SMARCOS PHILIPS RESEARCH LABS Educational Final Report Master ThesisNiels Molenaar

Final Master Project Draft Report

M2.2

14-04-2011

Niels Molenaar,

[email protected]

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

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

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

Table of ContentsAbstract .......................................................................................... 51. Introduction .................................................................................. 7

1.1. Stakeholders ....................................................................................81.1.1. Philips Research .................................................................................. 81.1.2. SmarcoS ............................................................................................ 81.1.3. Personal motivation ............................................................................. 9

1.2. What is type 2 Diabetes ....................................................................92. Research .....................................................................................11

2.1. General type 2 Diabetes treatment .................................................... 112.1.1. Interview with Diabetes nurse ...............................................................11

2.2. Effects of food intake on type 2 Diabetes ........................................... 112.2.1. Literature on food intake .....................................................................112.2.2 Interview with dietician ....................................................................... 122.2.3. Dietary monitoring ............................................................................ 12

2.3. Effects of activity on type 2 Diabetes .................................................132.3.1. Literature on activity .......................................................................... 132.3.2. Interview with physiotherapist ............................................................ 13

2.4. Behavior change strategies ..............................................................132.4.1. Literature on intervention ................................................................... 132.4.2. Technology versus human effects on intervention ................................ 14

2.5. User interviews ..............................................................................142.5.1. Interview goals .................................................................................. 142.5.2. Method ............................................................................................ 142.5.3. Results from interviews in requirements .............................................. 152.5.4. Use of requirements for food focus in project ....................................... 16

3. Design ........................................................................................ 193.1. Vision ............................................................................................19

3.1.1. Context for vision ............................................................................... 193.1.2. Motivation for vision ..........................................................................203.1.3. Concept Requirements .......................................................................20

3.2. Implementation ..............................................................................213.2.1. Shopping bag ....................................................................................213.2.2. Interaction with shopping bag .............................................................233.2.3. Form of shopping bag ........................................................................243.2.4. Technology in shopping bag ...............................................................26

4. Discussion ..................................................................................294.1. Relevance of vision ........................................................................ 294.2. Application possibilities ................................................................. 29

4.2.1. Different user or context .....................................................................294.3. Future research recommendations ................................................... 29

4.3.1. User studies ......................................................................................294.3.2. Technological advancements ..............................................................304.3.3. Importance of activity vs. diet.............................................................30

5. Conclusion ..................................................................................336. Bibliography ................................................................................357. Appendices .................................................................................39

7.1. Appendix 1: Interview Diabetes Nurse ................................................ 397.2. Appendix 2: Interview Diabetes Dietary Expert ................................... 42


7.3. Appendix 3: Interview Diabetes Physiotherapist .................................. 457.4. Appendix 4: Context mapping exercises ............................................ 487.5. Appendix 5: Context mapping quotes ................................................ 52

7.5.1. Interview A; Quotes ............................................................................527.5.2. Interview B; Quotes ...........................................................................567.5.3. Interview C; Quotes............................................................................ 617.5.4. Interview D; Quotes ...........................................................................65


abstract


AbstractThis 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. IntroductionThe 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. StakeholdersThis 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 ResearchThis 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. SmarcoSSmarcoS 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 motivationFor 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. ResearchThe 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 treatment2.1.1. Interview with Diabetes nurseAn 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 Diabetes2.2.1. Literature on food intakeThe 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 dieticianA 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 monitoringTo 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 Diabetes2.3.1. Literature on activityOften 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 physiotherapistA 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 strategies2.4.1. Literature on interventionWhen 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 interviewsWe 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 goalsType 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 requirementsThe 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 account my regular behav-ior, and give alternatives

Must The dietary expert doesn’t try to make me feel guilty

The system should be subtle, and try to change in small steps

Must The diet was too extreme, I couldn’t last this way

The system needs to help in portioning

Should I could eat less, but I only plate once, so why?

