SMARCOS PHILIPS RESEARCH LABS Educational Final Report Master ThesisNiels Molenaar

Empowering Diabetes patients,
support in making healthy food choices;
Help diabetes patients gain insight in the healthy food intake
by giving food information in the supermarket

Final Master Project Draft Report
M2.2
14-04-2011

Niels Molenaar,
niels@nmolenaar.nl
M22 Coach: E.I. Barakova
M22 Assessor: S.A.G. Wensveen
Faculty of Industrial Design, University of Technology, Eindhoven
Brain, Body & Behavior group, Philips Research, Eindhoven
Philips Research Coaches: A. van Halteren & J. Lacroix

Table of Contents
Abstract .......................................................................................... 5
1. Introduction .................................................................................. 7
1.1. Stakeholders ....................................................................................8
1.1.1. Philips Research .................................................................................. 8
1.1.2. SmarcoS ............................................................................................ 8
1.1.3. Personal motivation ............................................................................. 9
1.2. What is type 2 Diabetes ....................................................................9
2. Research .....................................................................................11
2.1. General type 2 Diabetes treatment .................................................... 11
2.1.1. Interview with Diabetes nurse ...............................................................11
2.2. Effects of food intake on type 2 Diabetes ........................................... 11
2.2.1. Literature on food intake .....................................................................11
2.2.2 Interview with dietician ....................................................................... 12
2.2.3. Dietary monitoring ............................................................................ 12
2.3. Effects of activity on type 2 Diabetes.................................................13
2.3.1. Literature on activity .......................................................................... 13
2.3.2. Interview with physiotherapist ............................................................ 13
2.4. Behavior change strategies ..............................................................13
2.4.1. Literature on intervention ................................................................... 13
2.4.2. Technology versus human effects on intervention ................................ 14
2.5. User interviews ..............................................................................14
2.5.1. Interview goals.................................................................................. 14
2.5.2. Method ............................................................................................ 14
2.5.3. Results from interviews in requirements .............................................. 15
2.5.4. Use of requirements for food focus in project ....................................... 16
3. Design........................................................................................ 19
3.1. Vision ............................................................................................19
3.1.1. Context for vision ............................................................................... 19
3.1.2. Motivation for vision ..........................................................................20
3.1.3. Concept Requirements .......................................................................20
3.2. Implementation ..............................................................................21
3.2.1. Shopping bag ....................................................................................21
3.2.2. Interaction with shopping bag .............................................................23
3.2.3. Form of shopping bag ........................................................................24
3.2.4. Technology in shopping bag ...............................................................26
4. Discussion ..................................................................................29
4.1. Relevance of vision ........................................................................ 29
4.2. Application possibilities ................................................................. 29
4.2.1. Different user or context.....................................................................29
4.3. Future research recommendations ................................................... 29
4.3.1. User studies ......................................................................................29
4.3.2. Technological advancements ..............................................................30
4.3.3. Importance of activity vs. diet.............................................................30
5. Conclusion ..................................................................................33
6. Bibliography................................................................................35
7. Appendices .................................................................................39
7.1. Appendix 1: Interview Diabetes Nurse ................................................ 39
7.2. Appendix 2: Interview Diabetes Dietary Expert ................................... 42

EMPOWERING DIABETES PATIENTS, SUPPORT IN MAKING HELATHY FOOD CHOICES | page 2

7.3. Appendix 3: Interview Diabetes Physiotherapist.................................. 45
7.4. Appendix 4: Context mapping exercises ............................................ 48
7.5. Appendix 5: Context mapping quotes ................................................ 52
7.5.1. Interview A; Quotes ............................................................................52
7.5.2. Interview B; Quotes ...........................................................................56
7.5.3. Interview C; Quotes............................................................................ 61
7.5.4. Interview D; Quotes ...........................................................................65


abstract


Abstract
This report addresses the design of a concept that supports type 2 Diabetes patients in
making healthy food changes and thereby change their food habits. This project has been
conducted within the context of the European SmarcoS project.

The prevalence of type 2 Diabetes is increasing rapidly. It is expected that in Europe the
number of people that have Diabetes will have increased from 7.8% in 2003 to 10.3% in 2025.
This increase is mainly caused by an unhealthy lifestyle, such as insufficient physical activ-
ity and unhealthy food choices.

Patients who have been diagnosed with type 2 Diabetes need to adopt a healthy lifestyle in
order to keep the amount of medication needed to manage their disease to a minimum. A
healthy lifestyle entails sufficient physical activity and a healthy diet. Currently, many Dia-
betes patients experience difficulties in adopting such a lifestyle. To make a change, patients
need information, encouragement and support to gradually change towards a healthier
lifestyle and maintain this lifestyle.

Qualitative interviews have been performed to gain insight into the problems that arise
during this lifestyle changing process. To apply the data from these interviews the MoSCoW
method was used to turn the results into design requirements. The outcome of these inter-
views shows that patients are often in doubt about how healthy a particular supermarket
product is.

The supermarket is a suitable location to encourage people to make healthy decisions, be-
cause this is where people decide what to eat. At home people pre-contemplate about what
to eat, but the actual decision is made in the supermarket. The concept presented in this re-
port takes this moment of doubt as a starting point to change people towards healthier sug-
gestions. It provides support to make healthy food choices at the exact moment of the buying
decision in the supermarket context where the healthier alternatives are readily available.

The concept is a shopping bag that can be taken to the supermarket and be placed in the
shopping cart. Products can be presented to the shopping bag. The shopping bag gener-
ates visual feedback unobtrusively to indicate the healthiness of a product. Products can be
checked or compared for suitability to the diet, so that an educated healthy decision can be
made.


introduction


1. Introduction
The project presented in this report focuses on the development of technology-based solu-
tions that positively influence the lifestyle choices of people with type 2 Diabetes. Explo-
rations have shown that patients experience many barriers when trying to change their
lifestyle. As a consequence many of them stick to their old habits. Literature shows existing
habits and rituals make it hard for people to change their lifestyle (DeWalt D. A., et al., 2009).
Although, making healthier food choices would result in a more active and healthier life with
less medication and complications for the patient (Tudor-Locke, et al., 2004).

When looking at ways to help people change their behavior, it is important to give them
insight into healthier alternatives, while at the same time let them be in control of their own
lives (Greef, Deforce, Tudor-Locke, & Bourdeaudhuij, 2010). Therefore, the approach used is to
support them to make healthier food choices step-by-step. In current treatments patients
participate in meetings with caregivers to learn how they can change their lifestyle. Al-
though these meetings are helpful, due to time constraints it is always based on perception
of the patient and a small moment in which this opinion is conveyed. By using technology
that is always at hand to provide support at the moment the patient needs it the adherence
of the lifestyle can easier be maintained by small stepwise changes. This is why technology
can make a difference.

Based on literature, interviews with caregivers and interviews with Diabetes patients, this
project specifically focuses on supporting Diabetes patients to make healthy food choices.
Patients perceive food as a more substantial problem compared to activity. On the other
hand the caregivers spend more time on helping patients to become more active.

Present-day a dietician supports the patient by looking at a patient’s current diet and sub-
sequently suggesting alternatives for certain food types. The support is thus based on how
unhealthy the food choices are and on the personal food intake habits/preferences of the
patient.

Rather than to suggest major changes it is easier for patients to promote healthier choices
by suggesting alternatives. It is important to find a way to suggest healthier alternatives that
stay close to the original choice of the user, even if it is not the healthiest possible alterna-
tive. Stepwise offering healthier alternatives over time is part of the concept to develop long-
term healthy eating habits.

Some healthiness food information can already be found in the Albert Heijn for example with
the “gezonde, bewuste keuze” images. The scale chosen for healthiness of food products is
based on the tables created by the “Voedingscentrum”. This organization has clear infor-
mation on specific products you can buy in the supermarket. However, this detailed under-
standable information is often not available in the context of the supermarket where the
actual food choices are made. Although there is nutritional information on the package, this
is not clear for the patient. The information which is understandable, by the “Voedingscen-
trum” is not available in the supermarket, only behind the computer at home. The informa-
tion the “Voedingscentrum” actually gives the consumer is too vague: healthy, not bad and
unhealthy. This doesn’t allow for small steps in the right direction as they only distinguish
three categories of healthiness.

