Rice Today, Roti Tomorrow:Diets and Diabetes in Urban Indian Households

Jasmine HentschelTHRIVE

Atlanta, GA, United Stateshentscj@gmail.com

Samyukta SherugarRui Zhou

Georgia Institute of TechnologyAtlanta, GA, United States

{ssherugar3, r.zhou}@gatech.edu

Vaishnav KameswaranUniversity of Michigan

Ann Arbor, MI, United Statesvaikam@umich.edu

Rajesh ChandwaniIndian Institute of Management

Ahmedabad, Indiarajeshc@iima.ac.in

Neha KumarGeorgia Institute of Technology

Atlanta, GA, United Statesneha.kumar@gatech.edu

ABSTRACTIn India, where diabetes is a growing concern and approx-imately 69 million are affected, we investigate the factorsthat influence diet management, a critical component of livingwith the disease. Taking the middle-income diabetes-affectedhousehold as our unit of analysis, we use a combination ofsemi-structured interviews and a design probe to understandif and how diets are monitored, tailored, and balanced. Weresearch the various information-seeking behaviors of ourparticipants and their culturally situated approaches to foodand eating. Our findings illuminate how contextual nuancesshape individuals’ beliefs around dealing with diabetes andthe ways in which family, friends, and broader social net-works influence dietary decisions. We conclude by offeringa framework of Learning-Being-Doing to inform the holisticdesign of technologies for managing diets and diabetes.

Author KeywordsDiabetes; Diets; India; Qualitative Methods

ACM Classification KeywordsH.5.m. Information Interfaces and Presentation (e.g. HCI):Miscellaneous

INTRODUCTIONThe incidence of chronic, non-communicable diseases hasbeen on the rise worldwide. Diabetes, in particular, is a ma-jor public health concern that is considered to be approachingepidemic proportions across the globe. According to the In-ternational Diabetes Federation, as of 2014, the number ofdiabetics in India alone is calculated to be approximately 69million [25]. In other words, roughly 17% of people with

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diabetes in the world live in India. To manage this ailment,patients are prescribed a regulated diet management, exercisemanagement, and self-monitoring regime. Although a multi-tude of technological approaches have been aimed at address-ing diabetes management in the U.S. [1, 31, 34], there is apaucity of research that examines the incidence of diabetesin India, the factors that drive its prevalence in the country,and ways in which the disease might be managed by thoseaffected.

Diet is a major component of diabetes management; many ex-isting mobile solutions for those with diabetes target healthierdiets [13, 14, 18, 38]. These tools, however, lack an under-standing of lifestyles, cooking styles, dietary preferences, andeating practices that are typical of Indian households. Thecultural specificity extends beyond cooking and eating prac-tices. Research shows that Indians are used to an approachto medicine with different roots from those of the West and adifferent style of doctor-patient interactions [7, 47]. Medicaland dietary consultations are irregular and infrequent, oftenexpensive, and not always helpful. Given that the incidenceof diabetes in India is among the highest in the world andgrowing rapidly [25, 45], it is critical that we also investigateand address concerns around diabetes management for the In-dian populace.

Our research presents a qualitative investigation of how diet ismanaged in urban, middle-income Indian households affectedby diabetes. Taking the household as our unit of analysis,we use a combination of semi-structured interviews and a de-sign probe to understand how persons with diabetes (PWDs)monitor, tailor, and balance their diet. We examine variousinformation-seeking behaviors related to food and eating, theroles friends and family play in providing care and assistancefor managing diet, and actions taken to effect lifestyle dietarychanges. Based on the insights gleaned from our findings,we present a framework of Learning-Being-Doing to informthe holistic design of technologies for the management of dietand diabetes.

RELATED WORKThe rising incidence of diabetes across the world, includingin India, has led to its recognition as a major public healthconcern. Our research examines those affected by Type 2Diabetes, a disease that affects a person’s ability to produceinsulin and properly control their concentration of blood glu-cose [19]. To avoid short- and long-term complications ofthe disease, medical management is critical; however, a highdegree of self-management around diet and physical activitylevels is also required [2].

Diet Management and Food as MedicineLifestyle changes around diet and exercise form the main-stay of the treatment of diabetes [30]. Diet modification isregarded as the first line of therapy [24]. Studies have shownthat diet modifications alone can achieve up to one third ofglycemic control [19] and lead to significant reduction inoverall morbidity and mortality [37].

Dietary preferences are highly contextualized and culturallyentrenched, and should be investigated as such [12]. Contex-tual nuances including local folklore shape beliefs related todiet, disease, and treatment. Apart from the formal biomedi-cal system, the culture in India draws heavily on multiple sys-tems of medicine including Ayurveda, Siddha, Unani, Home-opathy, and Naturopathy. These systems of medicine differin their conceptualization of disease and treatment, and takevarying approaches to etiology, diet, drugs, and treatmentprotocols [47]. Most of these systems emphasize the impor-tance of food in disease. In Ayurveda, for example, food isregarded as medicine itself [47]. These dimensions suggestthat an exploration of the relationship between diet and di-abetes in India must recognize these diverse viewpoints andconceptualizations.

Behavior Change for HealthLifestyle modifications such as diet alterations entail adjust-ment of preferences and behaviors that are deeply entrenchedin individuals’ lives [5]. Adherence to recommendations re-garding change of diet and lifestyle has thus been shown tobe poor among diabetes patients [3, 40]. People newly di-agnosed with diabetes may have difficulty adapting recom-mended behavior changes due to well-established habits, in-sufficient knowledge about healthy lifestyles, or lack of mo-tivation [5]. Stress-related overeating, inability to resist un-healthy food, old age, and lower education levels have alsobeen shown to relate to non-adherence [26, 36, 49].

Factors related to healthcare providers can often affect com-pliance with recommended behavior changes as well. Daly etal. [11] found that patients who reported better physician-patient communication had better blood glucose control.Nurse practitioners interviewed by Jansink et al. [26] reportedthat adherence can also be affected by healthcare providers’inadequate counseling skills or lack of time. Confusing vo-cabulary used by dieticians and doctors along with imprac-tical suggestions regarding the quantity of diet also presentchallenges for PWDs [49] in following recommendations. Inaddition, it has been found that there is no consensus re-garding dietary management in diabetes, and therefore advice

from doctors is frequently inconsistent [46]. Hale et al. [22]conducted a study of guideline repositories, diabetes organi-zation websites, and literature for protocols regarding treat-ment of diabetes. They observed that clinical practice recom-mendations were more patient-focused and consistent com-pared to nutrition-specific guidelines, which showed a highdegree of inconsistency.

Care and social influences also play a critical role within thediabetes-affected household. Lack of family or social sup-port can be a critical barrier to lifestyle changes for PWDs [2,49], and social influence can be a key determiner of successin behavior change [28]. Therefore, members of the greatercare network surrounding an individual must be taken intoaccount when designing health applications and services pro-moting behavior change [10, 15, 39]. Abowd [1] describeshow affected individuals are typically “considered the mostimportant link in the care network” and usually serve as pri-mary caregivers, but we seek to analyze how nuances in theIndian context challenge this notion. We aim to understandthe larger environments in which people live and eat, and thecollective needs and attitudes of all household actors involvedin diet and disease management.