The system informs the user what food is good

Should I eat less meat and fish, and more potatoes as I consider this healthy

The system should be quick to use

Must I don’t care about food in-take programs, they are too time intensive

The system makes projec-tions on what current behav-ior could lead to

Should Since I notice I get full faster, I am much more motivated

The system recognizes behavioral patterns

Could I always eat … for breakfast and lunch

The system needs to allow for extremities

Should I chose to go out to din-ner and eat unhealthy, this makes me happy and doesn’t happen very often


The system creates aware-ness of the effects of food choices

Must Why should I change my diet, I am not sick

The system understands exceptions/deviations from activities

Should Work and weather influence my activity

The system creates feedback on the basis of insight in activity

Must I actually got scared when I saw the amount of steps I took every day

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

Must Going to the supermarket gained me 1500 steps, I never saw that as healthy

The system raises confi-dence and activity by warn-ing for a hypo

Could I sold my bike as I am afraid to get another hypo while riding it

The system gives insight in daily moderate activity like walking and going to the supermarket as healthy behavior.

Could I have never been active and never will be, I don’t like sports

The system is reliable, and perceived as a trustworthy source of information

Should I try to find information on the internet, but I am not always sure how reliable it is

The system gives positive feedback

Must I prefer the dietary expert over internet as she is more concrete and positive

The system predicts positive aspects

Could I actually like how diabetes decreased my belly girth

The system learns about hypo’s and hyper’s

Should The distinction between a hypo and a hyper are very hard to understand

The system communicates numbers

Could I like numbers as it gives me insight in patterns. I might be able to attach those to my lifestyle

The system projects current behavior, and how this can postpone the moment when you have to start injecting insulin

Should Luckily I don’t have to inject insulin yet

The system should commu-nicate abstract information

Should I have a book with nutrition-al information, but I find it very hard to understand

2.5.4. Use of requirements for food focus in projectThe 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. DesignTo 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. VisionBelow 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 visionInterviews 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 visionIn 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 RequirementsR2: 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. Implementation3.2.1. Shopping bagContext-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 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.

Figure 2: Results from brainstorm


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.

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 3: Context impression (Image by Loblaws)

Figure 4: Model with light pattern indicat-ing two products.

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 bagThe 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 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.

Figure 6: Interaction idea sketches


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.

3.2.3. Form of shopping bagAfter 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 7: Scenario of interaction

SUPERMA

WHITEWHITEWhole wheat WHITEWHITEwheat

?WHITE wheat

>WHITE

WHITEwheatWHITE

WHITEWHITEwheat

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.

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

Figure 10: Eames Lounge Chair (Image by Vitra)

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 bagThe 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 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.

Figure 12: Diagram of technology



discussion


4. DiscussionThe 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 visionCurrently 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 possibilities4.2.1. Different user or contextDepending 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 recommendations4.3.1. User studiesFor 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 advancementsDepending 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. dietIn 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. ConclusionThe 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.


bibliography


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appendices


7. Appendices7.1. 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• Where does she stand in relation to other healthcare personnel?

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• Where does she stand in relation to other healthcare personnel?

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 quotes7.5.1. 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.


- With wine I can really invest my time in finding information and talking to it about others. More than the actual drinking of the wine.

- The computer is where I combine all my hobbies. Finding information.

- With electronics I want to know what is possible, and try these extremes.

- I want to go beyond the standard functionality of a product.

- I would like to understand how technology works.

- When I have questions or am confronted with the Diabetes, I go look on-line for more information.

- I go online to check what other people have to say about the medication I use.

- I am afraid something will happen to my feet. This is the sign that something more serious is going on.

- You really have to watch out on the internet to check the reliability of the source. I take this very seriously.

- When I eat, I really like a fitting wine with it.

- Currently I am not afraid that I have to change my diet, which is very important to me.

- It is ok to occasionally steer away from the diet and really enjoy a nice dinner in a restaurant with good wine. For me this is also like a reward.

- I always care on medication in a small box in my coat. This for emergency.

- In the morning and just before sleeping I never forget my medication. After dinner however can be difficult to remember.

