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The digital stress coach. Total control over your mental health, or 'Big Brother is watching you'?

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The digital stress coach. Total control over your mental health, or 'Big Brother is watching you'?

Abstract and Figures

It's an appealing idea to have a digital coach that helps you reduce work-related stress and get more energy from your work. We all feel stress. And we all want to do work that energises us. Stress is also something we'd like to avoid. It's a societal problem and a digital stress coach might offer a solution that fits within the 'future world of work'. The development of digital stress coaches is still in its infancy. That means that this is the right time to think about how we can guide their introduction in a responsible manner. This chapter describes current developments regarding stress coaches and discusses various issues related to their introduction.
Content may be subject to copyright.
Linda Kool, Jelte Timmer and Rinie van Est (ed.)
Sincere support
RATHENAU INSTITUUT
The rise of the e-coach
More and more people are using their smartphone to motivate them to jog or to
monitor their stress levels. The growing popularity of smartphones equipped with
sensors is leading to a new sort of coach: the electronic lifestyle coach or e-coach.
E-coaches can help their users attain personal goals, for example weight loss or envi-
ronmental awareness.
The next generation of coaching apps will quantify our behaviour, emotions, physical
activity, and bodily functions. Smart software can analyse all this data and discover
patterns that are invisible to us. In effect, these apps will function as a sixth sense and
help us make a whole range of everyday choices. There’s no doubt that such apps are
handy – but can we trust them? On what do they base their recommendations? Do
coaching apps adhere to the concept of professional confi dentiality? Who is actually
profi ting from the intimate data that they collect? How far can we permit technology
to go in infl uencing our behaviour and lifestyle?
Sincere Support examines these question by looking at fi ve case studies. It shows that
the quality of the e-coaches available today varies considerably. The requirements for
admitting e-coaches to the market and the standards that should be applied are still
under development. The Rathenau Instituut therefore advocates the introduction of
quality criteria to ensure that e-coaches have expertise, are reliable, respect the pri-
vacy and autonomy of their users, and act with integrity.
SINCERE SUPPORT: THE RISE OF THE E-COACH
The Rathenau Instituut promotes the formation of political and public opinion on
science and technology. To this end, the institute studies the organization and
development of science systems, publishes about social impact of new technolo-
gies, and organizes debates on issues and dilemmas in science and technology.
Who was Rathenau?
The Rathenau Instituut is named after Professor G.W. Rathenau (1911-1989),
who was successively professor of experimental physics at the University of
Amsterdam, director of the Philips Physics Laboratory in Eindhoven, and a
member of the Scientifi c Advisory Council on Government Policy. He achieved
national fame as chairman of the commission formed in 1978 to investigate
the societal implications of micro-electronics. One of the commission’s
recommendations was that there should be ongoing and systematic
monitoring of the societal signifi cance of all technological advances.
Rathenau’s activities led to the foundation of the Netherlands Organization for
Technology Assessment (NOTA) in 1986. On 2 June 1994, this organization
was renamed ‘the Rathenau Instituut’.
Sincere support
The rise of the e-coach
© Rathenau Instituut, The Hague, 2015
Rathenau Instituut
Anna van Saksenlaan 51
Correspondence:
P.O. Box 95366
2509 CJ Den Haag
The Netherlands
Telephone: + 31 70-342 15 42
E-mail: info@rathenau.nl
Website: www.rathenau.nl
Publisher: Rathenau Instituut
Translation: Balance2
Scenarios: Gaston Dorren
Cover image: Arjen Born (cover and chapter 1 and 7)
Illustrations: Frank-Jan van Lunteren (chapter 1,3 and 7)
Lay-out: Boven de Bank
Printing: Quantes, Rijswijk
This book is printed on FSC-certified paper.
First printed: January 2015
ISBN/EAN: 978-90-77364-64-2