HCI for Diabetes and Chronic Disease ManagementHCI research efforts have long explored chronic disease man-agement, and have typically focused on analyzing and design-ing for settings in the Western world. Work on managingchronic conditions has investigated how people collect andmake sense of data about their health-related behaviors, sethealth goals and track progress, and share health informa-tion via social networks. Projects in recent years have ex-amined a range of topics, including routines and preferencesaround sharing chronic disease-related information with ge-ographically distributed family members [42], web-based in-home treatment options for those without access to servicesin-person [48], ways to encourage increased physical activityto combat disease [9], as well as support for patients in self-management after being discharged from the hospital [43].

Within the realm of chronic disease management, HCI has re-cently seen a growing focus on diabetes in particular. Severalthemes have emerged from this body of work regarding theeffective design of tools for individuals living with the dis-ease. The work of Mamykina et al [34] and Mamykina andMynatt [33] analyzes how people living with diabetes man-age their health, highlighting the incessant struggle to findbalance between short-term pleasures and long-term healthgoals. As individuals cater health management routines totheir own unique conditions and circumstances, trial and er-ror become an inherent part of coping with diabetes. A sub-stantial part of this experimentation lies in critically reflectingon and analyzing one’s experiences, “one of the most crit-ical skills in the management of such diseases as diabetes”[32]. Self-reflection has thus evolved as a major componentin many tools designed for people with the disease, serving asa mode of sense-making and a promoter of behavior change[8, 32, 33, 41]. Involving the family and/or broader care net-work in the reflective process has also been demonstrated tohelp people look beyond their biases [1] and create a sharedmemory of behaviors and routines [21].

In addition to their immediate circles, many people livingwith diabetes engage with communities on the web for in-formation, advice, and support as they seek to manage theirconditions and identities. The MAHI platform [31], for exam-ple, provides free-form inputs to individuals to help improvetheir disease management skills through rich expressions ofidentity that serve purposes beyond those that are purely util-itarian. Zhou et al. [50] analyze how a grassroots online di-abetes forum in China called Sweet Home provides informa-tion and helps individuals to construct their identities, focus-ing on cultural factors that influence people’s understandingand interactions. Beyond identity, Mamykina et al. [35] ex-plore community engagement in “collective sensemaking” ofhealth information contributed to online forums.

These and related works highlight several principles of designrelevant to our analysis. Many articulate the need to explicitlyconnect information presented to individuals with outcomesrelated to behavior change efforts. Simply outputting or visu-alizing data without providing context and specific directionsor action points does not effectively promote behavior changein most cases, as it may just reinforce existing biases or provedifficult to mentally process [27]. Others pinpoint the im-portance of intricately integrating conceptions of time intodesigns. Individuals with diabetes must constantly balancetheir immediate needs and desires with their long-term healthgoals, and should be able to reflect on their past successesand failures to consistently improve their self-managementpractices. Beyond incorporating factors related to short- andlong-term considerations into designs, realistically evaluatinga solution’s effectiveness in behavior change requires analysisthat takes place over a substantial period of time [28].

While some existing models of behavior change leveraged inHCI research such as the transtheoretical model [44] and self-efficacy theory [4] pose certain limitations related to measure-ment, fragmentation, and inability to account for a majorityof variance in behavior change [23], frameworks such as BJFogg’s functional triad [17] provide valuable foundations foranalyzing persuasive technologies. We seek to extend theseand related works on behavior change in HCI by taking thehousehold rather than the individual as our unit of analysis.Given that food is frequently a family affair and not merelyan individual activity in the Indian context, it becomes im-perative for us to examine how food habits are adjusted andco-created in our target households.

METHODOLOGYOur research, approved by our institutional review board,took place in three distinct phases that we categorize and de-scribe below as (1) formative work, (2) semi-structured inter-views, and (3) EatingRight, our design probe.

Formative WorkIn October 2015, we attended a weekend-long hackathonin Hyderabad, India that included participants who workedacross India and internationally on matters concerning dia-betes management. To identify an area of need that couldbenefit from a technology-based solution in this domain, wewere provided with a carefully researched list of challenges

compiled by the organizers. Addressing diet management forthose with an Indian palate and lifestyle was the challengewe decided to investigate. At the hackathon, we had the op-portunity to do a rapid but extensive needs assessment of ourproblem space. We surveyed, brainstormed with, and soughtfeedback from 20-25 domain experts who were present, in-cluding endocrinologists, dietitians, physicians, and publichealth professionals. In November, we conducted a short sur-vey with approximately 75 individuals with diabetes at an en-docrinology clinic in Ahmedabad. The purpose of this surveywas to gain a preliminary understanding of prevalent beliefsand practices regarding dietary guidelines and restrictions forthose with diabetes. We used survey findings to design our in-terview approach for the next stage of data collection. In ad-dition, the endocrinologist who has runs this clinic for morethan 20 years gave us valuable inputs and feedback through-out our study.

Semi-Structured InterviewsThe next stage of data collection began in May 2016 andinvolved 36 semi-structured interviews with individuals indiabetes-affected households. Interviews were conducted byfour authors in five cities across India: Ahmedabad, Ban-galore, New Delhi, Kolkata, and Ramagundam. We chosemultiple cities in order to obtain a rich understanding of howfood practices varied across the Indian geography. We chosethese cities in particular because the authors collecting datahad strong local ties and were able to gain access to house-holds with relative ease. Within these cities, we recruitedparticipants using a combination of purposive and snowballsampling [20]. We targeted PWDs from middle-class house-holds; all participants were well-educated and reasonably fa-miliar with technology. In India, households often includeothers beyond the immediate nuclear family, such as grand-parents or adult siblings and their children. Since we wishedto understand diet management behaviors and concerns in thecontext of household dynamics, we strongly encouraged thepresence of other members of the household or larger carenetwork of the PWD, including extended family and closefriends. This was challenging to enforce for various unavoid-able reasons; thus, on a few occasions, we only interviewedthe PWD or caregiver. The details of our participants are in-dicated in Table 1. All interviews took place in person atparticipants’ homes and lasted 45-60 minutes on average.

Though we made a concerted effort to achieve gender bal-ance, 27 out of 36 PWDs in our sample were male. In oneinterview, a participant promised to introduce us to womenin his apartment building who had diabetes, but after severalfollow-ups informed us that the women were simply not com-fortable talking about their ailment. Many male participantswere also of the view that it was mostly men who had di-abetes. Since scientific data does not support this view, weconjectured that it was mainly because, culturally speaking,the women were not as open in talking about their condition.

In our interviews, we first asked participants more generalquestions, such as how they had discovered that they had di-abetes, whether there was family history of the disease, whatadvice and recommendations they received from their doctors

to manage it, and what behavior change they had put into ef-fect thus far. We then asked more focused questions aroundeating practices of the PWDs, their efforts to manage diet, andthe role of their friends and family in supporting diet manage-ment. All interviews were audio-recorded, but because sometook place at short notice or were in noisier settings, we alsotook extensive notes.