To support people to make a step in the healthy direction it is important to take their cur-
rent shopping behavior into account. To acquire a thorough understanding of how informa-
tion on the healthiness of a product can be communicated to the user in an appropriate man-
ner, we observed the daily shopping rituals. These rituals were used to develop a concept to
support healthy decision-making.


It would be a successful design when people intuitively interact with the product in their
already existing routine, especially when it is taken in their shopping rituals. It will provide
the information they need in such a way that they feel informed, not judged, and that it helps
them to make better food choices and to maintain a healthy lifestyle over time.

The report will describe the applied process. The research part of the project focuses on
three pillars: what is type 2 diabetes, what is the influence of food and what is the influ-
ence of activity on the healthiness of the patient. We relied on three sources of informa-
tion: existing literature, information provided by professional caregivers and information
provided by patients. After reading the literature of the experts in these fields, caregivers
are introduced to look at the problem of lifestyle intervention from their perspective. To set
up requirements users are introduced through a qualitative interview to observe how they
perceive and handle problems. This gives an insight in how healthcare is related to the user
and where problems occur that can be solved through technology. This generates require-
ments that result in a vision. This vision is important to communicate to partners, as this is
the part that can be used in a bigger project. To communicate this vision an implementation
is introduced that communicates the vision and user requirements to the stakeholders. The
report is closed with a discussion about the relevance and possible applications of the vision,
also including possible future extensions of the vision.

1.1. Stakeholders
This project is part of a larger project focused on smart communication solutions for promot-
ing a healthy lifestyle, in which Philips research participates with several other stakeholders.
Within this project, with the partners mentioned below, it is important to set a vision and
then communicate this vision through an experimental prototype. This prototype sets out
to apply knowledge about health and type 2 Diabetes in an accessible way. By this prototype
stakeholders can be inspired about context and technology.

1.1.1. Philips Research
This project should create a better insight in possible opportunities and problems for the
SmarcoS project in the next two years. My aim is to develop a vision grounded on qualitative
and quantitative research, and communicate this vision through a product as an inspiration
for Philips for the next two years.

1.1.2. SmarcoS
SmarcoS is a research project that involves several partners. For this project University of
Twente and Evalan were the partners that were mostly contacted. One of the use cases
within SmarcoS project revolves around type 2 Diabetes patients and how to empower this
target group to make healthy lifestyle choices across devices and situations.

The SmarcoS project is described as follows: “SmarcoS project aims to help users of inter-
connected embedded systems by ensuring their interusability.”

Nowadays, many products connect with web services (media players, refrigerators).
This distributed computing is becoming the norm in embedded systems. SmarcoS
allows devices and services to communicate in UI level terms and symbols, exchange
context information, user actions, and semantic data. It allows applications to follow
the user’s actions, predict needs and react appropriately to unexpected actions.

The use cases would be constructed around three complementary domains: attentive
personal systems, interusable devices and complex systems control. Several pilots
would be carried out to implement the use cases. SmarcoS is planning to run a large


trial based around the time of a major public event and is currently considering Lon-
don around the time of the 2012 Olympics. Along the project, several smaller prototypes
will be implemented.

Our results will be applicable to all embedded systems that interact with their users,
which is a substantial fraction of today’s market.” (Huuskonen)

A joint effort between different companies and universities is made in this project to look at
people between the age of 45 and 60 with Type 2 Diabetes who are diagnosed within the last
two years. This is a group that is new to the disease, allowing for a shaping of rituals to help
them to copy with their disease more efficiently.

1.1.3. Personal motivation
For this project I am interested in a two-sided personal perspective. I think people should
not step out of their routine when using a product to help them in a context. Therefore I am
interested in how a product can work by using minimal effort.

Food is a part of everybody’s daily life: most people get up in the morning, have breakfast
and go to work. Yet, in the case of Type 2 Diabetes patients, this isn’t as simple as it seems.
For them, as I will demonstrate in this proposal, food intake like breakfast has an effect on
the activities they can participate in during the day. I want to make an effort in helping these
people to gain influence through information in this cause-and-effect situation and helping
them in their daily routines.

1.2. What is type 2 Diabetes
“Diabetes is a metabolic disease characterized by higher than normal blood sugar levels.
Two main types of diabetes can be distinguished: Type I and Type II. In type I diabe-
tes, the body fails to produce sufficient levels of insulin. In type II diabetes, the body
shows an insulin resistance, which means the cells fail to respond properly to insulin,
sometimes with reduced levels of insulin production. Type II diabetes is far more com-
mon than Type I diabetes, affecting 90 to 95% of the diabetes population. This use case
focuses on diabetes types II patients.

The development of type II diabetes is related to lifestyle, in particular physical activ-
ity, diet, smoking, and alcohol consumption. Obesity is widely believed to be an impor-
tant contributor to the development of type II diabetes. Specifically, increasing levels of
physical activity and decreasing the intake of saturated fats and trans fatty acids and
replacing these with unsaturated fats reduces the risk of diabetes type II.” (Lacroix, Schwi-
etert, Halteren, Geleijnse, Saini, & Pijl, 2010)

Diabetes is a disease that is based on problems with regulating insulin levels. This regulation
depends for a large part on activity and food intake. To get to know what a certain type of
food is doing for your body is hard to grasp. People have to take blood measurement to see
how they are doing and whether they can participate in certain activities. It is known that by
giving these people insight information and helping them to manage themselves, they can
postpone and minimize their medication intake (DeWalt D. A., et al., 2009).


research


2. Research
The initial research phase was to gain insight into the problems that type 2 Diabetes pa-
tients face on a daily basis. The goal was to approach this from several angles to get a good
idea of what is going on in their lives.

In this first research step the focus was both on food intake as well as on the activity behav-
ior of the patients. These two are the most relevant factors when it comes to the health of
type 2 diabetes patients. First literature was studied to understand the physiological impli-
cations. Secondly interviews with caregivers were taken to understand the physiological and
psychological implications. Caregivers know what is healthy and unhealthy for a patient, and
are experienced with delivering this data. Moreover, they have experience with the patients
and understand what works in a treatment and what does not.

As a final and third step Diabetes patients were interviewed to map the problems that they
face in everyday life. Interviews were conducted to understand their barriers of motivations
to make healthy choices. Patients were interviewed to understand problems they come
across related to their context, family, daily routines, and what. The goal was to see whether
patients have similar problems compared to their peers, and how motivated they are to
change their lifestyle.

2.1. General type 2 Diabetes treatment
2.1.1. Interview with Diabetes nurse
An interview with a diabetes nurse, (presented in appendix 1) in Eindhoven, was initiated to
gain more insight into the encountered problems in treating the patients. This interview
gave good insights in the current treatment of the patients.

According to the diabetes nurse, type 2 Diabetes patients have a lifestyle problem. With a
proper lifestyle (being more active and eat less) they can do without medication and com-
plications for a long time. Yet as this behavior has been shaped over many decades it is hard
to change this, even for the better. The first problem is that people cannot estimate what is
wrong with their current behavior since they cannot see the implication of it in five years
time.

Currently the role of the diabetes nurse is to check blood glucose levels every three months
and give advice on medication intake. When the problem area is identified the patient can
be sent to a physiotherapist to become more active, or a dietary expert to focus more on the
food intake.

She argues that the most important thing is to make people more active and eat less. This
allows the caloric intake and output to become balanced.

2.2. Effects of food intake on type 2 Diabetes
2.2.1. Literature on food intake
The eating behavior of a Type 2 Diabetes patient is of major importance for their health.
Trans fatty acids for example increase a person’s risk of diabetes with 40% (Salmeron, et al.,
2001). When a person is diagnosed with Type 2 Diabetes, eating healthy is very important. By
caloric restriction you lose weight and by losing weight the body cells are more susceptible
to insulin (Harris, Petrella, & Leadbetter, 2003). People with a healthy weight are better at regu-
lating the glucose levels in their blood (Daly, Vale, Walker, Littlefield, Alberti, & Mathers, 1998). A


decrease in weight allows for a decrease in medication and a general improvement in health
(Williamson, Rejeski, Lang, Dorsten, Fabricatore, & Toldeo, 2009).