- Sometimes I notice that my family is worried about me.

- As a family we help each other and try to solve problems.

- My wife knows she has to be subtle to help me, otherwise I won’t allow her to help me.

- I have my own responsibility, so worrying, I have to do myself.

- I would maybe like to have an app for my phone to remind me of my medication. It has to be subtle though, since when it is too intrusive, I will delete it for sure.

- I would not be interested in a pedometer. I want to know what my standard pattern is, but then I won’t allow it to change my life.

- I don’t want to be a slave to numbers.

- Numbers can be use to pinpoint the problem. When a new measurement finds a sudden change in the situation, then I would like to be notified.


7.5.2. Interview B; Quotes- We once had video training for my deaf sun, they say to say what you do right, but you only see what you do wrong.

- We have a big round table, so during dinner everybody can look and see each other, especially our deaf son.

- We have a big family, my wife and I, and three sons.

- I like my worked, always liked it.

- My previous job was 11 hours a day, which turned out to be too long.

- With the family we like to occasionally go out to eat, like a treat

- We like going to a small famer camping, and just relax, nothing special.

- We like doing nothing, or a lot, but being together is important to me.

- A couple of time a year, I buy a German lottery ticket. Then we go with the family, have breakfast at a local bakery. Those moments are very important to me.

- Health is very important to me, this is the basis.

- It is important to not be restricted by my health.

- My diabetes has been very important to the whole family. As much to my wife as for me.

- My wife goes shopping, and has to consider the right groceries, which took a while to get used to.

- Every lunch, and after dinner I go walking for half an hour to an hour.

- I started walking because of my diabetes, I considered this important.

- Walking every day took some getting used to, but now it is normal to me. I actually miss it when I don’t go walking a day.

- I knew I had diabetes because I drank over 6 litres of water a day. When I got water in the kitchen, it was empty before I was back in the living room.

- I am very afraid of blood samples, but now I am ok with it, thanks to the diabetes.

- Within 4 months I managed to get my glucose to healthy levels.

- The last 6 months, I keep decrease the amount of medication.

- I do not really follow a diet, I kept eating similar food.

- Increasing my activity was very helpful to me.

- Luckily my cholesterol is good.


- Blood pressure is slightly high.

- I don’t really notice I have diabetes.

- In the beginning of my treatment I have had a couple of hypo’s due to the amount of medication.

- My toes are a bit sensitive, which I slightly worry about.

- I don’t consider my diabetes because I don’t notice it, this is why I don’t really make changes.

- With my sun I go to 70s and 80s bands like Deep Purple, I like the music, and the time I spent with my sons.

- With another son I have gotten my motorcycle license.

- If you can do it, do it. Life could end at any time.

- I always eat 2 volkoren bread slices for breakfast with 30+ cheese.

- Between lunch and breakfast I eat another sandwich.

- During lunch I eat three sandwiches, they don’t have the better cheese, so I put chicken on my bread.

- I always make sure I drink 2 litres of water a day.

- Normally we eat potatoes, veggies and meat. But my wife always buys the lean meat or sausages.

- I like my meatball, luckily lean meat allows this for me, especially due to my good cholesterol.

- I prefer water over light soda’s, this is better, and I don’t miss the soda.

- Although the meatballs are lean, I only eat this once a week.

- When there are three pieces of meat, and one is smaller, I try to take that one. This doesn’t always work though.

- When I have to, I could eat even healthier.

- Potatoes I enjoy, and probably too many, but I don’t have to cut back on this yet.

- I try to keep to the voedingscentrum of no, sometimes and yes.

- I can drink a lot, but I don’t miss it. I can still do it, which I consider important. But I don’t because it is a waste of my medication and effort.

- When there is a party, and there lies food, then I cannot control myself. When it is in sight, I have to eat it.

- When I get up in the morning, it takes ten minutes to get my body to wake up. Physically it is not too flexible anymore.


- When the sun is out, I like to go out walking, and really appreciate this.

- Sometimes when work runs late, then I don’t go walking.

