PEGASO Fit for Future

Renata Guarneri and Giuseppe Andreoni

Politecnico di Milano – Design Dept., Via Durando 38/A, 20158 Milano, Italy

{mariarenata.guarneri, giuseppe.andreoni}@polimi.it

Abstract. Challenging teen-agers in their own fields and areas of interest,

PEGASO – Fit 4 Future - aims at promoting a sustainable behavior change

towards healthy lifestyles, with a holistic and multidisciplinary approach.

PEGASO is based on a mobile, social and networked gaming platform,

considered as a powerful tool to actively engage the younger population in

activities that will stimulate healthier choices in their daily lives to counterfeit

sedentariness, overweight up to obesity. To support this action, in the platform,

represented by the smartphone, three main functionalities are implemented: an

individual & environmental monitoring through wearable devices, a feedback

system for providing a feedback in terms of “health status” changes, the Social

connectivity and engagement to support motivation.

1 Overview and Rationale

The rapidly increasing prevalence of overweight and obesity among children and

adolescents reflects a global ‘epidemic’ worldwide. Recently the US Center for

Disease Control and Prevention has evidenced that “Childhood obesity has more than

doubled in children and quadrupled in adolescents in the past 30 years.”[1, 2].

Fig. 1. The WHO web page on the priority to overweight and obesity prevention in children

(last accessed march 18, 2015).

Andreoni G. and Guarneri R.

PEGASO Fit for Future.

DOI: 10.5220/0006156800770096

In European Project Space on Computational Intelligence, Knowledge Discovery and Systems Engineering for Health and Sports (EPS Rome 2014), pages 77-96

ISBN: 978-989-758-154-0

Also WHO recognized prevention of juvenile overweight and obesity as a priority

for future health being in 2014 and in the WHO European region 1 on 3 11-years old

children in this condition.

The following histogram represents the dramatic situation and dimension of the

problem at European and worldwide level.

Fig. 2. Measured overweight (including obesity) among children aged 5-17 in 2010 or nearest

year.

Due to the associated serious medical conditions, it is estimated that obesity

already accounts for up to 7% of healthcare costs in the EU, as well as costs to the

wider economy associated with lower productivity, lost output and premature death.

Obesity in younger age groups has been recognized as an alarming key predictor for

obesity in adulthood, but also entails a number of short term health complications in

juvenile age such as hypertension, type 2 diabetes, metabolic syndrome, fatty liver

disease, sleep disturbances along with greater risk of social and psychological

problems [3, 4].

EPS Rome 2014 2014 - European Project Space on Computational Intelligence, Knowledge Discovery and Systems Engineering for Health

and Sports

Sedentariness and over-consumption of high calorie foods and beverages are a

priori determinants of overweight/obesity and poor health status also in adolescents,

according to well-grounded evidences.

“Prevention is of obvious importance and there is an urgent need for further

research into how physical activity and training, in addition to nutrition, can

prevent the steadily increasing average body mass index of Europeans. This

proposal includes a vision that integrates a lifestyle of healthy habits with an

environment that promotes healthy living by encouraging exercise and making

healthy food affordable.” (Visions for Horizon 2020) [3].

Healthy lifestyle habits, including healthy eating and physical activity, can lower the

risk of becoming obese and developing related diseases. The dietary and physical

activity behaviors of children and adolescents are influenced by many sectors of

society, including families, communities, schools, child care settings, medical care

providers, faithbased institutions, government agencies, the media, and the food and

beverage industries and entertainment industries.

2 Methodological Approach and Concept of the PEGASO Project

Juvenile obesity is a complex disorder with many interrelated consequences.

Addressing the obesity issues requires a comprehensive approach taking into account

the individual's physical-physiological characteristics, personality as well as the

social and psychological environments influencing decisions and habits in their

everyday life. Challenging teen-agers in their own fields and areas of interest,

PEGASO – Fit 4 Future - aims at promoting a sustainable behavior change towards

healthy lifestyles, with a holistic and multidisciplinary approach. The approach of

PEGASO is based on three level of intervention enabling teen-agers to become co-

producers of their wellbeing:

1. Generating self-awareness (acknowledgement of risks associated to unhealthy

behaviors),

2. Enhancing and sustaining motivation to take care of their health with a

short/medium/long term perspective,

3. Changing behavior towards a healthy lifestyle based on healthy diet and adequate

physical activity.

In order to achieve the above targets PEGASO applies behavior change techniques to

prevention and will develop a mobile-based Behavior Change Platform that can

effectively address teen-agers.

The solution proposed by PEGASO comes from the convergence of the need to

address through appropriate preventative measures the rapidly increasing prevalence

of obesity among children and adolescents on one side and the rapid development of

ICT, and in particular mobile technologies, together with their increasing diffusion

among the EU population, on the other side.

