweetened

Beverages Monitoring Application for Obesity Management

among Indonesian Adolescents

Eka Febriyanti

, Ratih Yulistika Utami

, Febrina Dewi Pratiwi Lingga

Department of Nutrition, Faculty of Medicine, University of Muhammadiyah Sumatera Utara, Medan, Indonesia

Medical Education Unit, Faculty of Medicine, University of Muhammadiyah Sumatera Utara, Medan, Indonesia

Department of Dermatovenereology, Faculty of Medicine, University of Muhammadiyah Sumatera Utara, Medan,

Indonesia

Keywords: Prototype, Application, Sugar-Sweetened Beverages, Formative Research, User Acceptance Test

Abstract: The increase in obesity prevalence in adolescents is caused by passive overconsumption, such as the intake

of sugar-sweetened beverages (SSB). There are limited useful applications that can help people to monitor

calories and sugar from drinks. We aimed to investigate the SSB application requirement, develop, and

explore the acceptance of a prototype SSB application. This study was conducted in three stages: formative

research, development, and acceptance of the prototype application. The formative research employed

qualitative methods to provide information from 17-22 years in Medan to plan the application development.

The stage of development included selecting a developer, selecting the programming language, and designing

the application. An acceptance test was performed among 100 adolescents in Medan afterward. Participants

required an informative, easy, and exciting application. EduDrink is a prototype application to monitor calorie

and sugar intake of SSB that has simple features, educational videos, notifications, a food database, estimated

portion sizes, and regular monitoring charts. The EduDrink prototype has excellent acceptance regarding

content, graphic, and flow applications. This prototype can be further developed into a mobile application for

validation in obesity management.

1 INTRODUCTION

The prevalence of obesity increases significantly over

the years. Basic Health Research Data (Riskesdas) in

2013 showed that 10.8% of adolescents aged 13-15

years in Indonesia had an overweight problem,

consisting of 8.3% overweight and 2.5% obesity.

There was also an increasing trend in the incidence of

being obese from 1.4% in 2007 to 7.3% in 2013 in

adolescents over the age of 15 years (Kemenkes,

2013).

This increasing trend can be caused by ignorance

in choosing beverages. Sugar-sweetened beverages

(SSB) are added with simple sugars during the

production process, adding energy content with little

nutritional content (McGrath et al., 2012; Miller et al.,



https://orcid.org/0000-0002-6689-4161

https://orcid.org/0000-0001-8360-4210

https://orcid.org/0000-0001-9252-5901

2019). Research at Harvard University (2009) found

that in 300-500 ml serving of sweetened drinks,

Indonesia's unit contains 37-54 grams of sugar. The

amount of sugar content is four times more than the

recommendation for a safe added sugar content, 6-12

grams (Harvard University, 2009).

Sugar sweetened-

beverages are the favorite drinks consumed by

teenagers. In America, adolescents aged 12-19 years

consume as much as 65.4% SSB at least one time per

day (Bleich and Vercammen, 2018). Basic Health

Research data shows the proportion of SSB intake in

Indonesia ≥ 1 times a day at ≥ 10 years of age reaches

53.1% (Kemenkes, 2013).

According to the British

Soft Drinks Association, SSB is divided into several

types, namely: carbonated drinks, dilutable, fruit

juices, still/ juice drinks, sports/energy drinks (

The

British Soft Drinks Association, 2014).

The high energy

Febriyanti, E., Utami, R. and Pratiwi Lingga, F.

Formative Research to Develop a Prototype of Sugar-sweetened Beverages Monitoring Application for Obesity Management among Indonesian Adolescents.

DOI: 10.5220/0010486900100014

In Proceedings of the 1st Jenderal Soedirman International Medical Conference in conjunction with the 5th Annual Scientiﬁc Meeting (Temilnas) Consortium of Biomedical Science Indonesia

(JIMC 2020), pages 10-14

ISBN: 978-989-758-499-2

and sugar content in these drinks have an impact on

health in the form of weight gain, obesity, type 2

diabetes mellitus, dental caries, and the risk of

cardiovascular disease (Miller et al., 2019; Scharf and

DeBoer, 2016; Bleich and Vercammen, 2018).