Our interviewing stage involved almost daily check-insamong authors to discuss findings, compare notes, and iterateon our interview protocol. Interview transcripts were trans-lated to English (since they were otherwise in multiple differ-ent Indian languages) and analyzed along with our notes. Wesubjected our interview data to thematic analysis as outlinedin [6]. This process was primarily driven by the first author,but all interviewers participated and we iterated through thefindings as a group. Our coding entailed a rigorous catego-rization of data as we identified patterns and arrived at ap-propriate themes. We began with manually conducting opencoding. First-level codes were carefully linked to our data,e.g., “experimentation with dark chocolate,” “thinks video istoo long,” and “tip learned from Facebook.” After multiplerounds of coding, we condensed the codes into larger themessuch as “trial and error” and “information-seeking practices.”

EatingRightBased on the data collected above, and in an effort to un-derstand how technology could ease the challenges of dietmanagement for diabetes-affected households by providingrelevant, friendly, constructive, and medically correct rec-ommendations, we designed a probe called EatingRight (seeFig. 1). Our process was highly iterative and began withthe hackathon, evolving as we obtained insights, advice, andfeedback from health and diet experts as well as our surveyand interview participants. We developed EatingRight in theform of a mobile application prototype, with its interface cen-tered around presenting users with new recipes appropriatefor people with diabetes through videos featuring a dietitian,endocrinologist, and female chef. Five videos shot in the for-mat of popular Indian cooking shows were factored into thedesign. Our goal was to target the “kitchen manager,” mostoften the woman/women of the house, by delivering recipesthat were diabetes-friendly and tasty (unlike doctors’ usualsuggestions) in a format that was familiar and engaging. Eat-ingRight was chiefly used in our interviews to determine par-ticipants’ level of interest in learning new recipes through themobile medium and glean what nature of content is seen asmost beneficial. It provided an opening for discussions re-garding who is seen as a credible source, how willing peopleare to experiment with new recipes in their families, and whatformats and channels they prefer to use for finding and shar-ing information related to diets for people with diabetes. Thisexercise allowed us to make more effective design recommen-dations, as outlined in our discussion section.

Researcher Backgrounds and BiasesWe are a team of six researchers, coming from a combinationof backgrounds. Five have background and training in HCI,two are designers, and two have researched public health con-cerns in India for a sum total of 13 years. Four of us are

Figure 1. An early iteration of EatingRight

of Indian origin while a fifth has done fieldwork in India.All interviews were conducted in languages that respondents(and interviewers) were fluent and comfortable in, includingHindi, Kannada, English, Gujarati, Bengali, and Telugu. Weacknowledge that while it was helpful that we were intimatelyfamiliar with Indian culture and the diverse health and med-ical practices it engenders, this may also have introduced abiased perspective and we ask that our paper be read as such.In addition, we clarify that although we heard many differentapproaches to health and medicine, we are not equipped toand have no desire to take a correctness stand regarding anyof the “cures” and/or “treatments” shared by our participants.

FINDINGSWe now present our findings with particular attention to howPWDs learn about “eating right” for diabetes, the roles playedby different members of their immediate social networks inthis regard, and how they put changes into effect.

Learning to “Eat Right” for DiabetesOur interviews indicated that the ways in which participantslearned about diabetes and the recommended changes to dietswere multiple and diverse. We lay them out below, highlight-ing the roles that “ambient” knowledge, trusted doctors, fam-ily and friends, and additional sources played in generatingtheir understanding of the ailment.

“Ambient” KnowledgeMost participants were familiar with the disease long beforebeing diagnosed with it. One man explained:

“My father, his father, his father’s father, my uncle, hisolder brother, everyone has had diabetes. So I knew Iwas also going to get it.” – P23

Like in P23’s case, many participants were already familiarwith the lifestyle recommended by doctors because they hadseen a parent, sibling, or other extended family member grap-ple with the disease. This also meant that they consideredthemselves to be equipped with necessary knowledge regard-ing the ailment, without having made an active effort to seekthis out.

Hou

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Year

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Dia

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Pres

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1 Ahmedabad 1.5 PWD2 Ahmedabad 7 PWD, wife3 Ahmedabad 7 PWD, wife4 Ahmedabad 5 PWD, daughter5 Ahmedabad 12 PWD, father6 Ahmedabad 14 son, daughter-in-law7 Ahmedabad 4 PWD, husband8 Ahmedabad 16 son9 Bangalore 15 PWD, wife, daughter10 Bangalore 10 PWD, wife11 Bangalore 5 PWD, wife12 Bangalore 15 PWD, wife13 Bangalore 30 PWD14 Bangalore 2 PWD, wife15 Bangalore 12 PWD, wife16 Bangalore 23 PWD, wife17 Bangalore 22 PWD18 Bangalore 8 son, daughter-in-law19 Delhi 6 PWD20 Delhi 29 PWD, wife, 2 friends21 Delhi 18 PWD, wife, daughter, cousin22 Delhi 7 PWD, extended family23 Delhi 15 PWD, close friends24 Delhi 3 PWD, close friends25 Delhi 8 PWD, family26 Delhi 2 PWD, family27 Delhi 6 PWD, husband28 Kolkata 10-15 PWD, family29 Kolkata 8 PWD, friends30 Kolkata 10-15 PWD, friends31 Ramagundam 8 PWD, husband32 Ramagundam 10 PWD, wife33 Ramagundam 9 PWD34 Ramagundam 15 son, daughter-in-law35 Ramagundam 9 PWD, wife36 Ramagundam 18 PWD, wife

Table 1. Participant Demographics

“Less of this, less of that”On first being diagnosed, PWDs are given a diet chart fromtheir doctors (as seen in Fig. 2). Doctors serve as an im-portant, credible, and trusted source about good food habits,particularly for newly diagnosed patients. While the doctor’sadvice was generally taken to heart, it was also viewed by par-ticipants as being impossible to follow. As shown in the chartabove, doctors list out meal times and options that are starklydivergent from patients’ existing dietary regimens. This con-trast is sufficient to deter many from making concerted effortstowards changing their diet. Further, advice from doctorstends to place emphasis on foods to avoid rather than foodsto include in one’s diet. Our participants complained that thedoctor’s advice was always in the form of “less of this, less ofthat” as opposed to “do this” or “do more of that.” This maybe especially relevant in the Indian context where the foodhas a high proportion of carbohydrates and sweets, which areparticularly diabetes-unfriendly. One PWD remarked:

Figure 2. A recommended diabetes-friendly diet regimen

“My doctor emphasizes on what not to eat such as extrasugar, sweet dishes, ice creams, colas. . . ” – P21

Accurate and fitting as these recommendations may be, theyleave patients at a loss for changes they feel they can realis-tically introduce into their diets. Beyond recommendationsbeing seen as overly idealistic, patients only touch base withtheir doctors at the time of diagnosis and at checkups that hap-pen once every several months at most for a majority. Con-versations with doctors only take place in person as far as wecould tell, so their suggestions are not reinforced on a consis-tent or regular basis.

“I saw it on the Facebook”Far more frequently than with doctors, information exchangestake place with family members, friends, and wider socialcircles through in-person conversations or via mobile com-munication applications such as WhatsApp. Information isalso encountered on television, social media platforms, andother web-based sources. Face-to-face discussions we ob-served were invariably centered around food, whether withfriends, family members, or extended social networks. Par-ticipants related to foods in ways that demonstrated their lovefor eating and experimenting, even outside of the constraintsof diabetes.