An aspect of eating is the Glychemic Index (GI). This index tells us how quickly the sugars of
food are absorbed by our body in glucose (Dunkley). High readings (above 50) mean a quick
increase in glucose, yet there is a big drop behind this increase. This can be compared to
foods that contain much sugar. They give a quick energy boost, yet afterwards you get tired
fairly quickly. A lower GI means a slow increase in glucose and no drop afterwards. This
means the energy from the food will be distributed more evenly over time. An even energy
spread is less of a shock to the body.

2.2.2 Interview with dietician
A talk with a dietician (presented in appendix 2) gave me insight in the current treatment and
problems. First of all, in the current way of working, the dietician talks to the patient only
once. This makes it hard to change the behavior since there is a lot of pressure on this one
meeting. A lot of information has to be taken in at once, and no help is provided afterwards
to initiate this drastic change in people’s life.

For type 2 diabetes patients it is considered important to keep your blood glucose levels as
healthy and constant as possible. This means that the first advice for patients is to spread
out the meals over the day. They are advised to eat a little less for breakfast, and take part of
their breakfast as a snack a couple of hours later.

Although sugar and carbohydrate intake is important, it is not extremely important for our
target group. For patients who only have diabetes for a maximum of two years, this is not yet
relevant. During the advisory meeting with new Diabetic patients the dietary expert focuses
on caloric intake. As the number one priority is to decrease the amount of calories in their
food. In this stage of type 2 Diabetes every weight loss has a very positive impact on the fu-
ture health of the patient. This is hard to understand for the patient while immediate effects
on their health stay out.

The current approach of the dietician is to find the problem areas, and for the patient to shift
towards healthier food. The dietician tries to estimate the change a client can make. This
estimated change is highly important, as people will not continue their diet if the shift is too
drastic.

2.2.3. Dietary monitoring
To gain insight in what people eat, possibilities of dietary monitoring were explored for this
project. Currently existing solutions (e.g., self-reports, diaries) are either inaccurate or labor
intensive or obtrusive. These problems make them impossible to use in a natural setting.
For example there are laboratory studies based on in ear monitoring of chewing sounds
(Amft, Stager, Lukowicz, & Troster, 2005). An analysis (Teunisse) was performed on this problem
(Figure 1, page 12).

At this point in time
there is no reliable
food monitoring
method available.
Even though this
is hard dieticians
experience a bigger
problem in the adher-
ence of a diet then in
understanding what Figure 1: Dietary monitoring analysis (Teunisse)


the patients eat. In that sense not being able to measure what people eat is not the first issue
to address. Educating patients in what is healthy and what is not is needed so they can take
small steps in improving their lifestyle themselves.

In line with the approach followed by the dietician, the focus of the project will be on provid-
ing information more effective at the decisive moment.

2.3. Effects of activity on type 2 Diabetes
2.3.1. Literature on activity
Often activity is described by patients as sports, yet patients underestimate the effects of
walking. By walking about three hours a day, or 19000 steps, patient health increases consid-
erably.

A change in behavior like this leads to an increase in insulin sensitivity (less medication)
(Tudor-Locke, et al., 2004) and a loss of weight. A decrease in the risk of high cholesterol
(Tudor-Locke, et al., 2004) and heart failure, and a general improvement of health.

When people stick to a regime of 19000 steps a day medication can be postponed for as much
as twenty years (Tudor-Locke, et al., 2004). 66% of the patients do not engage in physical activ-
ity (Tudor-Locke, et al., 2004). This can be due to a perception problem or a part of a sedentary
lifestyle. Most type 2 diabetes patients have a sedentary lifestyle. A 100-steps/day increase is
considered a good result (Greef, Deforce, Tudor-Locke, & Bourdeaudhuij, 2010).

2.3.2. Interview with physiotherapist
A physiotherapist (presented in appendix 3) gave me insight in the procedures used for helping
diabetes patients in becoming more active. In helping people to get more active the therapist
pointed out two important factors. First he explains that the self-efficacy of the patients
needs to be at a sufficient level. They have to believe that they are capable of becoming more
active. An often-used approach is to have them participate in an activity.

The second important factor the physiotherapist focuses on is helping people understand
that even moderate daily life activity such as walking is beneficial for the patients’ health.
Physiotherapists find it hard to talk about walking with patients. Although it is seen as a
useful form of activity, the perception of walking varies a lot. “When a patients tells you they
have walked for one hour, do they mean this as being active, and going for a walk, or is it
strolling around the city at a low intensity”. Yet a walk to the supermarket and walking dur-
ing lunch can increase you caloric output, and increase your health.

Although most patients are obese, this usually does not interfere with the treatment (Harris,
Petrella, & Leadbetter, 2003). Patients should not become athletes; they just need to get out
of their chair.

2.4. Behavior change strategies
2.4.1. Literature on intervention
When talking about changing a lifestyle, an intervention is necessary. This chapter discusses
known methods by researchers found in literature. This gives an overview of possibilities
that can be used.

In the current healthcare system type 2 Diabetes patients are confronted with busy physi-
cians and scarce resources. Often the patients themselves are not very motivated (Harris,


Petrella, & Leadbetter, 2003). To change their lifestyle, patients need to be motivated to do so. A
tried technique in this is self-efficacy, thus setting your own goals and experiencing that you
can live up to the goals (DeWalt D. A., et al., 2009).

To allow patients to manage themselves they need to be aware of their current behavior.
They need to be guided to adapt these behaviors (DeWalt D. A., et al., 2009). By allowing pa-
tients insight in their behavior and letting them set their own goals, the patients are motivat-
ed from a more intrinsic perspective than when a professional tells them what to do (Greef,
Deforce, Tudor-Locke, & Bourdeaudhuij, 2010).

Barriers to overcome with self-efficacy are described by social norm, support and help from
the family (Greef, Deforce, Tudor-Locke, & Bourdeaudhuij, 2010). By changing the perspective of
these patients they are more susceptible to change.

It is important to show the patients their own behavior, and make them question it. When
they understand they can change this, change is often the next logical step. Especially when
patients feel the want to change, but don’t feel they can.

2.4.2. Technology versus human effects on intervention
When patients talk with other people about their Diabetes they have acknowledged their
disease (Ornish). Although you cannot force people to talk with their peers, some parts of the
health care system might engage in social discussion.

2.5. User interviews
We performed interviews with Diabetes patients to understand their rituals and needs.
Below, we discuss, the goal, the method used for interviewing, the resulting insights and
requirement and the use of these in the project.

The process will begin with context mapping. This has been done with another member of
the research group, and an employee of Evalan (partner in the SmarcoS project). Evalan is
a company specialized in medical products. Marloes van der Hout, a recent graduate from
IO Delft and an expert on context mapping collaborated on the interviews. Together with
psychologist Joyca Lacroix the context sensibility techniques is chosen as support of the
interviews to get an insight in patients’ daily routines.

2.5.1. Interview goals
Type 2 Diabetes patients have experienced the influence of their disease on their life. How
do people go about in activities and eating, and how could a concept fit within their regular
scenario. But also in a technical sense, how can one describe and rate activity versus food
as to be able to make decisions on what is healthy for a person. This is two-sided. Literature
agrees on what is healthy and what not. Yet to present this information in a concrete way,
valuable to their daily life, and understandable within their references is the challenge.
These interviews were an important part of combining literature and information by the
caregivers in a human way.

The goal for this user test was twofold. First, to get insight in the daily routines of people
and to understand the moment at which they are most susceptible to change. Second, to
understand how important food, activity, medicine intake and stress are for them. And to get
a general perspective on their relation with type 2 Diabetes.

2.5.2. Method


Four participants received an envelope with 7 assignments (presented in appendix 4) one week
before the interview. These assignments were partly about rituals, and partly about photo-
graphing important aspects. This means that every evening they had to reflect on the day
based on themes. These themes are: food, activity, stress and medicine intake. This was to
have the patients think about these subjects before the interview. This means the patients
are more aware of their rituals and have more to say, so that the subjects being discussed are
not a surprise anymore.