Indeed the capabilities of ICT technologies (i.e. mobile phones, digital tablets)

together with the possibility to integrate them with the new and fashionable additional

technologies for data acquisition (e.g. wearable sensors) offer the opportunity to

develop an effective behavior change platform. The solution proposed by PEGASO is

PEGASO Fit for Future

therefore based on a mobile, social and networked gaming platform, considered as

a powerful tool to actively engage the younger population in activities that will

stimulate healthier choices in their daily lives.

From the technology point of view, cloud computing, and convergence towards

mobile are the key enablers.

The central element of the PEGASO platform is the smartphone. Europe‘s

smartphone penetration is already amongst the highest in the world, with projections

indicating a target of 55% in 2015. The smartphone indeed offers unique

characteristics that ensure to achieve a cost-effective and scalable solution and may

favour its adoption by the target audience.

In addition to the smartphone, wearable sensors - that can be added with a

modular approach and a cloud based service offering based on a behavior and

situation recognition system - represent the basic elements of the PEGASO platform

architecture.

The Figure 3 provides an overview of the PEGASO architecture.

Fig. 3. Key elements of PEGASO architecture and their inter-relations.

2.1 PEGASO Key Functions

The PEGASO system framework is addressing prevention, by offering to teenagers –

the primary target of PEGASO - three main functionalities:

1. Individual & Environmental Monitoring - This dimension consists of the

environmental, behavioral and physiological analysis of young users, through a

high level-monitoring platform including wearable sensors and mobile phone as

EPS Rome 2014 2014 - European Project Space on Computational Intelligence, Knowledge Discovery and Systems Engineering for Health

and Sports

well as multimedia diaries for the acquisition of physical, behavioral and

emotional attitude of adolescent.

2. Feedback System - This second functionality is aimed at providing a feedback in

terms of “health status” changes, required actions to undertake and so on. This

function will also propose personalized healthy modification of the lifestyle (in

terms of diet and/or physical activity), thus promoting the active involvement of

adolescents in changing their behaviors.

3. Social Connectivity and Engagement - The third dimension extends to include a

social network where the user can share experiences with a community of peers

concerning e.g. physical activity, food consumptions and everyday habits through

different gaming strategies.

PEGASO has adopted a User Centred Design approach (UCD) by considering the

target population (i.e. teenagers) at the centre of the system in a palingenetic process

[5]. The UCD approach integrates three main elements: user involvement in all stages

of the problem solving process; multidisciplinary research and development team; and

iterative design process to refine the solution set. The main target users in PEGASO

project are teenagers; however there are also several actors (who are also secondary

users – see Figure 4) and products (as shown by the inner circle in Figure 4) involved.

Fig. 4. PEGASO Stakeholders’ System.

The ecosystem of stakeholders and enablers is composed of three main parts that

are integrated in the user centred PEGASO system: technological frame (multimedia

PEGASO Fit for Future

diaries, embedded sensors systems, mobile & web platform), services frame

(stakeholders services to provide answers to users’ needs and desires in real time/not

real time, from the health companion to the serious gaming and social experiences)

and experts layer (which are knowledgeable groups of people from different

disciplines - medical/psychological/educational – able to interact with the system,

who provide them with filtered accurate and needed information to reach their

PEGASO objective).

Technological Frame. Teens are familiar with Internet, social networks, mobile

phones and apps, video gaming and, in general, with all the ICT platforms.

Smartphones also assures the highest level of technology acceptance. This key issues

are assumed as technological starting point to define the PEGASO architecture and to

define a successful strategy to empower the teen-agers awareness about healthy

lifestyle. The huge amount of personal and social exchanged and/or stored data

includes also health records, thus posing severe reliability and security requirements

that will be effectively managed through a cloud platform. Finally, PEGASO apps

and games from the software layer, as well as wearable sensor and other more

traditional systems (balance board for instance) complete the PEGASO technology

frame.

Services Frame. Social is the key word for service development: the services created

by stakeholders in PEGASO Project promote an individual and social healthier

lifestyle through motivating and engaging multiuser serious games. Nevertheless

individual support is provided both for data entry through multimedia apps that

simplify and engage the users (for instance through multimedia diary compilation or

through the health companion interaction). The health companion, developed by

PEGASO, constitutes the interface on the smartphone between the guidance system

and the teenager. All the stakeholders (including the Food Industry, Public and

Private Health Policy actors, Fitness industries, Media, Schools, and Insurance

companies) at different levels will offer to users the infrastructure to motivate (and

promote) the adoption a healthy behavior.

Experts Layer. in PEGASO motivation and engagement by means of gaming

strategies will be integrated with healthier lifestyle. All the information from the users

must be “handled” and processed and the corresponding feedback provided. This

means building an expert layer that is able to analyse all the data and deliver the

resulting answers to the teenagers. A part of this layer will be composed by automatic

algorithm (for real-time processing and feedback provision when applicable); a

second building block will be the experts’ team who will integrate the previous

assessment to better stimulate the teenagers’ consciousness about obesity and their

motivation to adopt a healthy lifestyle. The role of experts in PEGASO project is

assumed to be twofold: 1) to personalize information for each individual’s physical

and psychological models (i.e. personalized care) in order to reach the full acceptance

by each teenager and guarantee a correct interpretation; and 2) to follow up of each

teenager healthy status.