We did not find that our participants made particular effortsto search for diabetes-related information, but several men-tioned that they had encountered relevant advice on socialmedia that had piqued their curiosity (see Fig. 3). For ex-ample, when asked about dietary changes, one participantshared that she had started using vijaysaar (a tree). She wouldsoak pieces of the vijaysaar bark overnight and in the morningdrink the water in which it soaked. She followed this practicedaily, and over time felt it had improved her diabetes. Whenwe asked how she had learned to do this, she responded:

Figure 3. Image forwarded through WhatsApp

“I saw it on the Facebook.” – P27

Images, videos, and messages received via social media ap-peared to be willingly embraced and adopted. Our partic-ipants felt that if this information was being circulated sowidely, there must be a modicum of truth to it. Since ourparticipants were generally older, virality and social mediaare still somewhat novel for them, and this may be why theywere more receptive to these “forwards” than younger usersmore adept at social networking might be. We also witnesseda pervasive culture of relying on and turning to alternativeand/or home remedies for health, which we touch upon next.

Alternative RemediesUnlike most Western contexts, India has a rich traditionof folklore and Complementary and Alternative Medicine(CAM) related to diseases and their management, such asAyurveda and Naturopathy [47]. We found our partici-pants to be most willing to embrace knowledge about foodbased on these forms of CAM. One reason often cited wasthat allopathic forms of therapy would entail lifelong treat-ment through pills/injections without any possibility of cure.CAM, on the other hand, presented no known side effects andwas, in fact, a familiar and trusted alternative. One PWD em-phasized:

“I was advised to have soaked fenugreek seeds everymorning on an empty stomach to control diabetes. Thesehome remedies are very effective. Most important, theydon’t have any side effects like the English medicines.”– P27

There was a resounding sense that, as long as there is no harm,it is okay and even advisable to try home remedies. One PWDshared that four years ago, his friend had suggested he go to ahealer in Delhi who prescribed “drops” for PWDs. When weasked what kind of drops they were, he said:

“I asked him what was in the drops. He did not tell me.He said, ‘if you want them take them otherwise don’t.’ Idid not have any better options at my disposal, so I did.”– P20

We heard several stories such as this, illustrating the willing-ness of participants to adopt unknown and unfamiliar reme-dies even if they could not fully understand them.

The examples above and several others we heard naturallyraise the question of credibility; that is, when can advicereceived from non-experts be relied upon? We found thatour participants ascribed high credibility to a variety of in-formation sources other than doctors. Although doctors maybe considered the final authorities on disease-related matters,participants were also influenced by the prospect of having toswallow pills for life. One endocrinologist we spoke with dur-ing our formative research described the challenge of com-municating with patients who regularly consult a multitudeof information sources with varying credibility:

“Many times, patients come with typical queries. Candiabetes be cured with bitter gourd? Some of these reme-dies have scientific basis and have been proven as agentsfor enhancing control, but they perceive that these arecuring agents. On the other hand, some patients willcome with weird solutions like eating rotten tomatoes.It is a task to convince them that not all messages arereliable.” – Endocrinologist (Ahmedabad)

Participants asserted that remedies stemming from CAMsources rarely come from doctors; rather, they are learned pri-marily through family, friends, and broader social networks.While some participants expressed slight disavowal towardsAyurvedic medicine, citing unreliability of results and slowspeed of effectiveness, many more conveyed doubts about theeffectiveness of allopathy. Most participants expressed greatoptimism that Ayurvedic solutions and home remedies canimprove or cure their disease, even if the information comesfrom unknown sources or is somewhat eccentric. One coupledescribed the husband’s endeavor to seek out organic chick-ens with pittha (a black growth on the liver) that is said tostop diabetes if eaten by the affected person:

Wife: “He’s gone to his village and tried with about 10chickens!”

Husband: “I never found one with the black spot. Youget it in those fighter cocks. . . you have to swallow thatpart. . . if you take that every 6 months thrice, it’s suppos-edly enough and it stops the disease altogether.” –H12

The husband has not yet found an instance of this black spot,but was adamant to continue his search.

Do Videos Work?By employing the EatingRight mobile application prototypein our interviews, we were able to investigate questionsaround how people consume and share information relatedto diabetes management and whether videos are effective fordisseminating this. We quickly learned that men did not findthe idea of cooking videos engaging at all, not contrary towhat we expected. Many women we spoke with watchedcooking shows on television, but did so more out of curiosityor for entertainment than a desire to try the recipes they saw.They explained that most recipes from the shows are hard toremember, too complicated, and too divergent from normal

meal routines to be worth trying. When these women viewedthe 5 to 7 minute long EatingRight videos they would be en-gaged at first but soon lose interest. Feedback indicated thatthe videos were too long and the recipes were good but didnot generate enough interest.

Challenges Within and Outside the HomeWithin our sample, the special needs of people with diabetestypically permeate dietary practices at the household level.This was an initial insight that led to a more elaborate focuson our part, also deciding our interview strategy to examinehouseholds and not individuals alone. As a result, we wereable to perceive the care and attention that goes into home-cooked meals for those with diabetes. We also repeatedlyheard how eating meals outside of the home exponentiallyincreases the complexity of managing one’s diet and stickingto a regimen of any kind. Dishes specifically catered to peoplewith diabetes are likely to be scarce or unavailable in mostcases, and avoiding the temptation to eat “forbidden foods”proves tremendously difficult for most PWDs.

Gender and Kitchen ManagementThe Indian diet consists largely of meals eaten at home, mostoften prepared by a woman, typically the wife or daughter-in-law of the house. Consequently, a woman may controlthe diet of everyone in the household a majority of the time.Even if a husband, child, father-in-law, or some other mem-ber of the household has the disease but she does not, thewoman managing the kitchen often actively seeks out infor-mation about appropriate foods and implementing changes inthe family’s meals through in-person conversations and vari-ous digital channels. In one interview, the wife and caretakerof a PWD spoke of a female friend of hers whose husband haddiabetes. This friend, as she said, cooked special diabetes-friendly meals for her husband on a daily basis. She went onto explain:

“She is not very educated, you see, so she mostly busiesherself with cooking.” – C20

Gender roles are deeply entrenched and we found that dietmanagement becomes a family affair, involving more thanjust the individual with the disease. This contrasts with con-texts where an individual with diabetes may be solely respon-sible for his/her dietary intake and handles meals more inde-pendently. The care network immediately becomes relevant,with family members and friends playing a key role.

Although kitchen managers regularly go out of their way tolearn about appropriate food preparations for PWDs, advicegiven to diabetes patients by doctors occurs in a clinical setupwhere the doctor and patient interact with each other on aone-on-one basis. In many cases, this leaves the woman whocontrols the kitchen out of the conversation when she is notthe PWD. As one male participant remarked:

“I go to the physician who tells me about the dietarymodifications. . . No special counseling is given to mywife, who controls the food and kitchen in my house.”– P22

In almost all households we interacted with, taking steps toconsciously control diabetes is a process taken on by a hus-band and wife together when it is the male member with thedisease. However, when the woman herself had diabetes,she would manage it on her own without directly seekinghelp from her husband or others at home. In our interviewwith H28, we asked the husband of the woman with diabeteswhether he knew what his wife ate daily. He immediately re-sponded by saying that she knew what she was doing and didnot need him to “interfere.”

