Engaging Teen-agers in the Adoption of Healthy Lifestyles

for the Prevention of Obesity and Related Co-morbidities

The Approach of PEGASO

Renata Guarneri

, Mauro Brivio

, Giuseppe Andreoni

and Marco Mazzola

Fondazione Politecnico di Milano, Piazza Leonardo da Vinci, Milano, Italy

Department of Design, Politecnico di Milano, Milano, Italy

Keywords: Prevention, Lifestyle Management, UCD User Centred Design, Sensor System, Social Networks, Social

Gaming, Serious Games, Avatar, Fitness.

Abstract: Obesity and other lifestyle-related illness are among the top healthcare challenges in Europe. Obesity alone

accounts for up to 7% of healthcare costs in the EU, as well as wider economy costs associated with lower

productivity, lost output and premature death. Obesity in younger age is an alarming predictor for obesity in

adulthood, but also entails short term health complications in juvenile age along with greater risk of social

and psychological problems.

Knowing how to stay healthy is not enough to motivate individuals, and especially teen-agers, to adopt

healthy lifestyles. In view of this, PEGASO – recently funded by the 7

Framework Programme of the

European Union in ICT for Health, will develop a multi-dimensional cross-disciplinary ICT system that will

exploit social gaming to motivate behavioural changes towards healthier lifestyles.

PEGASO is based on three main features: individual & environmental monitoring; feedback to the user, for

alternative lifestyles; social connectivity, encouraging involvement in social network experience sharing and

social engagement.

For the development of the PEGASO system and in order to ensure engagement of the target population, a

user centred approach will be used based on social and networked games and together with online

education.

1 INTRODUCTION

The rapidly increasing prevalence of overweight and

obesity among children and adolescents reflects a

global ‘epidemic’ worldwide. 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.

Sedentariness (WHO Phys, 2010) and over-

consumption of high calorie foods and beverages

(WHO Rec, 2010) 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).

Juvenile obesity is a complex disorder with

many interrelated. 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.

Among the principal key strategies tackling the

569

Guarneri R., Brivio M., Andreoni G. and Mazzola M..

Engaging Teen-agers in the Adoption of Healthy Lifestyles for the Prevention of Obesity and Related Co-morbidities - The Approach of PEGASO.

DOI: 10.5220/0004938505690576

In Proceedings of the International Conference on Health Informatics (SUPERHEAL-2014), pages 569-576

ISBN: 978-989-758-010-9

 2014 SCITEPRESS (Science and Technology Publications, Lda.)

risk of obesity in young individuals, actions

developing awareness and enhancing motivation for

changing behaviour towards healthy diet (dietary)

and physical activity (active lifestyle)

will have great

relevance. (World Health Organization, 2009)

Effective management of this epidemic should

thus be directed to the environment where the

youngsters live taking into account social, ethical

and cultural background, as well as lifestyle patterns.

Such a behavioural management should be also

sensitive to social factors as relations with peers

through social network media and personal

opportunities focused on increasing awareness and

personal involvement.

In order to address the above challenges, the aim

of the PEGASO project is to develop a multi-

dimensional and cross-disciplinary ICT system that

includes game mechanics to influence behaviours in

order to fight and prevent overweight and obesity in

the younger population by encouraging them to

become co-producers of their wellness and take an

active role in improving it by:

 generating self-awareness (acknowledgement

of risks associated to unhealthy behaviours),

 enhancing and sustaining motivation to take

care of their health with a short/medium/long

term perspective,

 changing behaviour towards a healthy lifestyle

based on healthy diet and adequate physical

activity.

The proposed system gives guidance towards

developing good habits and provides a social

platform to stimulate young people’s willingness to

engage actively in their health management. This

social platform also enables contribution from all the

stakeholders of the health and wellness ecosystem,

as the solution starting from health prevention can

expand into a systematic approach to cover all levels

of influence of individuals’ health.

A well-established user centred methodological

approach is key for success and to achieve the

expected impact with regard to wide users’

acceptance and use of the PEGASO system with

consequent increase of quality of life through

healthier behaviours, ultimately leading to reducing

costs and time of healthcare services and driving

education towards self-care organizational model

2 PEGASO USER CENTRED

DESIGN

PEGASO will implement a User Centred Design

approach (UCD) (Sanders 2002) by considering the

target population of teenagers at the centre of the

system in a palingenetic process. This approach is

very effective to motivate and engage users, which is

an essential requirement for systems’ acceptance and

efficacy rather than forcing to accommodate

technologies, products, or services. It should be

underlined that PEGASO, as tool for prevention, is

addressed mainly to healthy people. Recruitment of

teenagers will be done through schools, focusing on

fostering communities of interest (i.e. all students in

a class), rather than teen-agers with identified risk

factors.

In UCD approach, there are three main elements

to be integrated which are: user involvement in all

stages of the problem solving process,

multidisciplinary research and development team,

and iterative design process to refine the solution set.

We expect this method to be very suitable and

effective for the purposes of PEGASO.