EPS Rome 2014 2014 - European Project Space on Computational Intelligence, Knowledge Discovery and Systems Engineering for Health

and Sports

2.2 The Elements of Behavior Change

PEGASO considers four levels of engagement towards persuasion for user (the teen-

agers) empowerment in healthcare [6]: awareness of obesity risks, motivation,

affective learning and finally behavior change.

Fig. 5.

Various types of expertise / knowledge and technologies feed these levels of

engagement towards healthier lifestyle and empower the teen-agers to take decisions

accordingly.

Develop Awareness: teenagers need to be aware of what they are doing; what is right

and what is wrong for their healthy living. Some of them are unconsciously and

automatically acting, and often under estimate or have no clear notion about

information they receive. Monitoring lifestyle of teen’s activity, collecting parameters

and integrating their own data will enable self-awareness on their current situation.

Through developing self-awareness and self-reflection, the user can frame the

problem or the opportunity area to act upon or intervene.

Affective Learning is the “highest” learning goal. The learner should trust in

something that happens in several years. That is also a good argument in a new

“learning level” to use a constructivist learning model and special media like “social

games” are adequate to reach this goal. Giving teenagers information through tools

they are affectionate is a strategy to reach their behavioral change.

Create Motivation: it is important to motivate teenagers to change their behavior and

keep this activity in a long-term period. The actors in the ecosystem offer healthier

benefits and services in the users’ environment towards satisfying their needs or

desires.

This part is quite challenging, since the motivation depends on many factors as

well as emotions, psychological environment and personality of teens. The system

needs to provide constant different layouts of motivational activities where experts,

PEGASO Fit for Future

technological frame monitoring and stakeholders services come into the scene.

Enable Behavior Change: once teenagers have the awareness and the motivation, it

is important to involve experts and use PEGASO system to support the behaviour

change process and reinforce existing virtuous behaviors. The turn from old unhealthy

behaviors into healthier new ones has to be monitored through technology on a longer

period.

In order to create prevention, it is important to change or stop old unhealthy habits

and develop new healthier habits. In this respect, PEGASO takes a holistic approach

involving the teenager’s environment and specifically the families, by means of an

education process empowered by training that will be provided on location (schools)

and on line. The expert team will give feedbacks to the users allowing them to change

their behavior on a long-term basis. The overall system takes advantage of gaming

strategies to persuade users to change their behavior.

2.3 PEGASO Evaluation Strategy

PEGASO will be validated by secondary school students with the support of their

schools and families. The reason for involving these students as sample population

lies on the assumption that around the age of 14 years old the teen-agers acquire more

independency and have increasingly the opportunity to make own and independent

decisions. It is therefore important that at this stage they become aware of the

consequences of inappropriate, unhealthy lifestyles.

Four validation studies will be carried out in Italy (Lombardy), Spain (Catalonia)

and United Kingdom (England/Scotland).

The validation activities will assess the following aspects of the PEGASO

Behavior Change Platform:

‐ System and Technology acceptance, usability and long-term use: these will

constitute also a secondary assessment of motivation and engagement;

‐ Reliability in assessing the teen-agers lifestyles and their changes (with focus on

the eating habits and on physical activities) and related efficacy of the sensing

platform (i.e. smartphone and wearable sensors’ system);

‐ Efficacy of the system in encouraging lifestyle change;

‐ Subjective assessment for awareness;

‐ System’s compliance to Stakeholders’ needs.

Further studies are required, and are currently out of PEGASO’s scope, to be able to

evaluate the longer term outcomes of the intervention, and to perform in particular the

evaluation of the user risk awareness regarding the development of obesity and

related comorbidities, the evaluation of user environmental factors (family and

school), the potential harms and costs, all of them assessable involving the same

target groups few years after the project completion.

3 Activities and Results

PEGASO Fit for Future has been running for over a year, with the first year being

EPS Rome 2014 2014 - European Project Space on Computational Intelligence, Knowledge Discovery and Systems Engineering for Health

and Sports

dedicated mostly to the consolidation of requirements from the user viewpoint and the

general architecture of the platform.

3.1 The Comprehensive Virtual Individual Model

The PEGASO project aims at pushing this concept further introducing the feature of

dynamically selecting the opportune tailored interventions based on the user’s

individual characteristics and interaction context [7]. Tailoring the intervention

involves modeling the user’s characteristics and for this purpose it has been

developed the Virtual Individual Model, which comes from the concept of the Virtual

Physiological Human. The latter is a methodological and technological framework for

integrated modeling of a living human body that describes the interaction of all the

physiological components of individuals from molecular to apparatus level [8]. The

Virtual Individual Model aims to include individual’s characterization composed of

physiological, physical, and psychological determinants. This allows integrating

biological aspects of human functioning with lifestyle behaviors and psychosocial

externalities that are crucial for the determination of the adoption of a certain life-

style. This model is integrated in the system through an ontology-based virtualization.