Balancing Household Needs and PreferencesMealtime for diabetes-affected households can quickly be-come a balancing act. We found that most households sitdown to eat their meals together and share the same dishes,so foods are rarely prepared separately for the person with di-abetes. Beyond consciously preparing appropriate meals andadjusting amounts of specific ingredients such as salt, kitchenmanagers strive to keep food preferences of the whole familyin mind. Attempting to entirely omit ingredients like rice thatare staples of the diet in many regions in India can prove tobe not just difficult but nearly impossible, since family mem-bers have been accustomed to eating these regularly over thecourse of their entire lives. Some participants claimed theirfamilies were entirely averse to trying new meals or evennew mealtimes (because they were so aligned with television-watching schedules), making the risk of such attempts essen-tially not worthy of the effort required. We found this oftenled to experimentation with small substitutions of particularingredients or cooking familiar ingredients in new ways tomaintain variety in meals.

Social OccasionsDuring social occasions outside the home, all bets are offabout what food might be available in any given situation.In India, it is generally considered downright impolite to turndown more helpings of food or decline when offered dessert.Many interviewees mentioned the intense social pressure theyface during social occasions to eat sweets or consume largerportions than they would at home. The PWD from H22shared that because it was shaadi season (the season for wed-dings), it had become impossible to control his meals. An-other brought religion into the conversation, describing a timesomeone had brought him prasad (a religious offering in theform of a sweet) from the temple:

“When you say something is prasad (blessing from god)can you not have? They’ll get one laddoo from Tiru-pati. . . can I not eat that?” – P12

Participants expressed how this added layer of social pres-sures often far outweighs the benefits of controlling one’s dietin such situations, and leads most of them to indulge evenwhen they know they should not.

Atithi Devo Bhava or “Guest is God”In addition to challenges with meals outside of the home, wefound that similar constraints arise when families host visi-tors in their homes. In India, where “the guest is god,” foodis an integral part of showing hospitality and a special meal isoften prepared for visitors. Sweets are an essential part of an

Indian meal, and the eating experience is said to be completeif it ends with a sweet or dessert. The post-meal sweet is,therefore, especially important for demonstrating hospitality.Participants explained how social pressures and reduced con-trol over avoiding temptation again come into play in thesescenarios. After the interview in H21, the participants in-sisted that the author stay for dinner. The male PWD sharedthat he was happy she had done so, because it meant he wouldget to partake of the fancier food items as well.

Striving for ControlWhile practices around managing diabetes are influenced bythe larger context in which they exist, the disease is physicallyonly experienced by the individual. One caregiver said:

“Only the one with the sugar (diabetes) can understandwhat is happening to them.” – C15

This highlights the extent of self-awareness, self-monitoring,and self-control required to manage the disease. Participantsshared that they had become so attuned to their body that theyknew when their sugar levels were high and needed attention.One PWD mentioned that every time she developed a skinrash, it was because of high sugar. Thus we note that bothgroup and individual perspectives are critical to consider.

Trial and Error with FoodEffecting a balance between food, exercise, and medicinepresents an endless challenge for any diabetes-affected house-hold, regardless of context. In India, where home-cookedmeals are an integral part of everyday life, diet management isespecially challenging. Participants explained how altering afamily’s diet to address the needs of a PWD is typically doneby controlling the ingredients used in meals, the quantitiesof food consumed, and the frequency with which meals takeplace. Households tended to skew more towards substitut-ing ingredients or making minor alterations to dishes they areused to consuming instead of seeking out entirely new recipesto try. We found some families to have a higher tolerance forexperimenting with new recipes, but need several factors tocome together: open-mindedness on part of all members ofthe household to try something new, willpower of the personmanaging the kitchen to learn and attempt a new recipe, andprocurement of possibly unfamiliar ingredients.

While PWDs expressed great reverence for medical profes-sionals, most also cited difficulties in following their advice.Some people expressed an interest in learning through exper-imentation what helps or does not help in controlling theirsugar levels. P26, for example, shared that he had conducteda two-week long experiment last year. In one week, he atea piece of dark chocolate daily and measured his sugar lev-els at the end of the week. In the next week, he did not eatthis dark chocolate and measured sugar levels at the week’send. He concluded that dark chocolate helped his diabetes,the hypothesis he was out to test, and this led him to eat darkchocolate without guilt thereafter.

In general, participants found it hard to give up their favoritefoods, even if they understand the risks. One participant ex-plained how he had just returned to Delhi from his home

town, Varanasi. Since it was mango season, there was a par-ticular kind of sweet made of mango and cream that he couldnot possibly miss out on. He ate several sweets a day, anddescribed the effects upon his return home to Delhi:

“I was in terrible shape. It took me three days to recover.And for those three days, I just did not know what to dowith myself. But now I am fine. . . .” – P21

This pattern of “crime and punishment” [16] was commonacross the board. Participants would indulge and then rollback their diet for a few days until they found an opportunityto indulge again. Cutting back on ingredients, or eliminatingfoods from their diet altogether, was difficult. Most Indiandishes made at home use one or more staple grains, vegeta-bles, and spices. In South India, for example, rice is a staplefood present in meals served throughout the day. Asking aresident of this region who is accustomed to eating rice everyday to simply cut it out of his or her diet is no simple request.Instead, we found that people seek to lessen their consump-tion of foods they know to be detrimental for their health.

Participants mentioned cutting back quantities of rice theyate or attempting to stop eating it altogether by replacing itwith alternative grain-based foods such as roti (whole wheatflat bread), ragi (finger millet), idli (fermented lentil and ricecakes), dosa (fermented lentil and rice pancakes), bajra (pearlmillet), or rava (semolina). They discussed consuming lesssweets, fruits, spice, meats, and oily/deep fried foods. Somedescribed a need to increase their intake of vegetables andgreens, particularly bitter gourd, slimy greens, and fenugreekgreens. Participants also claimed they were better able to con-trol sugar levels by eating less frequently and less overall.

‘Fixing’ Indulgence with Other Forms of ControlThose dealing with diabetes must find ways to balance theirdesires for certain foods with their health requirements, andoften press their limits in doing so. We found that as peoplegain more experience experimenting with combinations offood, medicine, and exercise, they become more in tune withhow to stabilize their condition after making dietary choicesthat are not ideal. One PWD described:

“If you increase your activity and you eat then it is not aproblem. If activity is less, you should not eat.” – P9

Overall, there was a general sense that one must never com-pletely give up foods that bring great happiness and satis-faction, but instead manage consumption and restore balancewhen lines are crossed. Beyond managing food intake, par-ticipants widely claimed to control their diabetes through ex-ercise. Walking was brought up in nearly every interview asa critical method of control. Some claimed walking after ameal would counteract the effects of bad dietary choices andstabilize their condition. In addition to controlling food andwalking, managing stress–typically referred to as “tension” inIndia–was also seen as critical. One couple explained:

“You shouldn’t take it too seriously. . . if you do dietingand all that you will become weak. . . then your diseaseswill increase. Just be tension free.” – P10

The relationship between tension and sugar–a term oftenused in India instead of diabetes–was mentioned by severalparticipants, some of whom believed that they had contracteddiabetes because of stress that they suffered on account oftheir jobs. One participant explained:

“If you get tension, you get sugar.” – P9

Participants hinted at a balance between exercising great con-trol over their habits and keeping a relaxed attitude for fearof exacerbating the effects of the disease. They expressedconcern that being too worrisome or neurotic would increasestress and and make their sugar levels even harder to control.