On the other hand the participants received a pedometer, and were asked to note down the
amounts of steps they took that day. This means that by the end of the week there is a record
of how many steps are taken on average on those days.

After a week of reflection, an interview took 90 to 120 minutes. During this time the assign-
ments and photographs taken each day were discussed.

2.5.3. Results from interviews in requirements
The interviews are transcribed into quotes (presented in appendix 5) and categorized with
the MoSCoW system. The goal was to find quotes related to each other and find common
problems. Categorizing the quotes gave an overview of the conducted interviews. The quotes
than can be turned into user requirements. This means looking for patterns and rating those
patterns in Must, Should, Could and Won’t (Clegg & Barker, 2004).

The results of the four interviews with type 2 diabetes patients can be seen in the table be-
low. This data is based on quotes from all the interviewed patients, which were categorized
in food, activity, stress and medication.

Requirement Description MoSCoW Comments, other data...
The system needs to take in Must The dietary expert doesn’t
account my regular behav- try to make me feel guilty
ior, and give alternatives
The system should be subtle, Must The diet was too extreme, I
and try to change in small couldn’t last this way
steps
The system needs to help in Should I could eat less, but I only
portioning plate once, so why?
The system informs the user Should I eat less meat and fish, and
what food is good more potatoes as I consider
this healthy
The system should be quick Must I don’t care about food in-
to use take programs, they are too
time intensive
The system makes projec- Should Since I notice I get full
tions on what current behav- faster, I am much more
ior could lead to motivated
The system recognizes Could I always eat … for breakfast
behavioral patterns and lunch
The system needs to allow Should I chose to go out to din-
for extremities ner and eat unhealthy, this
makes me happy and doesn’t
happen very often


The system creates aware- Must Why should I change my
ness of the effects of food diet, I am not sick
choices
The system understands Should Work and weather influence
exceptions/deviations from my activity
activities
The system creates feedback Must I actually got scared when
on the basis of insight in I saw the amount of steps I
activity took every day
The system motivates Must Going to the supermarket
by showing the relation gained me 1500 steps, I
between daily activities and never saw that as healthy
health
The system raises confi- Could I sold my bike as I am afraid
dence and activity by warn- to get another hypo while
ing for a hypo riding it
The system gives insight Could I have never been active and
in daily moderate activity never will be, I don’t like
like walking and going to sports
the supermarket as healthy
behavior.
The system is reliable, and Should I try to find information on
perceived as a trustworthy the internet, but I am not
source of information always sure how reliable it is
The system gives positive Must I prefer the dietary expert
feedback over internet as she is more
concrete and positive
The system predicts positive Could I actually like how diabetes
aspects decreased my belly girth
The system learns about Should The distinction between a
hypo’s and hyper’s hypo and a hyper are very
hard to understand
The system communicates Could I like numbers as it gives me
numbers insight in patterns. I might
be able to attach those to my
lifestyle
The system projects current Should Luckily I don’t have to inject
behavior, and how this can insulin yet
postpone the moment when
you have to start injecting
insulin
The system should commu- Should I have a book with nutrition-
nicate abstract information al information, but I find it
very hard to understand

2.5.4. Use of requirements for food focus in project
The MoSCoW analysis shows what is considered important for this project. Currently these
requirements are not context dependent, but based on a wide array of context, problems and
directions as communicated by the interviewed patients. Although the context is explained
later on in this report, the focus will be put on food intake. Activity is part of the problem,
yet people are not aware of it being a problem. To make most of their intrinsic motiva-
tion food is a more motivating direction as diabetes patients have questions and struggles


with food. With food intake people know that they can make a difference. They do want to
make changes and go look for information on healthy eating. The interviews show applying
information is a problem for the patients. The moment they need information, for example in
the supermarket, it is not available. Also when their partner goes shopping for food they are
given a large burden by having to pick the right food.


design


3. Design
To find a challenge in the treatment, the research results were translated into requirements.
To make use of information from users and experts, a vision has been created that takes this
challenge in account. First of all this vision will be tied to the user within a certain context.
Then the vision is summarized in more specific requirements that allow for an implementa-
tion. This implementation is what is communicated to the shareholders. The implementation
is explained by exploring a concept and defining it through interaction, form and technology.

3.1. Vision
Below is a subset of requirements that are chosen which fit the stakeholders, and how they
relate to food. For the stakeholders it is important to understand what patients prefer when
treating them. This explains the abstraction of the requirements, so that they can be used in
the SmarcoS project.

Although activity is a very important factor, it is not taken into account due to the complex-
ity of the problem and the current timeframe. But it is strongly recommended to incorporate
activity to create a complete solution in helping patients to manage their lifestyle.

R1: The system needs to take the patients regular behavior into account and give alterna-
tives

R2: The system should not be extreme by trying to change everything

R3: The system needs to help in portion size

R4: The system informs the user which food is good for them

R5: The system should be quick to use

R6: The system motivates by showing the relation between daily activities and health

R7: The system defines activity as not sports related

R8: The system gives positive feedback

R9: The system should communicate abstract nutritional values, not concrete information

These requirements will be summarized in the vision. The implementation has its own varia-
tion of requirements specific to the context. The vision can be formulated as: “By supporting
type 2 diabetes patients to gain insight into their food choices and possible healthier alterna-
tives, they can become more aware of their food intake which enables them to change and
thereby live with fewer complications.”

3.1.1. Context for vision
Interviews have shown that people are being confronted with an incredible amount of infor-
mation. When talking about food specifically patients mentioned that they are confused be-
cause of the enormous amount of choice they have when they enter the supermarket. By us-
ing a known and trustworthy source, for instance the “Voedingscentrum”, a patient is given
a way of accessing this information within the context where they need this information. A
dietician tries to educate patients about food intake. However in the interviews patients felt
this education about food was important, yet hard to apply in the supermarket. The patients
said that in the supermarket the information is very concrete and complex, while they are


taught by a dietician about abstract values like calories from behind a desk. On the other
hand they feel like they are putting pressure on their partner for having to understand and
apply all this information.

An additional problem for diabetics is their level of activity and movement. Activity is mainly
treated by caregivers. For example in Eindhoven, type 2 Diabetes patients have one meeting
with a dietician versus six to twelve with a physiotherapist in two years time. Also patients
do not consider their activity to be a problem. The motivation to change this is extrinsic;
the health care professional tells them to change it. For food this motivation is more intrin-
sic because of its clear influence on the disease. The effect of food is something with more
short-term effects: when they eat unhealthy, they notice direct effects such as feeling faint.
During interviews patients talked about looking up information on the Internet about what
is healthy and what is not. Some patients buy a book with caloric tables, but explain they still
find this hard to work with. To conclude: Healthy eating is an area really loaded with rel-
evant information, but people do not know how to apply this in practice at the supermarket.

Interview patient: “What we eat is always homemade, with ingredients from the super-
market.”

People make a decision in the supermarket about what food to buy. This moment of decision
is why the supermarket is an important context. People not only doubt what sort of food to
buy, but also make the choice between similar alternatives that are available. Other context
possibilities are the kitchen where food is prepared, or maybe in the dining room where food
is consumed. The supermarket is interesting for its part in decision-making and the possibil-
ity to pick out alternatives. This makes the supermarket unique and an appropriate place
to change you lifestyle regarding food choices. In the supermarket there is an abundance of
food, but it is very difficult to compare the different products or make a judgment about how
healthy a certain food product is.

Interview patient: “I really like eating healthy food, and picking right and wrong things
at the supermarket is very difficult.”

3.1.2. Motivation for vision
In the interviews patients have mentioned that shopping is a big problem. They have difficul-
ties in knowing what the healthier choice is for them. They also feel that their food restric-
tion puts a burden on the whole family, especially when their partner goes shopping for food.

Patients are motivated to eat healthier; they look for information online and go to see a
dietician. But they miss this information in the proper context. To generate context aware
information on a decisive moment, insight is needed in the normal behavior patterns (Fogg,
2002). This context aware information changes people’s degree of knowledge, which accord-
ingly lowers the threshold to change the behavior (Fogg, 2002).