Figure 1: User Centred Approach in PEGASO System.

2.1 PEGASO Ecosystem Architecture

The ecosystem of stakeholders and enablers is

composed of three main parts that are integrated in

the user centred PEGASO system: technological

frame, services frame and experts layer.

Technological Frame: To define a successful

strategy to empower the teen-agers awareness about

obesity, it is necessary to analyse and formulate

strong hypothesis about possible tools that can help

communicating with teens and that can provide the

highest level of acceptance from that. ICT based

technologies are not only familiar for teens, but they

are the most important channels they use to

communicate, create social connections, and

entertain. Teens are familiar with Internet, social

networks, mobile phones and apps, video gaming

and, in general, with all the ICT platforms. These

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key elements are the 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 data exchanged including also

health related information pose severe security

requirements that can be effectively managed

through a cloud platform. Finally, PEGASO apps

and games at the software layer, as well as different

wearable sensors complete the PEGASO technology

frame.

Services Frame: Social is the key word for

service development: the services created by

stakeholders in PEGASO 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. 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 behaviour. Figure 2 provides an overview

of the stakeholders ecosystem addressed by

PEGASO and that are directly or indirectly involved

in the development of the PEGASO approach.

Figure 2: PEGASO ecosystem of stakeholders.

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 is assumed to be

twofold: 1) to personalise 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.

2.2 Influencing Behaviour

Regarding the ecosystem of PEGASO, it is

important to consider all personal levels of influence

of one’s prevention in its environment.

Figure 3 below is based on the Circles of

Influence in Self-Management of Chronic Disease

(Clark and Patridge, 2002) and adapted to the needs

of PEGASO, i.e. address prevention management in

teenagers. The circle hierarchy revolving around the

end user is not defined in a fixed way; each ring of

the concentric circles represents different levels of

influence dispersed around the user: self-

management, family involvement, peers influence,

experts, school support, community awareness, and

environmental measure, industry and policy

decisions to the success of the user’s prevention

management efforts. Therefore for each individual

the circles of influence will have different

hierarchies, interactions and points of decisions for

healthy living.



Figure 3: Users’ Circles of Influence in Health

Management.

In each circle of influence, end users have an

interaction towards their everyday health. In some

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circles, the user has the possibility to contribute in

decision-making process, in some other they cannot.

Therefore, in PEGASO it is important to focus

on the interactions points between end users and

levels of their influences, in particular where end

users are able to take their own decisions, or where

the intervention of services and persuasion to

healthier lifestyle changes will be acted upon these

opportunity areas. This analysis is important to

define for user requirements for the design of the

PEGASO persuasion strategies.

Moreover PEGASO considers the various levels

towards persuasion for healthcare (Fogg, 2009).

Various types of experts and technologies will feed

these levels of persuasion towards healthier

decisions. As shown in Figure 4, there are four

different persuasion strategies: awareness of obesity

risks, motivation, affective learning and behaviour

change.

Figure 4: Persuasion Levels for Disease Prevention.

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 behavioural

change, an example in so far is the TV soap that

fostered towards birth-control in north Brazil.

Create Motivation: it is important to motivate

teenagers to change their behaviour 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,

technological frame monitoring and stakeholders

services come into the scene.

Enable Behaviour 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 behaviours. The turn

from old unhealthy behaviours 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 an

holistic approach involving the teenager’s

environment and specifically the families, by means

of an education process empowered by training that

will be provided within the schools and on line. The

expert team will give feedbacks to the users

allowing them to change their behaviour on a long-

term basis. The overall system takes advantage of

gaming strategies to persuade users to change their

behaviour.

3 SYSTEM ARCHITECTURE

PEGASO system is designed around a social

platform that integrates various gaming strategies to

involve teens to prevent and engage with their health

in a long-term period. The serious gaming broadens

into a social dimension, where the game takes place

in real-world situations, aims to solve real problems,

and come across real challenges of their life.

From a technology point of view, PEGASO is

based on a mobile platform, where the smart-phone

is the first and key sensor system. The mobile device

also acts as communication gateway towards the

other sensors.

Basic services, such as those related to location

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and basic motion sensors to detect physical activity,

are provided through sensors embedded within the

smart-phone. As the PEGASO system will be

modular it can be tailored to the specific needs and

preferences of the users. This means that the mobile

phone is the primary “sensor” and interface to

collect and analyse data from users with additional

sensors that can be added to the system, as required

by the services or context of use. Additional devices

foreseen to be used are:

 A bracelet (or similar wearable device) that

monitors physical activity;

 A scale (or balance board) that provides

information about weight and body

composition;

 Specific sensors to monitor fitness / sports

activities.

In addition to the monitoring of the individual

dimensions, that includes also collecting information

about the nutrition habits, the social dimension will

be covered, as key motivator to life-style change.

The social dimension will leverage the extensive use

of social networks and will be based on social and

educational/serious games.