- The pedometer gave me insight in that grocery shopping alone gains me 1500 steps, which was really positive to me.

- I appreciate spending time with my children

- I used to be able to eat extreme amounts.

- I had a wedding, there was this amazing salad, which I couldn’t let go. I did felt sorry afterwards.

- When I eat too much, I don’t feel down afterwards, I just tell myself it was a bad idea, and move on.

- Since I started with my diet, my hunger feeling decreased over time, and now I am full much faster.

- When I ate too much the day before, I try to eat a little less the next day.

- When we eat fries, I eat fries as well, I consider the portion size, and don’t take two snacks, but only one. Preferably a bitterbal according to the dietary expert.

- I chew longer now, this ensures I am full quicker, and eat less.

- I always get my food the last, this ensures I can’t take too much, but just eat the last. My wife tries to consider this when cooking, so not cooking too much.

- A nice side effect of my diabetes lifestyle is the decrease in belly girth.

- In the year I know I had diabetes, but was not diagnosed yet, I lost 20 pounds. This is a known side effect.

- If I hadn’t lost weight due to the diabetes, but I had to do this purposely, then I don’t know whether I would have managed. This would have de-motivated me a lot.

- Now my eight is healthy, so I only have to maintain it.

- Work does create some stress, when other people promise something, and then I have to hurry to solve it.

- Traffic jams create stress, as I always want to be on time, but traffic jams don’t al-low me to estimate my time of arrival.

- My son, and diabetes have brought the family together, instead of breaking it up.

- My son can give me some stress, but this is not related to diabetes, and something that you get with deaf people.

- I don’t feel sorry about anything; you are the way you are.

- I am not ambitious; just let me do my thing. I enjoy the way I live.


- Sleeping is a new problem, maybe related to the diabetes. It takes long before I fall asleep.

- My fingers or arm tend to tingle, this is a problem when trying to fall asleep.

- My son’s wake up between 5 and 6 in the morning, so I wake up as well then.

- This small village has only a normal general practitioner, who is not very knowl-edgeable with diabetes. This I really miss. More knowledge.

- I would like to know what works and what doesn’t with people around me, this can motivate me to try other solutions.

- My relation with the general practitioner is very bad, since they tend to create prob-lems for nothing. So now I try to go to the specialist directly.

- I take my medication on specific moments. During the making of my bread in the morning, I put a pill on top of my sandwiches, this works since I never forget I am hungry.

- During dinner my wife puts a pill next to my plate. When she forgets, then I get it myself.

- There is also a pill before going to bed, this is next to my toothbrush.

- In case I really forget, I have a couple of pills in my coat, so I always have backup.

- It is not that I am reminder by seeing them, it is that is has become such an impor-tant ritual, that I just never forget normally. Only on very special occasions, like on holiday, maybe once.

- During work I walk up and down the printer and the water, yet this is not enough, during lunch I walk 20 minutes.

- When walking, I don’t care about seeing something, but I care about being active. This is why I always take the same route.

- In the evening I walk for 40 minutes.

- I the evening I wind down while watching some TV.

- During walking I overthink by day, it really calms me down.

- I stopped playing volleyball 14 years ago. I wanted to spent more time with the children, I was getting older, and the club was doing not as well.

- When I notice I do something without enjoyment, I reconsider the activity. Enjoy-ment is important to me.

- When we go on holiday, my children want water. I like fishing, but I do not like swimming. Never have.

- Cycling is also something I don’t like, I prefer walking. I don’t care about the activ-ity, just making the steps.

- I like taking it calm, mowing the lawn. Walking about, those kind of activities.


- Medication is important to me, as well as activity. This increases my health.

- I don’t really worry about things, when problems arise, I take care of them.

- The only thing I slightly worry about are my feet as I feel they are changing.

- When I heard I had diabetes, I was confronted with my health in a negative way, this changed me instantly.

- 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 was more practical and positive.