3.1.3. Concept Requirements
R2: The system allows for specific timely changes, one at a time, in a person’s total diet.

R4: The system informs the user what food is healthy for their diabetic condition based on
expert knowledge from the Voedingscentrum.

R5: The interaction with the system is fast by just holding or pointing at the product.

R8: The system does not judge people when they pick something unhealthy because this
results in a lack of adherence to future advice.


R9: The system gives information about a product on a one-dimensional healthiness scale.

Also new requirements are set up to give pointers for the interaction for this specific con-
text.

R10: The system fits into regular supermarket shopping without taking more time then you
would without the system.

R11: The system gives access to dietary information in the supermarket.

3.2. Implementation
3.2.1. Shopping bag
Context-specific decisions and the user need for information and support at the moment of
decision-making is very important. Therefore the developed concept entails a solution that
matches the supermarket context and allows for easy communication about the healthiness
of products.

Interview patient: “I tried to find on the Internet what is healthy and what is not, but this
was hard. The dietary expert was more useful. She provided more practical and stimu-
lating information.”

Interview patient: “I am not sure whether meat is healthy.”

Interview patient: “When shopping for groceries, I consider the following things: is it
healthy, what is in it, is it varied?”

Concept: a personal dietician going with you to the supermarket that you can ask questions
about a specific product. With the opportunity to show several products where the dietician
can pick the healthiest.

After having established a vision, it was important to find an implementation suitable for
the user requirements, and as well capable of communicating the idea. A brainstorm based
around the question of abstract feedback about healthiness of products in the supermarket
was organized (Figure 2, page 21). After a range of ideas was generated:

The challenge is to
find a solution that
sticks in the stake-
holder’s imagination
while at the same
time being technolog-
ically feasible, as this
project aims to finish
in two years time.

The concept is a
shopping bag that
the patient brings to Figure 2: Results from brainstorm
the supermarket and
hangs in their shop-
ping cart. Instead of asking a dietician how healthy a product is, the patient holds it in front
of the shopping bag that then gives a personal answer with light.


The choice for a shopping bag is based on the fact that people are the most susceptible to
change and open for alternatives when they are making a decision or are in doubt. The
interviews made clear that patients have a hard time making a distinction between healthy
and unhealthy food. It becomes even more complicated when the patient’s partner is doing
the groceries because the problem of decision-making then shifts towards the partner. To
support them in this process, the patient has a shopping bag that is taken to the supermar-
ket. It is important not to try to get people from snacking on a mars bar towards celery. By
taking small steps at a time, and improving the eating pattern step by step, the patient is
more likely to change.

Figure 3: Context impression (Image by Figure 4: Model with light pattern indicat-
Loblaws) ing two products.

The shopping bag (Figure 3, page 22) contains a camera that scans product barcodes and
registers one or more products. The bag then connects to the “Voedingscentrum” database
to look up how healthy this product is. This information is communicated to the patients
via a light pattern (Figure 4, page 22) on the outside of the bag. This pattern corresponds to
the level of healthfulness of that specific product. Users can personalize the light pattern to
their own liking, thus preventing other people in the shop to stigmatize them as someone
who are obsessed with healthy eating. When you hold two products in front of the camera an
area around the camera lights up to show which product is healthiest considering their per-
sonal diabetes circumstance. The bag allows the user to keep their hands free at all times
and be able to move through the supermarket without having to grab additional tools like a
Smartphone, which might interrupt their shopping rituals (Figure 5, page 22).

Using light for
feedback is chosen
for its subtle nature.
Another way to
generate feedback is
for example sound
or touch. However
these are not suit-
able for this concept
because sound is too
obtrusive and touch
needs a different
approach. It would
mean that the pa-
tient needs to wear
something at all
times or hold some-
thing when they Figure 5: Technical prototype on a shopping cart


want to compare two products. Light allows for a hands-free exploration of the supermarket
without attracting too much attention. When other people see the light pattern generated,
there is still a degree of discretion. The colours used are personal and hard to understand
for outsiders. For other people in the supermarket it becomes an aesthetic element of the bag
without a direct health related meaning.

The personalized light scheme is used to create a way of feedback that is meaningful and
personalized for the specific user. This means that even if other people in the shop see the
light pattern, only the owner of the bag can understand the feedback and make healthy deci-
sions.

3.2.2. Interaction with shopping bag
The diabetes patients that were interviewed all go to the supermarket once or twice a week.
Patients use a shopping cart to be able to take this amount of groceries. Observations done
in the supermarket conclude that people often use a shopping bag that is hanging on their
cart, either on the front or at the back.

The observation of people using their own bag which hung on the front of their cart was
used as inspiration for the interaction. People have a ritual where they carry an object with
them to the context, and they hang it in a predictable location. To define possibilities for this
location a subset of interactions has been explored through a brainstorm. I explored ideas
ranging from a bag that closes when you put something unhealthy in it, to a big screen on
your bag comparing two specific products (Figure 6, page 23).

Inspiration used for
the feedback of the bag
was the act of weigh-
ing items. When people
make a distinction
between two products
often both items are held
in each hand. By then
moving them both up
and down, an estimation
about weight is made.
The concept is built
around the idea of taking
both these products,
holding them in the air
and getting feedback on
which is better. But in-
stead of a haptic result,
a visual result is created Figure 6: Interaction idea sketches
allowing abstract insight
in health values of a
product. This interaction allows for seamless integration within their shopping rituals (Fig-
ure 7, page 24). Patients are not judged based a decision resulting from the information given
by the bag, or they are being prohibited to perform a certain action. For example, a bag that
closes when you try to put something unhealthy in it.

For this interaction it is important to have free hands when interacting with the bag. This
means that the user can actually take products from the shelves and compare them on the
fly. This is better than having to take a mobile phone that interferes with shopping rituals,
and leave only one hand free to take a product to compare.


According to the dietician a small improvement is often quite a big step for patients. This
interaction allows the patients to pick two products they find acceptable and helping them to
show which is best for their health. It is then up to the patient to decide on what to buy. This
decision is not judged afterwards. While it was found in the requirements that people who
feel judged, tend to turn down future advice.

SUPERMA

Whole
wheat WHITE WHITE

? WHITE
>
WHITE
wheat wheat
WHITE
WHITE wheat WHITE WHITE

Figure 7: Scenario of interaction

3.2.3. Form of shopping bag
After the interaction was established the form was explored through drawing on a shopping
cart to take in account the context in which it will be used. By making photographs of the
cart perspective and ratio were used (Figure 8, page 24).

Figure 8: Exploration of form on cart


Ordinary shopping bags are used as an inspiration. Cheap plastic bags and paper bags hand-
ed to us in shops are iconic (Figure 9, page 25). They have certain aesthetic that is connected
to shopping, but can be used in a more sustainable way.

Figure 9: Paintings for inspiration (Images by Wagner Art Gallery)

By starting with the proportions and
folding lines of these bags and fitting
them to the proportions of the shopping
cart, a combination was made that allows
for a known form. Normally this form is
presented in paper or plastic which has a
cheap feel. But by applying more expen-
sive durable materials, such as leather,
an aesthetic is created that feels known
and fits to shopping, yet doesn’t have the
inexpensive feel to it.

Through an exploration with newspapers
to determine the proportions of the bag,
a model in cotton is made to understand Figure 10: Eames Lounge Chair (Image by Vitra)
how it relates to a shopping cart. The
model is taken to the supermarket, put on a shopping cart, and from there on a final model is
created. The final model design is inspired by a chair designed by Eames, and later changed
by H. Jongerius (Figure 10, page 25).

Although the chair itself is very high
end, the materials, leather and walnut
wood were used as inspiration for the
bag. The materials are durable, yet the
color of the wood is linked the paper bag,
and white leather reminds me of the col-
or of plastic with a more natural texture.
The color of the leather is also important
because the feedback lights will shine on
the material, and so the material needs
to be light to be able to see the effect.

Figure 11: Sewing patterns


A final visual model of the bag is created and presented at the presentation. This is created
from drawings, silhouettes in perspective and the right size. The silhouettes are transformed
into sewing templates (Figure 11, page 25). The first model was made out of canvas (Figure 5,
page 22), but the final model is made from cow leather.