Besides, SSB usually does not have the same satiety

effect as solid food. There is a tendency to consume

other foods to feel fuller, leading to higher calorie

consumption (Pan and Hu, 2011; Bachman et al.,

2006).

The use of technology-based mobile applications

has also increased its use in obesity prevention

because it is flexible, cost-effective, and easily

accessible (Paul et al., 2016). Obesity management in

the form of lifestyle interventions in the future

requires specific control, self-monitoring with mobile

applications, pharmacotherapy, education via the

internet, meal changes, and telephone interventions to

increase its success (Mahan and Raymond, 2017).

This phenomenon is also supported that smartphone

usage is getting bigger in the era of the 4.0 industrial

revolution, with more than 100 million users in

Indonesia in 2015. This number is predicted to reach

5 billion users in 2019 globally (Anderl, 2015;

Kemenkominfo, 2015). At present, technology

development is very rapid, including medical science.

Still, only a few applications exist in nutritional

science to monitor calories and food. There is no

Android technology-based application to monitor

SSB intake to control and prevent the increase in

obesity rates, hypercholesterolemia, and the risk of

other diseases. So, we want to create a prototype

application for monitoring SSB intake as one of self-

monitoring in preventing obesity.

2 MATERIALS AND METHODS

We developed a prototype of a mobile application

called EduDrink. EduDrink (Education and Drink)

can monitor calorie and sugar intake on SSB and

provide education according to the results. This

prototype can guide people to achieve weight loss or

maintain healthy body weight by self-monitoring

their calorie intake, sugar intake, and educational

video advice. People can also track their targets such

as their weight loss, Body Mass Index (BMI), calorie

intake, and sugar intake.

The study had three stages: formative research,

development of the mobile application prototype, and

the acceptance of the application prototype. The

formative research used qualitative methods to

provide users with information to plan the mobile

application prototype's development. The

development stage included selecting a developer,

selecting the programming languages, and designing

the application. The acceptance test was performed

among adolescents in Medan after the development

stage.

The formative research process is a critical step in

developing the application prototype. The feasibility

and the acceptability of the application were tested in

focus group discussions (FGD). The subject consisted

of 10 participants, divided into two focus groups aged

17-22 years. The participants were students in the

Faculty of Medicine University of Muhammadiyah

Sumatera Utara, Medan, Indonesia. They were asked

about their prior knowledge in SSB, history of using

food records, history of using the dietary mobile

application, and the kind of expected application. The

subjects were recruited in February 2020. Inclusion

criteria included being 17-22 years old, apparently

healthy, and owning an Android smartphone.

In the development stage, we collaborated with

application developers and graphic designers. The

application developers and the graphic designers

worked together to develop the application prototype

according to the FGD and literature input.

The acceptance stage was performed among

students in Medan after the development stage. The

subject consisted of 100 adolescents living in Medan,

Indonesia, who were recruited in May 2020. Inclusion

criteria included being 17-22 years old, apparently

healthy, and owning an Android smartphone. For

testing the application's acceptance, each subject was

provided the application to install it into their android

smartphone. Each subject received instructions and

was shown how to use the EduDrink app. The

subjects were interviewed to discover the acceptance

of EduDrink in terms of contents, design, and flow of

the application. They were also asked to comment on

its limitations, advantages, and suggestions for future

improvements.

The investigators designed a sociodemographic

survey to gather general sociodemographic

information, namely age, and sex. In the acceptance

stage, the sociodemographic information was based

on age and sex. The prototype allowed users to input

their weight, height, and date of birth to calculate

BMI and get the nutritional status and total energy

expenditure. The prototype also allowed users to

enter a particular type of beverage and obtain its

nutrition facts to be used as a dietary record.

Descriptive analysis was performed to describe

the characteristics of subjects and the acceptance of

EduDrink. The qualitative analysis was performed to

describe the formative research by matrix analysis.

Formative Research to Develop a Prototype of Sugar-sweetened Beverages Monitoring Application for Obesity Management among

Indonesian Adolescents

3 RESULTS

Table 1 describes the subject characteristics of FGD.