DISCUSSIONHaving studied diets and eating behaviors of middle-incomediabetes-affected urban Indian households, we now discusstakeaways from our findings. To understand how the beastof diet management might be addressed, we highlight fac-tors to be considered in designing technology for this goal.Our analysis drove the creation of a framework centered onthree important aspects that must be addressed for a holisticapproach: Learning factors, how one seeks and gains infor-mation regarding diet management; Being factors, how one issituated within his or her surroundings (such as one’s house-hold, family, and friends); and Doing factors, how one is will-ing and able to take action. We elaborate on these below.

LearningTo understand learning is to understand the different sourcesindividuals and caregivers are willing and able to turn tofor information and their receptivity towards varied sources.Doctors might be the trusted, authoritative figures we expectto view them as, and they may be the ones our participantsturned to if they were in discomfort or unease. However, theday-to-day routines recommended by doctors were consid-ered by participants to be impractical and unrealistic. Doc-tors provide dietary advice to patients in a clinical setup andspecifically address the patient rather than the person whocontrols the kitchen, mostly the woman of the house. Fur-thermore, the advice emphasizes strict “don’ts” and avoid-ing high carbohydrate foods which are normally abundant inthe Indian diet. Following a regimented lifestyle appearedtoo challenging, except for one participant who said he wasokay with strict regimens probably because he had been inthe army.

More than doctors’ advice, participants relied on “ambient”knowledge, or the knowledge that “everyone” had, shared,and disseminated. These real-life behavior patterns foundtheir way onto social media behaviors as well, as partici-pants reported that their friends, family, and broader networks“knew” how to deal with diabetes, and generously sharedand disseminated new tips and tricks they came across us-ing WhatsApp and Facebook. To receive this information,participants neither had to look hard for it, nor engage verydeeply with it. Photos, images, and even short videos wereviewed and assimilated without much reflection. It was theintroduction of our 5-7 minute videos to participants, in fact,that made them visibly uncomfortable.

Finally, the openness to alternative remedies or CAM alsoconditioned participants to be accepting of information fromvaried sources. While this may be particular to India, it isworthwhile to consider what kinds of information are viewedas meaningful and/or acceptable and why others are rejectedor overlooked. This proposed focus on how learning takesplace also draws on insights from Lave and Wenger, who em-phasize the importance of situatedness [29].

BeingThe being aspect of our framework alludes to the ways inwhich people and their behaviors are shaped by their intimatesurroundings and beyond. By taking the household as ourunit of analysis, we learned that disease in the context of ourstudy was not managed solely by an individual. It was a col-lective effort, with the spouse, children, children-in-law, andeven neighbors contributing to the management of this dis-ease. Participants were often able to follow their diet planbecause their spouse assisted them in doing so. Alternatively,they were sometimes unable to stick to their regimen becausethey found themselves in unfamiliar surroundings where thiscare was missing, such as in their daughter’s home, where thespouse would focus on cooking for the daughter and son-in-law instead of the husband with diabetes.

Gender roles are important to consider when examining so-cial contexts, especially in our scenario where it is consideredunderstandable that women who are not very educated like tocook for those around them. More holistically, however, wemight consider what care networks look like and how powerrelationships are negotiated to influence the lifestyle and dis-ease management behavior of the one with the disease.

DoingAs highlighted above, our first observation with regards todoing was that our participants found it difficult to not do. Inthe doctor’s chart we shared, there were more “don’ts” than“dos”. We also heard from most participants that a doctor’sadvice is structured more around what is not recommendedrather than what is recommended. Participants were lookingto find constructive suggestions for steps they could take, andnot doing something did not seem like solution enough. Thismeant that they were very willing to try out new things, aslong as they did not view it as potentially harmful. The highreliance on CAM and on folklore was instrumental in the trialand error behavior adopted by the patients. We also found thatparticipants were very open to self-experimentation, tryingdifferent things to figure out what would reduce their sugarlevels even if doctors said that there were no cures for the dis-ease. Additionally, “bad” behavior with respect to food con-sumption was frequently balanced by “good” behavior else-where. Trying to understand these mental checks and bal-ances and how they manifest should be a critical aspect ofdesigning for contexts like those we studied.

Implications for DesignBased on the Learning-Being-Doing framework, we makerecommendations for designing technologies for engagingdiabetes-affected Indian households in diet management.

Towards Informed Decision-MakingOur analysis indicated that members of diabetes-affectedhouseholds in India seek out and receive information aboutthe disease from numerous sources but often have limited in-sight into its credibility. While recommendations from healthcare professionals are always taken as medically sound, fearof adverse side affects and the necessity of sticking to a strictregimen makes some hesitant to follow the advice. On theother hand, CAM approaches are viewed as more innocuousto adopt, but inspire less confidence than hope regarding theresults. Designers of technologies that present patients withdietary recommendations could consider integrating indica-tors of credibility such as “stamps of approval” from medicalprofessionals, reviews from patients who have tried a partic-ular approach, or testimonials from well-known figures. Wecould further support members of these households in effec-tively evaluating treatment options from diverse schools ofthought by providing socially sourced information regardingpotential side effects, perceived effectiveness, how a treat-ment was derived, combinations with other treatments, orlimitations for certain groups (e.g., pregnant women).

Towards Holistic UnderstandingsThe immense influence gender and family roles have on dis-ease management in this context came up repeatedly in ouranalysis. Established gender roles mean that women, whilesubject to patriarchal pressures, also control the householddiet and prepare foods for the family members with diabetes.This tension between agency and patriarchy that our researchuncovered deserves greater attention. Information discon-nects often arise in cases where the patient is not the kitchenmanager, as generally only the patient is present when med-ical professionals provide dietary advice. Designers can fa-cilitate better joint decision-making around meals by creatingsystems where these kitchen managers can more easily accessdietary information provided to patients by doctors. Becausethe needs of the PWD typically permeate household dietarypractices, we can also support kitchen managers by creatingtechnologies that help them balance these needs with prefer-ences of all their family members. Technologies might fa-cilitate group communication about food choices or considerproviding ideas or recommendations in a range of formatspreferred by cooks and caregivers.

Towards Actionable RecommendationsTo be seen as plausible alternatives to current options anddeemed worth sharing on their social networks, participantsdescribed how dietary recommendations must be easy to im-plement in their family’s everyday life. A majority were opento experimentation, but primarily interested in tweaking fa-miliar dishes or substituting certain ingredients rather than at-tempting to try entirely new recipes. We propose that design-ers focus on helping people make small changes rather thanoverhauling their recipe repertoires. Beyond promoting sim-ple, easy to remember, and regionally-specific content, mo-bile application or web-based interfaces might do this by inte-grating refined functionality for searching, sorting, or filteringby ingredients or geographical regions, helping users exploreand analyze appropriate substitutions for ingredients in a ro-bust manner, or supporting discussion among users about how

to tweak and personalize dishes. Most importantly, design-ers should prioritize presenting recommendations in a highlyadaptable format over providing a larger quantity of them.