3.2.4. Technology in shopping bag
The electronics are created in such
a way that they are able to commu-
nicate the concept (Figure 12, page
26). It is not created to be foolproof
or efficient in size or power con-
sumption. Based on this idea some
shortcuts were made to prototype the
interaction. The working interaction
is important as a communication to
stakeholders.

To use Processing to recognize a real
barcode is very time intensive to cre-
ate. Therefore reacTIVision was used.
This is an open source framework
used for multi touch tables. The reac-
TIVision project designed special bar-
codes, called fiducials, which can be
recognized at incredible high speed
and with great accuracy. The reac-
TIVision server sends coordinates
for the fiducials to Processing. Using
the fiducials instead of barcodes was
a way of making a prototype faster
to be able to communicate the vision Figure 12: Diagram of technology
and interaction more clearly.

In Processing the date from coordinates is re-mapped into a circle of light. The feedback is
given on the side of the bag where the products are held. By moving the product in front of
the shopping bag the projected light on the bag itself is updated and moves with the product
creating a mental connection between the product that the user holds and the side on which
the product is placed in relation to the light source. The values of these light patterns are
sent via serial communication to an Arduino. The Arduino is used to interpret the data from
Processing and sends this to LED drivers. The LED drivers are updated every time a new
signal is sent from Processing.

For the current implementation it is necessary to have a laptop hidden from sight because
the shopping bag can’t function with only a microcontroller hidden in the bag. Currently a
laptop is needed for the calculations. The webcam is connected via USB to the laptop, calcu-
lates the lighting pattern, and tells the Arduino exactly which LED should light up at which
brightness.


discussion


4. Discussion
The implementation is a means of communicating a vision. The vision has a certain rel-
evance and application which is explained in this chapter. When you look at this vision in a
broader perspective, it can be used for other target groups as well, depending on the user
and information displayed. Moreover, we believe the solution can be extended in several
meaningful ways. These aspects will be discussed below.

4.1. Relevance of vision
Currently dietary advice and making food choices are separated in context. A dietician tells
you about what is healthy and unhealthy in an office context. This information is over-
whelming and hard to grasp due to its complexity. Patients have said in interviews that they
search for different sources about healthy foods on the Internet. But in the supermarket the
choice is overwhelming and they are not sure how to apply this knowledge in a concrete way.
The shopping bag concept is a first step in addressing this problem by giving the necessary
information without forcing people upon a different diet.

4.2. Application possibilities
4.2.1. Different user or context
Depending on the personal need and available information, the vision could be applied in
a number of situations and for different goals. For example, this shopping bag can also be
used for managing healthy diets for other patient groups. Patients with a kidney disease can
decrease their consumption of salt, or people with chronic heart problems can reduce the
amount of fatty acids. Also people interested in eating healthy, either to lose weight or feel
better, can be helped to make choosing healthy food an easier process.

The current invention could also be used with another database to compare the sustain-
ability of food, for example to show the difference in their carbon footprint. The basis of this
vision gives insight in the needs for a specific target group, and a database containing the
information to answer this need in an abstract way.

The shopping bag is part of a large array of solutions for helping Type 2 Diabetes patients
with a healthier lifestyle. It resembles the vision because it gives people information about
how healthy products are within context. The shopping bag is a way of communicating this.
Yet this vision also allows for different implementations. One could think of a mobile applica-
tion or becoming integral to a shop by designing a variation on the shopping cart.

4.3. Future research recommendations
4.3.1. User studies
For now this implementation is a means of communicating a concept to stakeholders, but it is
also possible to communicate this idea to the user and ask for feedback.

It would be a good idea to create a user test that gives users the ability to give feedback on
the vision as well as the implementation. This would make the vision also stronger in the
communication to the stakeholders. By knowing what the type 2 Diabetes patients appreci-
ate about the vision and implementation, further steps can be made to evolve the vision and /
or implementation. This can result in a feasible product that makes a change in people’s lives
and helps them to maintain a healthy lifestyle.


4.3.2. Technological advancements
Depending on the communication the technical prototype is not yet up to a lot of travel and
interaction. It is a working prototype, but needs a separate computer and is programmed to
understand only a very small array of products. When the current implementation is found to
be successful by users, a step can be made to recognize barcodes and tie this to the database
of the “Voedingscentrum”. This way the product can be tested in the supermarket under
real life conditions.

4.3.3. Importance of activity vs. diet
In the future an extension of the system will focus on combining support for healthy food
choices with support to increase physical activity. The caregivers told us that it is important
to understand that food and activity relate to each other. The simplest way of communicat-
ing this relation is by comparing calories. The ultimate goal for a patient is to balance their
caloric input (food), and output (activity) so that it is balanced and the patient doesn’t gain
weight, or even loses weight until a healthy weight is achieved.

This implementation is a first step into the right direction, but by applying this with other
research projects a new more complex system can be designed that combines all food and
activity. This gives a real insight for the patient and allows for more information to care-
givers, which is usable in a treatment. In the end hopefully people get to understand this
relation, so they can eat a bit more, but become more active, or the other way around. This
way caloric balance can be reached, yet the patient can choose the direction and receives a
personal treatment.


conclusion


5. Conclusion
The goal of this project was to develop a vision on solutions that help diabetes patients with
healthy lifestyle choices, and to communicate this vision to partners in the SmarcoS project.

The vision is about giving people abstract information about food products in such a way that
they can apply this in the context where they make the decision. An experiential imple-
mentation, shopping bag, was created that communicate this vision. The shopping bag was
chosen for its innovative and communicative characteristics, with the aim to communicate
and inspire people.

The stakeholders will use the results of this project in the context of the SmarcoS proj-
ect. The results of the SmarcoS project should contain an abstraction of information, and
adherence to rituals within that context inspired by this design. This implementation was
designed to show a possibility when taking in account context, users and expert knowledge
about disease and its treatment. This resulted in a vision and implementation that could be
part of the solution that helps type 2 diabetes patients in living a life with less medical com-
plications and less medication.


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appendices


7. Appendices
7.1. Appendix 1: Interview Diabetes Nurse
• Where does she stand in relation to other healthcare personnel?

o The nurse is second line. This means that she gets patients who are sent from the
“huisarts”. This not always means that all her patients are diabetes patients, but she also
treats pre-diabetes patients. These are people with high blood pressure, overweight, high
glucose levels in their blood.

o She relies on HbA1C values from the lab, and decides upon medication. Although
she is not qualified to give the actual medication, she gives over a suggestion that is usually
taken over by a physician.

o She stands in the middle of changing the lifestyle in contact with an activity expert
and a dietary expert. She looks at the combination of eating, activity and medicine intake.
Weight, height. Keeping accurate measurements of the person.

o The “Diagnostisch Centrum” is used to analyze blood, and generate the lab values
on which the treatment is based. When necessary also ECG’s are recorded in the hospital.

o Her role is pretty unique. “Huisartsen” usually handle this themselves, and are not
trained, like the nurse, specifically in Diabetes.

• How holistic is the approach with a patient. Does she consider everything from BMI,
psychological wellbeing to willingness to cooperate?

o Motivation is the most essential part of treatment. There is a small group of moti-
vated patients who are willing to change, and work on this. This is for her, in the role of a
coach, very easy to work with.

o There is a very large group of unmotivated people. They often lie about their activ-
ity patterns and food intake. This makes treatment hard, and is found through the lab values
of HbA1C. The problem is with the patient. She tries to be very specific about the risks, yet
the patient has to do all the work.

o You are handling patients that are almost addicted. You are treating to change a
behavior that has a very solid and psychological foundation in a person. Are you willing to
stop smoking, leave certain foods untouched or go out more?

o People need insight to change. Why do they need more activity? How can this be
done, and what does it mean for me?

o A psychologist is a current undervalued part of helping diabetes patients. Currently
the relation to a “huisarts” is the most common, but extra help, when necessary, from an
activity and dietary expert.

o The treatment is currently psychological, physiological and societal.

• Does she consider details of the treatment? People who want to know what to do vs.
People who want to know what the reasons are, and make their own plan?


o People know what is wrong and what to change. This as they portray themselves
better then they did. So for example say they had more walks, more physical activity, and
ate less. Yet in the end the lab values HbA1C tell otherwise. This shows that the patients are
educated on what is wrong and right.