7.5.3. Interview C; Quotes- I compare myself to a dolphin. I like swimming as well, and am very empathic.

- Dolphins do things for fun, so do I. I want to do things because I want to, not be-cause I have to.

- I like to make nice food for the people around me. I enjoy seeing other people enjoy their food.

- Family is very important to me. This is very cosy and comfortable.

- I don’t care what I cook, I enjoy the moment of deciding what to eat, to the point of seeing people enjoy. They don’t have to tell me they like it, I see it on their faces.

- I do not only create food for my husband every day, but also once a week for all his colleagues.

- The things I enjoy the most are making music and photography.

- Due to my diabetes I don’t have the energy to play the Sousaphone anymore, so to not get depressed I started doing photography.

- A hobby is to relax and just enjoy myself.

- I used to play music in a club, where I now take the photographs.

- Although I don’t play music anymore, I still get to wear the uniform and take photo-graphs. This way I am recognised as part of the group.

- In the summer I sit on the bag of a scooter, and shoot photographs.

- I like sharing hobbies with my husband. We are together and go out.

- I have problems with people understanding the diabetes, people tend to underesti-mate it.

- Sporting and activity is a problem in the beginning. I have had a lot of hypo’s.

- Getting to know the hypo’s was done within a couple of months.

- Getting to know your body has to start all over.

- Hypo’s are a reason to be less active since I am afraid to faint.

- Going to the toilet often, and a decrease in eyesight were an indication of diabetes, and was the reason for me to go to the general practitioner.

- Drinking still is an indication of a problem with the glucose level, a hyper.

- The distinction between hypo and hyper is one of the biggest problems.

- I once had a hypo during cycling, which turned me off cycling, as I am afraid for falling on my bike.


- I do not only cook, my husband cooks as well. This makes food and diabetes a team effort.

- During lunch I always eat the same. Two sandwiches with either ham or cheese.

- Breakfast usually is a sandwich and some coffee.

- During the day I usually eat a sultana or something like that.

- I am always in a good mood, unless I am sick.

- Sometimes, when I am very busy, I tend to forget to eat, and this can result in a hypo, which is why I carry liquid glucose.

- Hypofit(liquid glucose) works really fast, which gives me more confidence during the day. Dextro energy is a good alternative.

- Hypofit usually is enough, it gives me some time, and then when I get hungry, I eat.

- My diet hasn’t really changed. I use more oil then butter during cooking.

- I use diabetes cook books, which makes it easy to change my eating habits. I don’t have to think about the ingredients.

- I eat more brown bread then before.

- I never drank alcohol, so in that sense nothing has changed.

- I always put sweetener in my coffee instead of sugar. And lean milk.

- During the holidays I do not consider my diabetes. The dietary expert said this as well. Those moments are so difficult, that you only feel guilty, so enjoy it instead.

- When there is a birthday at the company, I don’t eat cake.

- After a day of elaborate eating, the day after I don’t want to know the results. I do not measure my glucose level, I just continue as normal, and check it after two days.

- When I start to sweat I measure my glucose, as it indicates something is wrong.

- I measure my glucose when I notice a problem.

- My colleagues know how to measure my glucose, so that in emergency they can help me.

- Although it takes some time to wake up, I am in a good mood from the start.

- When I get sick, I worry about my health. I try to go to work, but when I can’t I go to the general practitioner.

- I get sick very quickly, now with my diabetes, it is even worse. I get sick more often and more intense.

- When I have a mosquito bite, it stays on my body for six weeks. Those things all take really long to heal.


- I always eat an apple, as this is healthy to me.

- I am not sure whether meat is healthy.

- I always cook big portions, and then freeze what is over. Although I prefer fresh, this is not always feasible due to work.

- What we eat, is always homemade, with ingredients from the supermarket.

- I have been to a dietary expert, but the diet was to extreme. I couldn’t eat anything. I am very active, and what was prescribed, was too little for my lifestyle. I couldn’t make the sudden change, yet I was willing to do it in steps.

- The diabetes nurse was the one who was more flexible with my diet, and together we find nice menus and good diabetes cook books.