This process allows turning the information contained in the Virtual Individual Model

into a structured knowledge that can be dynamically updated and elaborated by the

computer to select the best interventions for each individual. Tailored interventions

make the information personally relevant and researches demonstrated that computer-

tailored health education is more effective in motivating people to make dietary

changes [9] and that it could be also a good practice to promote physical activity [10].

3 Tailored Intervention Forms The Virtual Individual Model characterizes the user’s

nutritional habits, physical status, and psychological status to provide personalized

intervention to foster the adoption of a healthy life-style. Obviously, the interaction

between the system and the user plays a crucial role in the tailoring process and to

facilitate the effectiveness of the intervention. Since the teenagers are the targets of

the PEGASO project, the smartphone has been chosen as the mediator of the

interaction. Indeed, the smartphones are already perceived as a companion and it is

most likely that this relationship between user and smartphone will strengthen in the

future [11]. The smartphone is the perfect companion because it is personal and it is

ubiquitous. It will provide the possibility of interacting directly with the user asking to

enter some information or in a discreet and implicit manner allowing monitoring the

user activity. The sensed data referring to the parameters that concern the selected

characteristics modeled for the tailoring will be updated constantly in the Virtual

Individual Model. Moreover, with the many connection possibilities, the smartphone

can allow accessing the information stored in the cloud and can connect to other

devices, such as wearable accessories that can improve the physical activity

monitoring. Since it is ubiquitous, it can always provide the appropriate trigger, as

tailored messages, to influence the user’s behavior. This is very important, since Fogg

observed that “without an appropriate trigger, behavior will not occur even if both

motivation and ability are high” [6]. Moreover, the many sensors integrated in the

smartphone allow capturing the contextual information, which can help to generate

the trigger at the opportune moment maximizing its effectiveness. Moreover, the

smartphone allows installing many applications as media services and games that will

PEGASO Fit for Future

motivate the teenagers to interact with the system. The mobile game will be designed

to promote physical exercise. The integration with social networks will add the social

aspect of the users’ life to the parameters for the tailoring of the interventions and,

most importantly, the social factor represents a very effective motivator. Another

mobile application will be a sort of personal food diary, where the user will be able to

note his/her alimentary behavior. This diary will help to understand the alimentary

behavior of the user in order to provide the right feedback. For example, some data

suggest that breakfast consumption is associated with higher intakes of

micronutrients, fruit and vegetables and less frequent use of soft drink [12]. This

means that the breakfast consumption habit can help to adopt a healthy dietary

behavior. The diary allows following this behavior and to intervene through an alarm

in order to remind to the teenager to have breakfast. The eating behavior is not only

related to homeostatic reasons. In fact, an important factor that influences people’s

need and choice of food is represented by the emotional state [13]. The diary will

allow noting also the mood in order to include the emotional state in the recognition

of behavioral patterns. In fact, this information can be used to find some specific

behavioral pattern related to emotional eating in order to generate the best

intervention.

The introduction of biological models empowering technological actions for the

promotion of citizen's health and well-being is considered to lead to a higher user

centricity producing a more individualized strategy of health management and a

stronger empowerment and engagement of the user [14].

The concepts supporting the PEGASO Virtual Individual Model (VIM) stem from

a background of European experiences based on the vision of the individual as a

unique multiple organ system, overtaking the traditional approach - in force in the

medical practice - of the human body as a set of independent sections. The current

modelling of a living human, such as the Physiome model [8], relies on different body

functions incorporating knowledge from several biological disciplines and converges

into a holistic integrative architecture. However, such an approach does not account

for the behavioral and social externalities, which are known to interfere with and

determine the biological balance of functions in health and disease.

By contrast, the PEGASO VIM's ambition is to provide a definition of individual's

characteristics relevant for the condition of overweight/obesity, including both

biological specifications and alimentary and exercise behavior factors, along with

their psycho-social drives, specifically analyzed for young people, in a defined age

range of 13-16. To this aim, the contribution of experts from different Europe

countries has been integrated into a comprehensive view joining competences

including medical, exercise physiology and nutritional knowledge, together with

psycho-social expertise.

The PEGASO VIM overall structure is depicted in Figure 6 and considers the

individual's health and well-being as resulting from the balance between components

of physical, functional and psycho-social domains, according to the World Health

Organization founding definition [15].

The model is based on elements relevant for overweight/obesity among

adolescents. It considers health and well-being as primarily settled on a balance

between physical body structure, body functionalities and psycho-social factors

which, on turn, influence dietary and exercise behaviors and their possible changes.

Alimentary and physical activity habits are key life-styles for preserving good

EPS Rome 2014 2014 - European Project Space on Computational Intelligence, Knowledge Discovery and Systems Engineering for Health

and Sports

physical conditions and a well-functioning organism.

Fig. 6. Overall PEGASO Virtual Individual Model.

Dietary and physical activity behaviors are important life-styles affecting health

and well-being through the preservation of optimal physical conditions and functional

order. The model thus involves also concepts related to behavioral and psycho-social

domains which are only partially covered by current vocabularies and ontologies.