We could also contribute to positive dietary changes by sup-porting the practice of “checks and balances” that many par-ticipants described as part of their daily decision-making. Pa-tients who have significant experience living with the diseasegradually become more adept at restoring balance to theircondition through medicine, exercise, or other foods afterconsciously making detrimental dietary choices. Technolo-gies we design for newly-diagnosed patients, in particular,could promote more rapid acquisition of these skills by vi-sualizing which approaches help them achieve their desiredbalance in the healthiest way and suggesting similar alterna-tives that they might try.

Limitations and Directions for Future WorkOur work presents a first look into behaviors associated withdiet management for diabetes in an urban Indian context. Oursample was limited to middle-income households and did notinclude enough women with diabetes. Future work could ex-amine the challenges of addressing diet management acrossdiverse socioeconomic strata and among women with the ail-ment. Although our research offers a deeper understanding ofthe different information sources that PWDs and caregiversrely on, future work might also examine which sources aremore successful in effecting behavior change and/or whichresult in greater spread. Lessons learned from EatingRightcould be leveraged towards further pursuit of technology de-sign for diet management. Finally, our research finds that inthe Indian context where health infrastructures may be under-equipped to ensure chronic disease management, care net-works are rich and could be examined and leveraged suitablyfor other ailments as well.

CONCLUSIONWe investigated the ways in which middle-class diabetes-affected households in urban India experiment with and adoptcertain dietary practices to manage the disease. Our re-search highlights nuances in information-seeking behaviorsand challenges to diet management specific to the Indian con-text. We present a framework of Learning-Being-Doing tohighlight important contextual factors that should be consid-ered when taking a holistic approach to designing tools fordiet management for diabetes. Finally, we discuss designguidelines for future applications intended to support house-holds dealing with diabetes management.

ACKNOWLEDGMENTSWe thank our participants, anonymous reviewers, partners inIndia, and Tanisha Wagh for their invaluable inputs.

REFERENCES1. Gregory D Abowd, Gillian R Hayes, Julie A Kientz,

Lena Mamykina, and Elizabeth D Mynatt. 2006.Challenges and opportunities for collaborationtechnologies for chronic care management. TheHuman-Computer Interaction Consortium (HCIC 2006)(2006).

2. Noemi B Albarran, Martha N Ballesteros, Gloria GMorales, and Maria I Ortega. 2006. Dietary behaviorand type 2 diabetes care. Patient Education andCounseling 61, 2 (2006), 191–199.

3. Alice S Ammerman, Christine H Lindquist, Kathleen NLohr, and James Hersey. 2002. The efficacy ofbehavioral interventions to modify dietary fat and fruitand vegetable intake: a review of the evidence.Preventive medicine 35, 1 (2002), 25–41.

4. Albert Bandura. 1977. Self-efficacy: toward a unifyingtheory of behavioral change. Psychological review 84, 2(1977), 191.

5. Alison O Booth, Carole Lowis, Moira Dean, Steven JHunter, and Michelle C McKinley. 2013. Diet andphysical activity in the self-management of type 2diabetes: barriers and facilitators identified by patientsand health professionals. Primary health care research& development 14, 03 (2013), 293–306.

6. Virginia Braun, Victoria Clarke, and Gareth Terry. 2014.Thematic analysis. Qual Res Clin Health Psychol(2014), 95–114.

7. Rajesh Chandwani and Vaibhavi Kulkarni. 2016. Who’sthe Doctor?: Physicians’ Perception of InternetInformed Patients in India. In Proceedings of the 2016CHI Conference on Human Factors in ComputingSystems. ACM, 3091–3102.

8. Yunan Chen. 2010. Take it personally: accounting forindividual difference in designing diabetes managementsystems. In Proceedings of the 8th ACM Conference onDesigning Interactive Systems. ACM, 252–261.

9. Sunny Consolvo, David W McDonald, Tammy Toscos,Mike Y Chen, Jon Froehlich, Beverly Harrison, PredragKlasnja, Anthony LaMarca, Louis LeGrand, RyanLibby, and others. 2008. Activity sensing in the wild: afield trial of UbiFit Garden. In Proceedings of theSIGCHI Conference on Human Factors in ComputingSystems. ACM, 1797–1806.

10. Sunny Consolvo, Peter Roessler, Brett E Shelton,Anthony LaMarca, Bill Schilit, and Sara Bly. 2004.Technology for care networks of elders. IEEE PervasiveComputing 3, 2 (2004), 22–29.

11. Jeanette M Daly, Arthur J Hartz, Yinghui Xu, Barcey TLevy, Paul A James, Mary L Merchant, and Robert EGarrett. 2009. An assessment of attitudes, behaviors,and outcomes of patients with type 2 diabetes. TheJournal of the American Board of Family Medicine 22, 3(2009), 280–290.

12. Feiyue Deng, Anran Zhang, and Catherine B Chan.2013. Acculturation, dietary acceptability, and diabetesmanagement among Chinese in North America.Frontiers in endocrinology 4 (2013).

13. Ontrack Diabetes. 2016.https://medivo.com/ontrack/. (2016). (Accessed on09/21/2016).

14. DiabetesConnect. 2016. DiabetesConnect - DiabetesManagement. http://www.diabetesconnect.de/en/.(2016). (Accessed on 09/21/2016).

15. Sara Diamond, Bhuvaneswari Arunachalan, DerekReilly, and Anne Stevens. 2014. Workshop on designingthe future of mobile healthcare support. In Proceedingsof the 16th international conference onHuman-computer interaction with mobile devices &services. ACM, 589–592.

16. Rujuta Diwekar. 2011. Don’t Lose Your Mind, Lose YourWeight. Random House India.

17. BJ Fogg. 2003. Persuasive Technology: UsingComputers to Change What We Think and Do. MorganKaufmann.

18. Fooducate. 2016. Lose weight & improve your healthwith a real food diet. http://www.fooducate.com/.(2016). (Accessed on 09/21/2016).

19. Mary C Gannon and Frank Q Nuttall. 2006. Control ofblood glucose in type 2 diabetes without weight loss bymodification of diet composition. Nutrition &metabolism 3, 1 (2006), 1.

20. Leo A Goodman. 1961. Snowball sampling. The annalsof mathematical statistics (1961), 148–170.

21. Andrea Grimes, Desney Tan, and Dan Morris. 2009.Toward technologies that support family reflections onhealth. In Proceedings of the ACM 2009 internationalconference on Supporting group work. ACM, 311–320.

22. Kelli Hale, Sandra Capra, and Judy Bauer. 2016. Arenutrition messages lost in transmission? Assessing thequality and consistency of diabetes guidelinerecommendations on the delivery of nutrition therapy.Patient Education and Counseling (2016).

23. Eric B Hekler, Predrag Klasnja, Jon E Froehlich, andMatthew P Buman. 2013. Mind the theoretical gap:interpreting, using, and developing behavioral theory inHCI research. In Proceedings of the SIGCHI Conferenceon Human Factors in Computing Systems. ACM,3307–3316.