• What kind of extra information of influence might help the current treatment?

o When communication between the nurse, “huisarts”, dietician and physical activity
expert is good, then all information needed is ther

o People who suffer from diabetes in a lot of times don’t have any problems and feel
good. This makes it hard to motivate people. A higher glucose level doesn’t need to have any
immediate effects, yet over time might result in severe physical problems.

• If you could be alongside the patient all day, what would you note down, and how
would that influence treatment?

o Lifestyle. How often do they engage in activity and how many calories do they use.
This versus how many calories do they eat.

o How did the patient sleep? Was he calm or slept very bad? Then the question is
whether this is physiological or psychological. Both these need a different treatment. The
sleep is not so much important for rest, but because it show how well the sober glucose level
is maintained.

o Does he eat regularly, and does he have a breakfast. How well timed is his medica-
tion intake?

o Some people are not honest, nor do they have the verbal skills to explain their situ-
ation.

o How do you currently go about with these unknowns?

• How does she see the relation between eating and physical activity?

o Ideally you want to balance caloric intake and output. When you have a glucose
meter, activity meter and food meter, you can put them all next to each other. This gives
valuable information to the patient and the healthcare professional.

o HbA1C level only tells us about the glucose level of the past couple of weeks. Yet
when this is too high, the reason is no per se known. It could be with food, or exercise. Also
since people sometimes make mistakes in their diaries, or present it different. It is hard to
say where the problem is.

o She is not interested in BMI. This is not as good as people think. For a good insight
in overweight the belly girth is more important.

o The nurse has the tool to give a coarse caloric estimate on how much people eat,
when this is considered to high in relation to their activity, she sends people to the dietary
expert.

o The first priority is to reduce the intake of saturated fats; the second is regulating
the sugar intake.


o All the above can be used by the nurse to motivate people. Whether people as sus-
ceptible to the actual concrete values, she doubts this.

o In the end, a healthy eating lifestyle is the main goal for the dietary part.

o Strong diets are not recommended. This is too hard on the body and results in
severe glucose fluctuations.

• What is your one golden tip?

People need to eat healthy and get more active through motivational tools.


7.2. Appendix 2: Interview Diabetes Dietary
Expert

o How do you get your patients? What is typical for them?

• People are sent through the Diabetes Nurse.

• All patients should get a consult in Eindhoven; this is called “ketenzorg”. Yet, in
practice this is not always true.

o On what values do you rely during treatment? And how precise are they?

• Blood values from the Diabetes nurse, belly girth.

o How long do you keep in touch with these people?

• Only once, and this is way too few. You don’t have insight in what works, and how
people go about with your tips.

• When something happens, or people are very obese, a second consult can be ar-
ranged.

• A meeting takes an hour. People already gave their current diet to the nurse, who
gives this to the dietary expert. During the meeting she asks for the specifics, and tells
people about the relation between food and diabetes.

• This is partly advice, part answering questions.

o What is the bottleneck during treatment? -> How hard are these people to motivate,
and how do you motivate them?

• The dietary expert tries to create a new diet advice based on their current diet.
This to allow them to make a change that is not too big, and keeps them motivated.

• The biggest problem is that she only sees the patient once, this puts a lot of pres-
sure on the one meeting, and she can’t see the effects of the new diet, or change it according
to wishes.

• You can’t tell people what to do, they have to change. The difficulty is that going
from 1 liter coke a day, to a half is positive, yet not ideal. But ideal usually can’t be reached.

• It is really hard to change, because you can see that people are getting more obese,
and the number of Diabetes patients in the Netherlands is still increasing.


o People need insight to change. Why do they need to eat different? How can this be
done, and what does it mean for me? How concrete/abstract is the information they receive?


• She needs to know what their current diet is, and tells people about what is good or
not. Based on this, in a discussion with the client, she allows them to set new goals and allow
for insight in what to change or not.

• The largest group of diabetes patients (not using insulin through needles) doesn’t
have to count their carbohydrates. By eating healthy (Voedingscentrum standards) they
should be fine. So the information she gives are not very technical.


o How do you combine your treatment with the other healthcare personnel?

• She receives blood measurements and a diet from the Diabetes nurse. Things she
looks at are glucose levels (over time), blood pressure, and cholesterol and belly girth.

o What information is easy to find, and what is not?

• When is the glucose a problem? Morning low levels for example. Yet this minute
specific information is usually not available as this is over weeks.

• Also psychology plays an important role, have people tried to lose weight? Why
didn’t this work? How can we change this?

• There is an imbalance with 99% of all patients. 99% is obese, this means that they
are not active enough, they eat too much calories or both. This allows for specific changes,
and focus on a certain area that is most problematic.


o How honest are people during their treatment?

• You never know, but usually people tell that they eat less than they do, and are more
active than they are.


• You can ask the client if you think you miss something. Or contact the diabetes
nurse.

• She would be interested in have a view in the refrigerator. Seeing what people buy.

• Also an insight into their activity would be interesting, as it allows her to show a
relation between food and activity. People tell her that they walk 10 minutes a day. She won-
ders how active this is, and this allows her to create a connection between foods. How many
calories in activity combine with what type of food?

o Are there restrictions you have to take in account due to the disease?

• Not really. Cake for example is allowed, yet it has to be in balance with your activ-
ity. This means that the amount and frequency needs to be adjusted to this.

• People who use insulin injections do have specifics.


• What is specific is that instead of three big meals a day,, diabetes patients are pre-
ferred to eat smaller meals more often. This is better for a constant glucose levels. What is
preferred is 6 eating moments a day. Breakfast, lunch and dinner continue to be the biggest
meals, yet in between and in the evening dairy products and fruits/vegetables are advised.

• When people are doing well, then medication can be adjusted afterwards. When the
dietary experts sees a problem in the morning for example, this can be communicated to the
diabetes nurse, who can use this in her medication advice.


o What measurements do you use?

• A dietary book is almost never done. Patients don’t follow through with this since
they consider it too time consuming.

o How obtrusive are they? Time? Blood samples?

• They take a lot of time.

o What is most important to change in the current behavior? How does this evolve
over time?

She does tell people that when you are very active, you have to eat. For example eating a
sandwich after cycling can be important to allow for a healthy glucose level. This is usually
asked by patients who have experienced this.


7.3. Appendix 3: Interview Diabetes
Physiotherapist

o How do you get your patients? What is typical for them?

• There is a four year program running in Eindhoven where people are put in 3
different groups based on their motivation. This scales from not motivated at all (biggest
group) to very motivated.

• People are sent by the diabetes nurse. The patients she receives are people with
specific activity problems, or the obese people for whom this is life threatening.

o On what values do you rely during treatment? And how precise are they?

• You try to gain insight in their psychology. Why did they stop being active, can we
do something about those reasons? Are there self management problems? Is the goal too
high or too low?

• She also tries to give people insight in their current behaviour. Show the bottle
necks. Where can it be improved and what way?

• Also making sure people try something once is important. Giving them a feel for
what a certain activity feels like, so that they can get a sense of what is possible for them.

o How long do you keep in touch with these people?

• Three months on a very intensive basis with physiotherapist under track of this per-
son, and afterwards the patient returns to the diabetes nurse who keeps track of this person.

• The second less intensive treatment is 6 weeks with five meetings where the pa-
tients are shown what are active places in Eindhoven, they take them there, and make sure
they try it at least once.

• The least intensive track is giving people a map of Eindhoven with active places,
and be there for questions.

• For a normal treatment this expert is in contact with the patient 6 times the first
year, and then the patients goes back to the diabetes nurse four times a year.

o How hard are these people to motivate, and how do you motivate them?

• Very difficult. People tend to fall back in their original behaviour. Changing people
for a short amount of time is do-able, but to keep this over time is hard.

• Even though people experience their diabetes, and have negative effects of this,
they are still not very motivated to change.

• You can help people, yet they have to do it themselves.



o People need insight to change. Why do they need more activity? How can this be
done, and what does it mean for me? How concrete/abstract is the information they receive?