- Going on holiday gives me a lot of stress, I am afraid that I forget items.

- During dinner I switch off the phone during dinner.

- Eating with my husband is very important. Talk about the day, and then we do not want to be disturbed.

- We took the eating table away from the TV, this ensures a moment together, and talk about things that happened.

- When I have stress at the workplace, I am more sensitive to hyper’s.

- Since the stress at my work is less, my diabetes is more constant as well.

- Since I can take a pill less, I am very positive and motivated.

- Medication is a real motivator to me, less is not only healthy, but it shows I am doing well.

- I go to the internet to find information about my medication and problems.

- When I hear people around me with diabetes about medication, I get curious and tend to ask my diabetes nurse.

- Some medication is only for people with a BMI above 35, but my BMI is not high enough, yet I have heard really positive things about it.

- At the office I walk around, up and down the stairs a lot.

- Walking stairs has given a benefit to my health. I notice this gets easier and easier.

- I have had so many hypo’s on my bike that I sold my bike and bought a scooter. This as to keep my freedom.

- I prefer to walk, I walk a lot since this is safer, and when I get a hypo’s falling is less dangerous.

- I was disappointed when the number of steps was less than it should be.


- My husband is my biggest help with diabetes. He keeps me positive.

- During my eyesight problem my husband was needed to go outside.

- I try to be more considerate about my food intake, so I bought a book which con-tains dietary values. Although this is difficult to use, I try to look things up more and more often.

- I use my Sunday to sort all my medication and prepare all the intake.

- My feet are very important to me. They now need more care. I use them to walk and go everywhere.


7.5.4. Interview D; Quotes- Like a bee, I am always busy.

- Friends and family are important to me, and take up a lot of time.

- The disorders of my son take up a lot of my time and energy.

- I find helping other people very important.

- Once a week I take the dog to obedience training, and have to be consistent with him.

- The dog is very important to the family for its social cosy roll, but also for my son.

- I work four days a week, and then the house get’s dirty.

- I want the house to be organised, so my head feels organised.

- I work four days a week at a primary school, where I teach all ages.

- Groceries are for me the hardest part about diabetes.

- I really like eating hearty food, and picking right and wrong things at the super-market is very difficult.

- I always do groceries, yet my husband and I take turns in cooking.

- When shopping for groceries, I consider the following things: is it healthy, what is in it, is it variety?

- I look for sugar’s and fat, not carbohydrates. That is not yet relevant to me.

- My father also had diabetes, and I know some things about diet from that period.

- Shopping relaxes me. I like looking around with a friend or my daughter. Buying something is not important.

- When I work late, I like to do a mindless computer game to wind down.

- After a day of thinking, I need something mindless to calm down and clear my head.

- I am afraid to go out in the evening, and leave my son behind.

- In the evening I watch the news once alone. The rest of the family is not interested in this.

- The dog is very playful, and gives a good distraction.

- I like going out for a walk, with the dog for example, but not when it rains. It has to be dry, for the rest I don’t care.

- I go to my work by car, as cycling is too far, and I don’t care for cycling. I prefer walking.


- On Sunday’s I like to eat a “worstenbroodje”.

- We occasionally go out to eat, which we see as a treat.

- We do out groceries depending who eats’ along.

- When I do groceries I buy some light products especially for myself as a snack. For dinner there is no distinction between my food intake and the other’s.

- In the morning I eat my breakfast with a newspaper in the kitchen.

- Between breakfast and lunch I take some coffee and, with a biscuit.

- I always make my work lunch at home, and take it with me to my work.

- Sometimes I drink a glass of wine in the evening to relax.

- In the evening I know it is not good to eat a biscuit, yet I can’t resist and really want to.

- I get slowly more and more conscious about food.

- I try to get a little bit of fish and meat, and more vegetables and rice or potatoes.

- I am afraid I will miss eating without thinking about it.

- My father was very strict in his diet, and got sick anyway. Probably for me it will go in the same direction unfortunately.