FGD subjects were 70% women and predominantly

aged 19-20 years.

Table 1: Characteristic of subjects in formative research.

Variable n

(

)

Sex

Male 3

(

)

Female 7(70)

Age (years)

17-18 3(30)

19-20 6

(

)

21-22 1

(

)

Table 2 describes the subject characteristics for

User Acceptance Test. The subject was

predominantly female with an age range of 19-20

years. All subjects have android at least the last six

months.

Table 2: Characteristics of subjects in development and

acceptance test of EduDrink.

Variable n (%)

Sex

Male 23

(

)

Female 77(77)

Age (years)

17-18 13(13)

19-20 76

(

)

21-22 11

(

)

Time of havin

an android smart

hone

<6 months 0(0)

≥Six months 100(100)

It was found that the subjects were not very

familiar with SSB, including the calories and sugars

contained therein. The hope of an application that is

easy to use, interesting and informative (Table 3). It

can be understood that EduDrink is well accepted in

terms of its content, graphic, and flow app. However,

some parameters are below 70%, such as an

appropriate font size (67%) and an attractive

appearance (69%). Those were shown in table 4.

Detailed SSB items (name of SSB, portion size,

and nutrient) and educational video were uploaded

into the database server in the development stage. The

exact food items (SSB) were uploaded from the

database of NutriSurvey. Educational videos were

made based on SSB energy and sugar sufficiency

figures and uploaded manually into the database

server. The formulation of the Body Mass Index and

total energy expenditure based on the Harris-Benedict

formula were also uploaded to calculate the

nutritional state and the total energy expenditure

individually. This application also has a push

notification reminder if any gap from the

recommendation of calories and sugar deviates from

the required amount.

Table 3: Focus group discussion result based on matrix

analysis (n=10).

Topic Quotation

Understanding SSB SSB is a sweetened

drink containing added

sugar, drinks with

artificial sweeteners

such as canned drinks

and boxes. The effects

of SSB on health are

obesity, diabetes,

stimulate thirst as it

contains high calories.

How to control SSB

consumption

Unable to know the

amount of calorie or

sugar in a drink, unless a

Boba drink and a

packaged drink, which

included its composition

/nutrition facts on the

back label

Understanding about food

record

Do not know

To do a food record with

paper-based, web-based,

mobile-apps

Preferably using mobile

applications because it

is easy, efficient, and

mobile

Using dietary mobile apps

efore

Know but do not use it

Helpful features There is information on

the type of drink, the

amount of calorie, the

right menu with a simple

application to enter a

drink with a picture, or

the menu is in the form

of images and writing

Level of boredom filling

dietary mobile app

It depends on features

and input frequency

How mobile apps are

expected to be

Easy to use, simple,

attractive, informative,

and user-friendly

JIMC 2020 - 1’s t Jenderal Soedirman International Medical Conference (JIMC) in conjunction with the Annual Scientiﬁc Meeting

(Temilnas) Consortium of Biomedical Science Indonesia (KIBI )

Table 4: Acceptance of EduDrink (n=100).

Parameters

(

)

Goo

Moderate Poo

Understanding of

information

84(84) 16(16) 0(0)

Understanding of

terminolog

77(77) 22(22) 1(1)

Appropriate food

icture

76(76) 24(24) 1(2)

Appropriate

information

83(83) 17(17) 0(0)

Ability to monitor the

goal

77(77) 22(22) 1(1)

Know calorie intake

and the com

osition

77(77) 22(22) 1(1)

Know nutrition facts 75 (75) 22(22) 3(3)

Useful reminde

76(76) 23(23) 1(1)

Useful information 80(80) 20(20) 0(0)

Gra

hic

Attractive color

combination

75(75) 22(22) 3(3)

Appropriate font size 67(67) 31(31) 2(2)

Attractive a

earance 69

(

)

(

)

(

)

Flow a

Understanding of

comman

82(82) 17(17) 1(1)

Easy step to input

everages

75(75) 25(25) 0(0)

Easy to track the

calorie intake and its

composition

86(86) 13(13) 1(1)

4 DISCUSSION

This study aims to investigate the requirement

(content, feature, and design), to develop, and to

explore the acceptance (content, feature, and design)

of a mobile application prototype based on SSB. As

we know, formative research is crucial to do in

developing this intervention. We found that a dietary

mobile app's expected requirements are easy to use,

informative, and enticing through the study.