• People receive their blood levels from the diabetes nurse. For the movement expert
it tells them whether people are improving.

• They also use weight as a part of their treatment.

• The HbA1C value is monitored very closely. When these values are constant, or
preferably decreasing, people feel better.

• The blood values are communicated to show people how they are doing.

• People who suffer from their diabetes consider this a de-motivation instead of a
motivation. The problem is that they see their complaints as a problem and boundary to go
out and be active. This is mostly a personality problem. Some people are just more active and
easy to motivate as others.

• She works with the norm “gezond bewegen”, and is happy when people become
more active. Getting them to the norm is usually very hard to reach. People who live up to
this, are motivated from themselves, and don’t need healthcare personnel, or at most for oc-
casional questions.


o How do you combine your treatment with the other healthcare personnel?

• She receives HbA1C values and weight values from the diabetes nurse.

• The neighbourhood also pays a role in the treatment. People who live there usually
belong to a certain social class, which influences the level of the information and motivation.
People from a lower social class usually are harder to motivate as they can’t see the serious-
ness of their decease, and can’t understand the insight in what is right or wrong.

o What information is easy to find, and what is not?

• Patients are given flyers of information about diabetes, activity and activity in their
neighbourhood. For patients this is easy to find, but hard to get them there.

• What healthcare personnel look for is a digital map of Eindhoven with all the activ-
ity locations, so that people can look them up at home. Paper maps are not as values, and
people lose them, or throw them out. Also, activities change over time, and keeping the map
up to date is important for motivation.


o How honest are people during their treatment?

• People are not necessarily honest, they overestimate their activity.



• She gives some patients the assignment to use a book, and write about their activ-
ity. Yet this is so hard to maintain, and is not accurate that this is done less and less. Yet she
misses the objective date to compare weeks for example, and talk about these differences.

• To judge the accuracy the healthcare professionals use a fair bit of psychology to
get an insight in this, and judge for themselves how much they move.

• She wants to know whether people become more active. In this an activity moni-
tor is considered ideal by her. This shows people what they are about. This insight in their
behaviour is one of her most powerful motivational tools. People really like to see how well
they are doing.


o What measurements do you use?

• The logbook is sometimes used, but is considered too time consuming.

• When people don’t use a log, she just talks to people and tries to find out how active
they are.

o How obtrusive are they? Time? Blood samples?

• The measurement are obtrusive in a time sense.

o What is most important to change in the current behaviour? How does this evolve
over time?

• They try to give people insight in the relation between eating and activity. This is
very important to show to people, as this information shows them what is going on, and how
to influence this. Yet one meeting with the dietary expert and 6 meeting with an activity
expert are not that much. Generally this insight is not gained, and they try to make people
eat a little bit healthier, and be a little more active.

• They also try to combine their treatment, show people that eating a sandwich after
activity is very important to raise your glucose levels.

• People are told how active they have to be to burn off a Mars bar.


7.4. Appendix 4: Context mapping exercises


7.5. Appendix 5: Context mapping quotes
7.5.1. Interview A; Quotes
- Holiday is important to get out of my daily routines, and see/experience new things.

- One moment I use a wrench, and the other moment I write extensive reports.

- Family is home and ground. The reason to go to work.

- I especially like the combination of Italian eating and wines.

- Eating is normally during a normal week very important to me.

- Normally I eat breakfast, lunch sandwiches, and a simple vegetables, potatoes and
meat.

- Sometimes in the evening I eat a cookie, or a little bit of chocolate.

- I always make my bread in the morning, and take it to work.

- Who gets home first, is the one to cook.

- In the weekend we try to cook something special and eat it with friends.

- During the evening I sit behind my computer, and my wife behind the TV. To do
something together we eat a little cookie or something, and continue.

- We always snack minimally.

- Since my diabetes I tend to look more for “light” products. The change is actually
not that big.

- My diabetes is always in my head while I make my sandwiches or cook. During the
rest of the day I don’t think about it.

- In the morning my medication is next to the bread, but sometimes in evening, due
to other rituals, I forget to take my evening medication.

- My medication is not dependant on what I eat.

- When I eat something not standard, then I think about Diabetes especially.

- In the morning it is better to leave me alone. I don’t have morning grumpiness, the
rest of the world does.

- At the end of the working day, when I go home, I feel quite happy.

- I go to sleep between 10 or 11 thirty.

- When I am involved behind my computer, I tend to go on longer then I should.

- I should eat a little less meat, and more vegetables. But I just like meat, as it is very
important to me.


- If I haven’t eaten meat a day, then I haven’t eaten at all.

- The dietary expert couldn’t really change my diet, except maybe for smaller por-
tions. All the things she said to us, we already knew. About change to a less fatty diet for
example.

- When I compare myself during lunch with my collegeas, my portion sizes are very
modest.

- In the evening I only get one portion, and never seconds, so why should I eat less?

- When we organize a dinner, and cook well, then I eat more.

- I am not an extreme eater anymore. It used to be more about quantity, now I prefer
quality above quantity.

- When people ask me too much to do, I get very stressful.

- I learned to say “no” to other people to prevent myself from getting stressed.

- People are very happy, or very disappointed with work, so I prefer to do things well,
and not just half. This only makes everybody unhappy.

- At holiday, when I go to dinner, I want to know where my bed stands; this gives me
the rest I need to go out eating.

- When people something has to be done a certain way, or “you have to ...”, then I
tend to not do it. You can ask me to do something.

- In groups of people I don’t know, I feel uncomfortable with doing small-talk.

- Stress certainly affects how healthy I am.

- When the stress goes away, I feel the calm and rest. During the stress itself I don’t
notice it.

- I don’t think stress influences my Diabetes.

- Whether my Diabetes is under control, I feel from my body. Things like getting
thirsty are a reminder that I should consider my Diabetes.

- I use my glucose meter to check my assumptions, how I think my body is doing.

- I wanted the glucose meter since measuring is knowing. I just want to know what is
happening, and the 3 month period is not often enough.

- Currently I don’t measure my glucose level that often, and it doesn’t hurt. I can
imagine though then when I need to do it more often, it gets more uncomfortable.

- When, after measuring, my glucose level is too high, then I think about what I ate,
so that I know for the next time. But usually I just continue with my standard patterns.

- When I see a high values, I want to check it tomorrow as well, to see if the problem
is persistent.


- Luckily I don’t have to inject insulin yet.

- Not all my medication is specifically for Diabetes. They are also for high blood pres-
sure and cholesterol, which are Diabetes related.

- Just is just a very small pill.

- In the morning I prepare my bread, put my pills next to it, and then just start the
day.

- To miss one pill once is not a problem for me. I don’t notice it.

- If I miss my pill in the morning, then I do notice it. Even though this is the smallest
pill.

- My night pills are next to my toothbrush.

- I don’t want to be confronted with my medication. It is something I use in a reflex.

- If I would stop and think about my medication every time, I would get depressed,
and it would interfere with my life.

- I actually got scared when I saw the amount of steps I take every day.

- In the weekend I like to vacuum after reading the paper. This gives me some exer-
cise.

- I travel by car, and spend most of my evening behind my computer.

- My activity is mostly dependant on my work schedule.

- I am glad my office is on the first floor, this gives me some regular exercise.

- Being active is not my hobby. I just see what I come across.

- I should be more active, but I find it really hard.

- Walking after dinner doesn’t appeal to me, too much of an effort.

- My knee is damages during a car accident, which makes it hard for me to be active.

- Since I have never been active, I find the threshold to start too big.

- When it comes to activity I take me knee injury more in account then my Diabetes.

- The music group Yes, I have been following for over 25 years. They help me relax.

- Yes can really change my mood, and trigger important memories.

- When I am not stressed, I find it very easy to relax.

- What can’t be done today, I can do tomorrow.

- Family, music and eating are all very important to me, but none is more important.
It depends more on the moment.


SMARCOS PHILIPS RESEARCH LABS Educational Final Report Master ThesisNiels Molenaar

SMARCOS PHILIPS RESEARCH LABS Educational Final Report Master ThesisNiels Molenaar

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SMARCOS PHILIPS RESEARCH LABS Educational Final Report Master ThesisNiels Molenaar