Since healthy life-style awareness, motivation and engagement among adolescents are

the principal objectives of the PEGASO system, a particular emphasis is given in

VIM to the aspects related to behavior change strategies and their relation with

psycho-social components driving alimentary and exercise behaviors, especially if

liable to be modified.

It is important to consider the psychosocial aspects of overweight and obesity in

adolescents because problems associated to these aspects (E.g. peer pressure, low

confidence, low self-esteem, depression and attitudes towards food) are likely to have

an impact upon their lives and contribute towards differences in physical activity

patterns and weight fluctuations. The following sections describe the social and

psychological aspects of obesity in adolescents, using a behavioral model based on

the analysis of Capability, Opportunity and Motivation as main components of

behavior (COM-B). Where relevant in relation to the target behaviors selected for

PEGASO adolescents, examples will be given with details.

At the core of the Virtual Individual Model analysis of behaviors is a

psychological model of human behavior incorporating the psychological components

associated with behavior change. COM-B components are applicable to all human

behaviors and are the starting point for developing new behavior change

interventions. Each component in the COM-B model directly influences behavior, and

interacts with the other components. In combination they can provide the rationale for

why the target behavior is not engaged in, and this then identifies the appropriate

PEGASO Fit for Future

components to be addressed to bring about a change in that behavior. In this way all

the components of the COM-B model are interdependent, and work in unison to help

change a target behavior, or support the maintenance of a target behavior once an

individual has adopted it into their regular pattern of behavior. Each component of the

COM-B model is divided into sub-components which are used to capture the more

refined details of the COM-B components that are specific to the target behavior.

Fig. 7. The functional flow-chart of the PEGASO intervention.

Designing the PEGASO products and service systems the co-design methodology

was adopted as key strategy. This is relevant for the specific target population to

achieve high acceptance and compliance.

Smartphone, Wearable sensors and Multimedia Diaries have been categorized as

sensors of the PEGASO system, and their acceptance and use by the end-user is the

first essential requirement for the project success. Together with the sensors two other

main fundamental categories constitute the PEGASO system architecture: the Social

level of the platform, and the gamification of teens’ life.

In this project, Social Network is intended as the creation of a social community

that shares the same objective, i.e. healthy lifestyle habits. The End-User

requirements aimed at retrieving opinion about the Information Sharing, in particular

what teenagers want to share, people they’d prefer to be connected with, how they

would like to share those information (feedback system and notification)

Finally, the Social platform represents also the gamification of teens’life and the

role of experts is to monitor results from physiological data and to send specific

feedback information on the health status of the user through the Health Companion.

Schools play a particularly critical role by establishing a safe and supportive

environment with policies and practices that support healthy behaviors. Schools also

provide opportunities for students to learn about and practice healthy eating and

EPS Rome 2014 2014 - European Project Space on Computational Intelligence, Knowledge Discovery and Systems Engineering for Health

and Sports

physical activity behaviors. For this reason we involved and collaborated with schools

in organizing the focus groups and recruiting teenagers in the user requirements

definition phase. 16 focus groups in three nations were carried out with about 200

teenagers to gather this information and to iteratively design services and devices,

according to the identified directions of PEGASO interventions.

Fig. 8. PEGASO interventions assets.

Fig. 9. The prototypes of garments and wearable devices.

PEGASO Fit for Future

This is a sort of life compass that the PEGASO project aims at helping teenagers

to build, through a positive message and tool dedicated to teenagers, for improving

their lives. The identified 4 pillars/directions are: a) move, i.e. the adoption of an

active lifestyle, b) play, i.e. the serious game sustains engagement and motivation in

the choice, c) eat, i.e. food education and pleasure, and d) share, a community and

social approach to mutually engage in the actions.

The initial systems have been designed and prototyped and are currently

undergoing pre-pilot tests.

A key feature is the PEGASO companion. The smart companion is a Personal

Digital “Friend” acting as a daily-life guide for Coaching, Caring for, and

Empowering teenagers in their activities toward healthy habits. From this definition

the companion has multiple facets fostering behavior change.

• Digital: the companion exists in the smartphone

• Personal: the companion is customized to the single user

• Friend: the companion would establish an affective relationship with the user

• Daily-life guide: the companion accompanies the user (coaching, caring and

empowering) during her daily activity

• Toward healthy habits: supporting behavior change to promote healthy lifestyles

is the main goal of the companion and PEGASO project in general

Figure 10 highlights the most relevant services that the companion, represented by the

circle in the center, should offer to the user in relation to the COM-B model.

Fig. 10. The reference COM-B model and related services for Companion design.

The main goal of the Companion is to support teenagers’ behavior change

increasing Capacity, Opportunity and Motivation to achieve a set of target behaviors.

As we can see from the previous definition, the COM-B model of behavior is at

the base of the design of the companion. In particular, the target behaviors have been

selected in collaboration with PEGASO experts and taking into account the results of

the focus groups. The selected target behaviors are:

• Physical activity: 10.0000 steps, 60 minutes of physical activity per day,

Community sports teams, School sports teams, Screen viewing duration, Sleep

duration & quality, Walk or cycle to school;

• Alimentation: Breakfast eating, Fruit consumption, Vegetable consumption, Sugar

sweetened drinks.