24. Rury R Holman, Carole A Cull, Charles Fox, andRobert C Turner. 1995. United Kingdom prospectivediabetes study (UKPDS) 13: relative efficacy ofrandomly allocated diet, sulphonylurea, insulin, ormetformin in patients with newly diagnosed non-insulindependent diabetes followed for three years. BritishMedical Journal 310, 6972 (1995), 83.

25. International Diabetes Federation. 2016. India.http://www.idf.org/membership/sea/india. (2016).(Accessed on 09/21/2016).

26. Renate Jansink, Joze Braspenning, Trudy van derWeijden, Glyn Elwyn, and Richard Grol. 2010. Primarycare nurses struggle with lifestyle counseling in diabetescare: a qualitative analysis. BMC family practice 11, 1(2010), 1.

27. Anne Marie Kanstrup, Pernille Bertelsen, MarieGlasemann, and Niels Boye. 2008. Design for more: anambient perspective on diabetes. In Proceedings of theTenth Anniversary Conference on Participatory Design2008. Indiana University, 118–127.

28. Predrag Klasnja, Sunny Consolvo, and Wanda Pratt.2011. How to evaluate technologies for health behaviorchange in HCI research. In Proceedings of the SIGCHIConference on Human Factors in Computing Systems.ACM, 3063–3072.

29. Jean Lave and Etienne Wenger. 1991. Situated learning:Legitimate peripheral participation. Cambridgeuniversity press.

30. Alice H Lichtenstein, Lawrence J Appel, MichaelBrands, Mercedes Carnethon, Stephen Daniels,Harold A Franch, Barry Franklin, Penny Kris-Etherton,William S Harris, Barbara Howard, and others. 2006.Diet and lifestyle recommendations revision 2006 Ascientific statement from the American HeartAssociation nutrition committee. Circulation 114, 1(2006), 82–96.

31. Lena Mamykina, Andrew D Miller, Elizabeth D Mynatt,and Daniel Greenblatt. 2010. Constructing identitiesthrough storytelling in diabetes management. InProceedings of the SIGCHI Conference on HumanFactors in Computing Systems. ACM, 1203–1212.

32. Lena Mamykina, Elizabeth Mynatt, Patricia Davidson,and Daniel Greenblatt. 2008. MAHI: investigation ofsocial scaffolding for reflective thinking in diabetesmanagement. In Proceedings of the SIGCHI Conferenceon Human Factors in Computing Systems. ACM,477–486.

33. Lena Mamykina and Elizabeth D Mynatt. 2007.Investigating and supporting health managementpractices of individuals with diabetes. In Proceedings ofthe 1st ACM SIGMOBILE international workshop onSystems and networking support for healthcare andassisted living environments. ACM, 49–54.

34. Lena Mamykina, Elizabeth D Mynatt, and David RKaufman. 2006. Investigating health managementpractices of individuals with diabetes. In Proceedings ofthe SIGCHI conference on Human Factors in computingsystems. ACM, 927–936.

35. Lena Mamykina, Drashko Nakikj, and Noemie Elhadad.2015. Collective Sensemaking in Online Health Forums.In Proceedings of the 33rd Annual ACM Conference onHuman Factors in Computing Systems. ACM,3217–3226.

36. Todd R Marcy, Mark L Britton, and Don Harrison.2011. Identification of barriers to appropriate dietarybehavior in low-income patients with type 2 diabetesmellitus. Diabetes Therapy 2, 1 (2011), 9–19.

37. Jill A Metz, Judith S Stern, Penny Kris-Etherton,Molly E Reusser, Cynthia D Morris, Daniel C Hatton,Suzanne Oparil, R Brian Haynes, Lawrence M Resnick,F Xavier Pi-Sunyer, and others. 2000. A randomized

trial of improved weight loss with a prepared meal planin overweight and obese patients: impact oncardiovascular risk reduction. Archives of InternalMedicine 160, 14 (2000), 2150–2158.

38. MyFitnessPal. 2016. Free Calorie Counter, Diet &Exercise Journal. https://www.myfitnesspal.com/.(2016). (Accessed on 09/21/2016).

39. Elizabeth D Mynatt. 2011. IT in healthcare: a body ofwork. interactions 18, 3 (2011), 22–25.

40. Karin M Nelson, Gayle Reiber, and Edward J Boyko.2002. Diet and exercise among adults with type 2diabetes findings from the third national health andnutrition examination survey (NHANES III). Diabetescare 25, 10 (2002), 1722–1728.

41. Tom Owen, Jennifer Pearson, Harold Thimbleby, andGeorge Buchanan. 2015. ConCap: Designing toEmpower Individual Reflection on Chronic Conditionsusing Mobile Apps. In Proceedings of the 17thInternational Conference on Human-ComputerInteraction with Mobile Devices and Services. ACM,105–114.

42. Carolyn E Pang, Carman Neustaedter, Bernhard ERiecke, Erick Oduor, and Serena Hillman. 2013.Technology preferences and routines for sharing healthinformation during the treatment of a chronic illness. InProceedings of the SIGCHI Conference on HumanFactors in Computing Systems. ACM, 1759–1768.

43. Ari H Pollack, Uba Backonja, Andrew D Miller,Sonali R Mishra, Maher Khelifi, Logan Kendall, andWanda Pratt. 2016. Closing the Gap: SupportingPatients’ Transition to Self-Management afterHospitalization. In Proceedings of the 2016 CHIConference on Human Factors in Computing Systems.ACM, 5324–5336.

44. James O Prochaska. 2013. Transtheoretical model ofbehavior change. In Encyclopedia of behavioralmedicine. Springer, 1997–2000.

45. Ambady Ramachandran, Simon Mary, AnnasamiYamuna, Narayanasamy Murugesan, and ChamukuttanSnehalatha. 2008. High prevalence of diabetes andcardiovascular risk factors associated with urbanizationin India. Diabetes care 31, 5 (2008), 893–898.

46. J Salas-Salvado, MA Martinez-Gonzalez, M Bullo, andE Ros. 2011. The role of diet in the prevention of type 2diabetes. Nutrition, Metabolism and CardiovascularDiseases 21 (2011), B32–B48.

47. V Sujatha. 2007. Pluralism in Indian medicine Medicallore as a genre of medical knowledge. Contributions toIndian Sociology 41, 2 (2007), 169–202.

48. Andrea Taylor, Angus Aitken, David Godden, andJudith Colligan. 2011. Group pulmonary rehabilitationdelivered to the home via the internet: feasibility andpatient perception. In Proceedings of the SIGCHIConference on Human Factors in Computing Systems.ACM, 3083–3092.

49. S Vijan, NS Stuart, JT Fitzgerald, DL Ronis, RAHayward, S Slater, and TP Hofer. 2005. Barriers tofollowing dietary recommendations in Type 2 diabetes.Diabetic Medicine 22, 1 (2005), 32–38.

50. Xiaomu Zhou, Si Sun, and Jiang Yang. 2014. SweetHome: understanding diabetes management via achinese online community. In Proceedings of the 32ndannual ACM conference on Human factors in computingsystems. ACM, 3997–4006.