According to Duff et al., the technical aspects of the

application (such as push notifications and the user

interface) and interactive contents are the techniques

to modify a healthy behavior (Duff et al., 2016). So

we have applied all of these in the prototype that we

have developed.

In the development process, the EduDrink mobile

application prototype is a tool to record dietary data

and to give the individuals educational videos based

on the number of calories and sugar that they should

be restricted. EduDrink also gives some health

videos, push notifications, food databases, and

estimated portion sizes to improve compliance in the

long term for dietary interventions. Ananda et al. said

that mobile applications might be an innovative tool

for an individual's health behavior change

intervention (Ananda et al., 2016). This process's

limitation was the availability of the Indonesian food

composition table that is important data to estimate

the nutrient intake. All food databases in EduDrink

are from Nutrisurvey 2007 food database, but the

database is not up-to-date (Ananda et al., 2016).

This application prototype is also equipped with

nutrition education related to monitoring individual

calorie and sugar intake. Nutrition education is

adjusted to the amount of individual calorie and sugar

intake per day. Education that utilizes unique factors

on online platforms is an effective intervention to

change behavior, which can reach a larger sample size

(Murimi et al., 2019; Backinger et al., 2011).

Visualized nutrition education has a better effect on

increasing fiber intake than un-visualized education

and without education. This effect occurs in culturally

adapted short-duration treatments and is delivered in

series (Li et al., 2018). Several factors influence the

success of online nutrition education interventions,

namely 1) the use of specific messages and individual

feedback; 2) participant involvement, as measured by

the level of interaction between investigators and

participants; 3) duration of intervention for three

months; 4) identification of specific vs. general health

targeted behaviors; 5) alignment of intervention

activities with stated objectives; 6) and the use of

theory-based interventions. On the other hand,

several factors represent the poor design in online

nutrition education interventions, including

comparisons of bias, lack of specific details on

duration or dose, lack of objective measurements, and

lack of tracking systems (Backinger et al., 2011).

EduDrink was found to have a good acceptance

among the users regarding its content, features, and

design. Respondents found EduDrink to be a useful

application, easy to carry and use because of its

typical feature as a paperless food record. However,

some users gave feedback that EduDrink should be

improved for the appropriate font size and more

attractive appearance. This feedback means that

EduDrink also has some good points but needs to be

improved in the future. The Technology Acceptance

Model (TAM) and constructs related to diet

application usage adoption (i.e., Technical Barriers

[TB], Social Norms [SN], Personal Innovativeness

[PINN], and Perceived Enjoyment [PE]). Perceived

Usefulness (PU) and Perceived Ease of Use (PEOU)

are crucial in deciding an individual's aim to use a

particular technology. Okumus and Bilgihan (2014)

stated that diet applications do not only offers tools to

Formative Research to Develop a Prototype of Sugar-sweetened Beverages Monitoring Application for Obesity Management among

Indonesian Adolescents

have utilitarian aims such as losing weight, but they

also have hedonic aims such as the excitement of

using the app. When the goal is to discover ITU in

managing a diet on a smartphone application, the

model should be supported by other theories that

incorporate both utilitarian and nonutilitarian motives

for use. Users may be motivated to use technology

due to PE while using it (Okumus et al., 2015).

5 CONCLUSION

In conclusion, EduDrink has good acceptance

regarding its content, features, and design. The

improvement of this mobile application prototype in

the future might include design problems and food

database update. This prototype can be further

developed into a mobile application for validation to

be used for obesity management.

ACKNOWLEDGEMENTS

Funding was provided by Research Institutions and

Community Service (LPPM) University of

Muhammadiyah Sumatera Utara. There are no

conflicts of interest to disclose.

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JIMC 2020 - 1’s t Jenderal Soedirman International Medical Conference (JIMC) in conjunction with the Annual Scientiﬁc Meeting

(Temilnas) Consortium of Biomedical Science Indonesia (KIBI )