- I chose to go to a dietary expert since I want to lose weight, not necessarily for my diabetes.

- The dietary expert told me alternatives for my current food intake.

- Currently I eat “Evergreens” instead of “peperkoek”.

- The dietary expert doesn’t try to make me feel guilty or force me certain habits. This works well, and motivated me for a second appointment.

- Usually I am quite happy throughout the day. Yet in the end, when things get busy or complicated this has its effect on me.

- When I get sudden important tasks that take up too much time, I get grumpy. Then going out in the evening with a friend helps me to relax.

- If people want to make small talk, and I am busy, then I will send them away.

- If I get home, and dinner is ready, everything is fine, and I am good.

- I am used to doing some work in the evening, so I am fine with that.

- I notice nothing with stress in relation to my diabetes.

- I have never experienced a hypo or hyper as I have seen with my father.


- I am not afraid of a hypo or hyper. I know it can happen, but I will deal with it when the time is there.

- When something important comes along I have no problem with sacrificing a free day for work.

- I get really annoyed when I clean, and the rest of the household keeps making things busy, and move them around.

- When people come over I find it very important to have the house be clean.

- Now, when Christmas comes along, I like to go to “Intratuin” to see the atmosphere.

- I really like cheese, but I really should eat less.

- I should eat more vegetables.

- I eat an apple to do well.

- I prefer water to stay clear, but after a long day, or people coming over, I like to wind down with a glass of wine.

- I never drink soda, always water, coffee or tea.

- Cleaning the house for me is activity. Walking about is the most important part of this.

- Taking out the dog is also part of my activity. At least once a day for 45 minutes.

- Once a week I do groceries for the whole week, but during the week I go twice after work to update the inventory.

- During the week I usually by extra bread or soda for the children.

- Usually I buy a variety of ingredients, and people just see what they can use to cook.

- When the children eat along, then we eat meat, when the children are out, we tend to eat fish or shellfish.

- When I go out for eating I usually eat fish.

- If I want something fished, and I can’t then I get stressed.

- When something is not necessary to finish, I have no problem to put them aside, and leave them there for a long time. Sometimes too long.

- I have a pile of things to do, which nobody can touch. That is my system, and I get stressed that I lose something.

- Food can be something to help me to calm down and enjoy myself. Especially in the evening on the couch.

- Sometime in the evening eating can also be a reflex as something to do.


- We chose to move the computer to the living room so that we are together in the evening.

- Stress influences my eating as such that I eat more.

- When I am stressed I reward myself by eating something tasty.

- When I am stressed I don’t feel like doing anything, and then I don’t go sporting.

- I have a subscription to a gym, but haven’t been there in over a year.

- I forget my medication quite often. It is just not part of my routine, and I don’t really notice it when I miss it.

- When I have an appointment with the doctor, I take my medication very strictly a week in advance.

- I have thought about shooting insulin, and I don’t really see any problems with that.

- I have had a stoma once, and when I had to live with it forever, there is no problem. I have to adjust, but I can continue.

- I have known that I would get diabetes all my life. Everybody in my family had it. As long as I don’t have it, I wanted to enjoy myself as long as possible until I can’t.

- I can still do anything I want, so I don’t consider diabetes a disease.

- When I heard I have diabetes I was relieved. I knew it was coming, and it explained my itching and feeling energy-less.

- I don’t listen to the diabetes nurse very carefully. I already know it all from my childhood.

- I want to enjoy my eating as long as possible since I know it will end around 50 when I expect diabetes.

- Both my feet have numb areas, yet the general practitioner tells me it is not diabe-tes related.

- I prefer the diabetes nurse above the general practitioner as this person is more knowledgeable and trustworthy.

- When I have questions about my diabetes I try to find that on the internet. For examples about my hands and feet.

- I don’t care about programs where I have to input my food intake. This is too time and energy intensive.

- I use my car to work as a bicycle messes up my hair.

Health & Medicine

SMARCOS PHILIPS RESEARCH LABS Educational Final Report Master ThesisNiels Molenaar