EPS Rome 2014 2014 - European Project Space on Computational Intelligence, Knowledge Discovery and Systems Engineering for Health

and Sports

Fig. 11. The first conceptualization of the PEGASO Companion.

Fig. 12. The first draft PEGASO Companion.

4 Conclusions and Expected Impact

PEGASO believes that we are at a key turning point in the history of the Internet.

Convergence of major trends is occurring which is driving changes in people behavior

and expectations. These trends include the exponential rise in use of smartphones and

PEGASO Fit for Future

tablets, increased Internet access speeds, new business models driven by online

commerce and app stores, the impact of social online communication, and software

delivery transitioning from prior PC/internet models to cloud-based services accessed

with touch-based devices (smartphones and media tablets).

With more than five billion mobile users worldwide and a massive global

network, for the first time in history mobility is attracting significant attention among

the healthcare and life sciences community.

Integrating mobility, gamification and life science has the potential to motivate

individuals to adopt healthy lifestyles, with personalization techniques and incentives

that will be delivered through the PEGASO system.

The following key issues however have to be adequately addressed and are at the

center of the PEGASO rationale:

‐ Knowledge of how to stay healthy is ubiquitous; however, obesity and lifestyle-

related illness are still among the top healthcare challenges in Europe.

‐ Although clinical content and health information have been available through the

Internet for years, there has been no improvement in overall health in Europe.

‐ Motivating individuals to change behavior is not just a clinical issue. Successful

programs include incentives along with personalized programs and, increasingly,

the inclusion of behavioral science.

‐ Gamification has emerged as a recognizable trend that can have a significant

positive impact on all businesses and is yet to be leveraged by wellness and

healthcare.

‐ Because gamification's goal is to change human behaviors, PEGASO as a

wellness player will confront both opportunities and risks, requiring a clear vision

of the value of the system.

The strategy proposed by PEGASO, based on behavior changes, is expected to have

favorable effects in reducing overweight/obesity and associated diseases and social

costs in proportion to the national prevalence of body mass excess in this age class

taking advantage of the possibilities offered by innovative ICT and of teens’ affection

to mobile and social network.

4.1 Enhancing Self-awareness of Younger People for Health Issues, by

Means of Inclusive Approach Integrating Individuals into a

Community Context, and Promoting Behavioral Changes in Favour

of Physical Activity and Healthy Diets

Recommendations specific for children and young people have been released in 2005

also by the Commission of European Communities in the Green Paper on healthy

diets and physical activity for the prevention of obesity among EU citizen [16].

Reducing the risks deriving from unhealthy diets and physical inactivity and

increasing awareness and understanding of the influences of diet and physical activity

on health are the core objectives of the global strategy dictated by the World Health

Organization (WHO) against non-communicable disease and changes in behavior has

been indicated by WHO among the outcome indicators for assessing actions

fostering such a global strategy [17, 18]. The relationship between diet, physical

EPS Rome 2014 2014 - European Project Space on Computational Intelligence, Knowledge Discovery and Systems Engineering for Health

and Sports

activity and health is based on strong scientific evidence. Studies using motion

sensors have shown that children who spend less time in physical activity are at

higher risk to become obese during childhood and adolescence [19, 20]. Television

and video games contribute to more sedentary leisure activities and are reported to

favour concurrent consumption of energy-dense snacks and beverages [21]. In the

greatest majority, behavioral aspects related to lifestyle and diet (with a relevant

interference of socioeconomic factors) play an important causative role. The findings

from the 2009/2010 survey in EU countries from Health Behavior in School-aged

Children (HBSC) international report indicate that young people who are

overweight/obese are more likely to exhibit unhealthy alimentary patterns, are less

physically active and watch television more [22].

4.2 Preventing Juvenile Overweight/Obesity and Reducing Morbidities

Associated to Juvenile Overweight/Obesity in the Short Time, and

Long Term Health Consequences, including Adult Obesity, and

Associated Medical, Social and Personal Costs

According with the 2007 report of the EU Public Health Program Project "Global

Report on the Status of Health in the European Union - EUGLOREH", the number of

EU children affected by overweight and obesity is estimated to be rising by more than

400,000 a year, adding to the over 14 million of the EU population who are already

overweight (including at least 3 million obese children) [23]. Overall, across the

entire EU, overweight affects almost 1 out of 4 school age children/adolescents.

Childhood obesity has physical, psychosocial and economic consequences.