The PEGASO social platform represents a

gamification of the teens’ healthy life. Typical

components of the platform are: Game, Avatar,

Diary, Daily Challenges, Group Challenges, etc.

As shown in Figure 5 above, the platform

dynamically changes its form according to time, and

so the status of people, their objective, motivation

and the relations within the network. Teens act as an

active participant, information sharer, peer leader,

co-creator and self-tracker of their activities in the

social platform. The change of their role depends on

their activities and the evolution of the platform over

time.

The first phase is the phase of AWARENESS,

where teens develop self-awareness on their

everyday behaviors and self-reflect on their

decisions and activities towards healthier change.

Diary has a more important role in this phase.

The second phase is the ACTION phase, once

teens develops awareness and they decide where is

the point of intervention, and the platform provides

materials to enable proactively act upon the

intervention area.

The third phase is the CHANGE phase, where

the old behavior turns into a new healthier one. In

this stage, experts have a primary role, where they

will help teens, through their feedback, to change

their behavior.

The fourth phase is the FOLLOW UP phase,

where the system and the experts will follow up the

change and make sure the healthier habits can be

sustained in the longer term.

4 VALIDATION OF RESULTS

The evaluation strategy of PEGASO will be twofold:

 A technical validation of the platform;

 A large scale pilot involving a population of 300

students in three countries.

Figure 5: PEGASO Evolution of Platform over time.

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The validation of the PEGASO platform will assess

the following factors:

 System and Technology acceptance, usability

and long-term use: these will be 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 on the sensors’ network system;

 Efficacy of the system in encouraging lifestyle

change;

 Subjective assessment for awareness;

 System’s compliance to Stakeholders’ needs.

The overall PEGASO service framework 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, teen-agers

acquire more independence and have increasingly

the opportunity to select on their own their snacks

and the extra-school activities influenced by what

their friends do. Therefore it is important that at this

stage they become aware of the consequences of an

incorrect eating behaviour and that they perform a

sufficient physical activity.

During the four validation studies that will be

carried out in Italy (Lombardy), Spain (Catalonia)

and United Kingdom (England and Scotland),

PEGASO will take into special consideration the

socioeconomic environment of the selected schools

where the pilot will be run and the involvement of

the students’ families.

Through the pilot PEGASO will demonstrate the

effectiveness of the approach in support of:

 discovering at an early stage potential risks of

developing obesity and related comorbidities

and encouraging lifestyle changes by means of

an approach based on social/networked games;

 educating teen-agers towards healthier lifestyles

through an approach based on serious games;

and

 engaging the educational environment (families

and schools) reinforcing the messages delivered

through physical seminars to teachers and

parents by means of online educational

modules.

5 EXPECTED IMPACT

The strategy proposed by the PEGASO project is

expected to have predictable favourable 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.

More specifically the following impact areas will

be addressed:

Enhancing self-awareness of younger people for

health issues, by means of inclusive approach, and

promoting behavioural changes in favour of

physical activity and healthy diets. 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-Diet 2004, WHO-Diet 2006)

against non-communicable disease and changes in

behaviour has been indicated by WHO among the

outcome indicators for assessing actions fostering

such a global strategy. The relationship between

diet, physical 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 (Consensus 2015,

Lobstein 2004).

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"

(EUGLOREH2007), 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). Overall, across the entire EU,

overweight affects almost 1 out of 4 school age

children/adolescents. Childhood obesity has

physical, psychosocial and economic consequences.

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 medical costs, indirect costs, and

intangible costs (Müller-Riemenschneider 2008,

Dent 2010).

Developing a system suitable for interventions

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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 behavioural

changes in favour of physical activity and healthy

diets in order ensue an effective obesity prevention

in childhood.

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 industrialised and developing countries

worldwide, prompt also to a EU co-ordinated effort

in research and industrial development to face such

an epidemic in member countries. The promotion of

research for the prevention and control of non-

communicable diseases is one of the main

objectives recently focused by the WHO 2008/2013

Action Plan (World Health Organization. 2008-

2013), proposing for international partners the action

of work jointly on "research on socioeconomic

determinants, lifestyle and behaviour modification

as well as community-based interventions".

6 CONCLUSIONS

The principal aim of the project PEGASO is the

promotion of changes in behaviours concerning

active lifestyle and healthy diet in younger people,

based on awareness on health issues.

• 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 behaviour is

not just a clinical issue. Successful programs include

incentives along with personalised programs and,

increasingly, the inclusion of behavioural science.

Gamification has emerged as a recognisable trend

that can have a significant positive impact on all

businesses and is yet to be leveraged by wellness

and healthcare.

The PEGASO partners believe 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 behaviour and

expectations.

These trends include the exponential rise in use of

smartphones and 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, through the use of

personalisation techniques and incentives that will

be delivered through the PEGASO system.

ACKNOWLEDGEMENTS

This paper is based on the discussions and on the

material produced during the preparation of the

PEGASO project to which all project partners have

contributed. The PEGASO project is co-funded by

the European Commission under the 7

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.

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