Overweight and obesity in the juvenile age are associated with a number of serious

medical conditions such as sleep-related breathing disorders and asthma, fatty liver

disease, poor glucose tolerance, increased risk of non-insulin-dependent diabetes,

hypertension, and can lead to increased rates of non-communicable disease in

adulthood such as cerebro-vascular disease, diabetes, certain types of cancer,

osteoarthritis, gall bladder and endocrine disorders, in relation with the high

probability for obese children to become obese adults [24]. Recent estimates indicate

that more than 27 000 children in the EU have type 2 diabetes and more than 400.000

have impaired glucose tolerance. About 1.1 million suffer from hypertension and 1.2

million suffer from metabolic syndrome (consisting in a clustering of hypertension,

abnormalities of lipid metabolism, and raised blood glucose levels)[23]. Moreover,

body mass excess in the juvenile age leads to low self-esteem, depression and social

exclusion, with immediate consequences in the psychological and social domain,

possibly leading also to concurrent or subsequent psychiatric pathology. Specifically,

social exclusion in childhood has been associated with reduced psychological

functioning in adulthood [19].

4.3 Reducing Medical, Social and Personal Costs Associated to Juvenile

and Adult Overweight/Obesity

The economic impact of overweight and obesity on health care and social systems is

definitely sizable. Such an economic burden has been recognized in terms of direct

PEGASO Fit for Future

medical costs (including preventive, diagnostic, and treatment services related to

obesity), indirect costs (attributable the value of income lost from decreased

productivity, restricted activity, absenteeism, and bed days), and intangible costs

(which can be referred to as the social and personal costs or losses associated with

obesity) [25, 26]. In recent years, health costs deriving from obesity among adults in

different Western European countries have been conservatively estimated to amount

up to over 10 billion Euros with relative economic burdens ranging from 0.20% to

0.61% of each country's gross domestic product [25]. A fairly higher economic load,

although scarcely definable with accuracy, can be considered to arise from the impact

of obesity on the wider economy in terms of loss of productivity [26]. It is even more

difficult to estimate the overall cost of obesity among children and young people. In

the perspective of health care costs, in fact, it has been assessed that overweight and

obese children exhibit significantly higher expenditures for outpatient visits, drug

prescriptions, and emergency room admissions, and have a higher probability of

being high utilizers of health care services [27]. Additionally, in the personal context,

it has determined by different studies that individuals who were obese, as adolescents

become adults with lower educational attainment, earning less money, experiencing

higher rates of poverty and having a lower likelihood of marriage, compared with

thinner peers [28]. Furthermore, as childhood obesity is a risk factor for adult

diseases, mortality costs in terms of the value of future income lost by premature

death in adulthood, should be considered.

4.4 Developing a System Suitable for Interventions based on Equity and

Inclusivity

The PEGASO system, integrating state of the art technologies within an holistic

approach including social and human aspects, fully complies with WHO guidelines

indicating the priority of comprehensive and coordinated multiple-strategy

interventions across the whole population promoting behavioral changes in favor of

physical activity and healthy diets in order ensue an effective obesity prevention in

childhood [4]. An increased prevalence of overweight/obesity is also significantly

associated with low family affluence [23]. The principles of the intervention included

in the present proposal, based on a "virtual individual" model considering as basic

features also social status and social behaviors, are in accordance with the main

outcomes from the 2009/2010 HBSC report recommending to address not only health

and health behavior issues, but also the social context in which young people live,

providing equal opportunities for all [22].

4.5 Providing a Transnational Opportunity for a Coordinated Effort to

Tackle a Transnational Issue

The transnational relevance of the growing prevalence of overweight/obesity among

younger population in industrialized and developing countries worldwide, prompt

also to an EU co-ordinated effort in research and industrial development to face such

an epidemic in member countries, which is another main feature entailed in the

present proposal. Indeed, the promotion of research for the prevention and control of

EPS Rome 2014 2014 - European Project Space on Computational Intelligence, Knowledge Discovery and Systems Engineering for Health

and Sports

non-communicable diseases (which include overweight/obesity) is one of the main

objectives recently focused by the WHO 2008/2013 Action Plan, proposing for

international partners the action of work jointly on "research on socioeconomic

determinants, lifestyle and behavior modification as well as community-based

interventions" [29].

Acknowledgements. This paper is based on the discussions and on the material

produced during the preparation and the activities of the PEGASO project to which

all project partners have contributed. The PEGASO project is co-funded by the

European Commission under the 7

th Framework Programme. PEGASO is part of the

cluster of projects in the ICT for health area, it has started in December 2013 and will

run for 42 months.

The authors wish to thank all the project partners for their contribution to this

work.

References

1. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in

the United States, 2011-2012. Journal of the American Medical Association 2014; 311(8):

806-814.

2. National Center for Health Statistics. Health, United States, 2011: With Special Features on

Socioeconomic Status and Health. Hyattsville, MD; U.S. Department of Health and Human

Services; 2012.)

3. Visions for Horizon 2020 - Copenhagen Research Forum, 2012.

4. World Health Organization. Population-based prevention strategies for childhood obesity:

report of a WHO forum and technical meeting, Geneva, 15–17. December 2009.

5. Sanders, E. B., (2002). From User-Centered To Participatory Design Approaches. Design,

1-7. Taylor &Francis.

6. Fogg, B.J., (2009). A Behavior Model for Persuasive Design, Proceedings of the 4th

International Conference on Persuasive Technology Persuasive 09, ISBN: 9781605583761.

7. Caon M, Carrino S, Guarnieri R, Andreoni G, Lafortuna CL, Abou Khaled O, and

Mugellini E. A Persuasive System for Obesity Prevention in Teenagers: a Concept. Second

International Workshop on Behavior Change Support Systems (BCSS 2014) pp 17-20,

http://ceur-ws.org/Vol-1153/Paper_2.pdf)

8. Fenner JW, Brook B, Clapworthy G, Coveney PV, Feipel V, Gregersen H, Hose DR, Kohl

P, Lawford P, McCormack KM, Pinney D, Thomas SR, Van Sint Jan S, Waters S,

Viceconti M. The EuroPhysiome, STEP and a roadmap for the virtual physiological human.

Philos Trans A Math Phys Eng Sci. 2008; 366: 2979-2999.

9. Brug J., Oenema A., and Campbell M., Past, present, and future of computer-tailored

nutrition education., Am. J. Clin. Nutr., vol. 77, no. 4 Suppl, p. 1028S–1034S, Apr. 2003.

10. den Akker HO, Moualed LS, Jones VM, and Hermens HJ, A self-learning personalized

feedback agent for motivating physical activity, Proc. 4th Int. Symp. Appl. Sci. Biomed.

Commun. Technol. - ISABEL ’11, pp. 1–5, 2011.

11. Carrino, S., Caon, M., Abou Khaled, O., Andreoni, G., Mugellini, E. (2014). PEGASO:

Towards a Life Companion, in the Proceedings of the 16th International Conference on

Human-Computer Interaction, 22 - 27 June 2014, Heraklion, Crete, Greece.

12. Merten MJ, Williams AL, Shriver LH. Breakfast consumption in adolescence and young

adulthood: parental presence, community context, and obesity. Journal of the American

Dietetic Association, 2009, 109(8):1384-1391

13. C. Science, A. Kapoor, P. Johns, K. Rowan, E. A. Carroll, M. Czerwinski, and A.

PEGASO Fit for Future

Roseway, “Food and Mood : Just-in-Time Support for Emotional Eating,” ACII2013, pp.

252–257, 2013.

14. Honka A, Kaipainen K, Hietala H, Saranummi N. Rethinking Health: ICT-Enabled

Services to Empower People to Manage Their Health. IEEE Rev Biomed Eng. 2011; 4

:119-139.

15. World Health Organization, 1948. Preamble to the Constitution of the World Health

Organization as adopted by the International Health Conference, New York, 19-22 June,

1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the

World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. Available

at: http://www.who.int/about/definition/en/print.html.

16. Commission of European Community. Green Paper - Promoting healthy diets and physical

activity: a European dimension for the prevention of overweight, obesity and chronic

diseases. COM(2005) 637, Brussels, December 2005.

17. World Health Organization. Global Strategy on Diet, Physical Activity and Health, Geneva,

2004.

18. World Health Organization. Global Strategy on Diet, Physical Activity and Health. A

framework to monitor and evaluate implementation, Geneva, 2006.

19. Consensus statement: Childhood Obesity. J Clin Endocrinol Metab. 2005; 90: 1871-87.

20. Lobstein T et al. Obesity in children and young people: a crisis in public health. Obes Rev.

2004; 5 Suppl 1:4-104.

21. Rey-López JP et al. Food and drink intake during television viewing in adolescents: the

Healthy Lifestyle in Europe by Nutrition in Adolescence (HELENA) study. Public Health

Nutr. 2011;14(9):1563-9.

22. Currie C et al. eds. Social determinants of health and well-being among young people.

Health Behavior in School-aged Children (HBSC) study: international report from the

2009/2010 survey. Copenhagen, WHO Regional Office for Europe, 2012 (Health Policy for

Children and Adolescents, No. 6).

23. EUGLOREH2007 project The Status of Health in the European Union: Towards a

Healthier Europe, available at: http://euglorehcd.eulogos.it

24. World Health Organization. Obesity: Preventing and Managing the Global Epidemic.

Report of a WHO Consultation. WHO Technical Report Series no. 894. WHO: Geneva,

2000.

25. Müller-Riemenschneider F et al. Health-economic burden of obesity in Europe. Eur J

Epidemiol. 2008; 23: 499-509.

26. Dent M. The economic burden of obesity. Oxford: National Obesity Observatory, 2010.

27. Trasande L & Chatterjee S. The impact of obesity on health service utilization and costs in

childhood. Obesity (Silver Spring). 2009; 17: 1749-54.

28. Gortmaker SL et al. Social and economic consequences of overweight in adolescence and

young adulthood. N Engl J Med 1993; 329: 1008–1012.

29. World Health Organization. 2008-2013 Action plan for the global strategy for the

prevention and control of noncommunicable diseases. Geneva, 2008.

EPS Rome 2014 2014 - European Project Space on Computational Intelligence, Knowledge Discovery and Systems Engineering for Health

and Sports