Preferred citation:
Kool L., J. Timmer and R. van Est (ed.), Sincere support. The rise of the e-coach.
The Hague, Rathenau Instituut 2015
The Rathenau Instituut has an Open Access policy. Reports and background studies, scientific
articles, and software are published publicly and free of charge. Research data are made freely
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publication may be reproduced and/or published by means of print, photocopy, or any other
medium without the prior written permission of the Rathenau Instituut.
Sincere support
The rise of the e-coach
Linda Kool, Jelte Timmer and Rinie van Est (ed.)
Board of the Rathenau Instituut
Mrs. G.A. Verbeet (chairman)
Prof. dr. E.H.L. Aarts
Prof. dr. ir. W.E. Bijker
Prof. dr. R. Cools
Dr. H.J.M. Dröge
Drs. E.J.F.B. van Huis
Prof. dr. ir. H.W. Lintsen
Prof. mr. J.E.J. Prins
Prof. dr. M.C. van der Wende
Dr. ir. M.M.C.G. Peters (secretary)
Rathenau Instituut 5
Foreword
When I recently got a new smartphone, I was surprised to find out after a few
weeks that it had been tracking my activity. My new phone came with a pre-
installed app. Apparently activity tracking has become so popular that compa-
nies pre-install such features. This books shows that indeed an increasing
number of people use their phone to attain personal goals, such as weight loss
or personal finance. Such coaching devices analyse data regarding our behav-
iour, communication and physical activity and learn new insights about us –
sometimes in ways we don’t know or don’t notice.
With this book, the Rathenau Instituut reflects on the social and political signifi-
cant of e-coaching, as part of our studies on intimate technology, as it is our task
to foster dialogue and support decision-making on developments in science and
technology. Can e-coach devices provide effective and reliable support for
behavioural change? Can we compare e-coaches with human coaches? What
standards do e-coaches need to meet?
We asked experts to contribute to this book. Sander Voerman, Harro Maas, Niels
Compen, Jaap Ham, Andreas Spahn, Joris Janssen, Mark Neerincx, Marc van
Lieshout, Noortje Wiezer, Elsbeth de Korte researched five case studies. Via
literature study and interviews with experts and users they shed light on the new
world of e-coaching. The results were discussed with our advisory committee. I
would like to express our gratitude and appreciation to its members: Elly
Plooij-van Gorsel (Dutch Association of Psychologists), Reinder Haakma (Philips),
Leon Kenemans (National Initiative Brain & Cognition), Wouter Segeth
(Technology Foundation STW) and Emile Aarts (Eindhoven University of
Technology). Finally, science writer Gaston Dorren added scenarios to show
future technological possibilities.
The results show that e-coaches can be very valuable to help individuals, but
they also bring new challenges and dilemmas. Interestingly, we learned that
existing codes for responsible human coaching can be an important guide in our
interactions with e-coaches: expertise, respect for privacy and autonomy,
integrity and responsibility. The Rathenau Instituut therefore advocates the
introduction of criteria to ensure the quality of advice from e-coaching. I hope
this book inspires the discussion about the development of responsible e-coach-
es. To me, that means no unobtrusive monitoring in the background: I asked the
electronic store to help me switch off the activity tracker on my smartphone.
Dr. ir. Melanie Peters
Director, Rathenau Instituut
Rathenau Instituut 7
Content
Foreword 5
Coaches everywhere 9
1 Coaches everywhere 11
Jelte Timmer, Linda Kool and Rinie van Est
1.1 Technology as a helping hand 11
1.2 What is an e-coach? 12
1.3 Coaching practice 17
1.4 Outline of the book 21
1.5 Bibliography 23
Box 1 Self-tracking 26
Health coaches 29
Scenario: Exercising more with MoreStuFit 31
2 Tackling your lifestyle with the body coach 34
Sander Voerman
2.1 Introduction 34
2.2 Changes in actual practice 36
2.3 Societal and normative issues 46
2.4 Implications for politics and policy 55
2.5 Conclusions 58
2.6 Bibliography 60
Box 2 Certification of medical software 65
Financial coaches 69
Scenario: Banking at the community garden 71
3 E-housekeeping books. Moral economy in the digital age 74
Harro Maas
3.1 Introduction 74
3.2 What e-housekeeping books are available? 76
3.3 Financial and moral bookkeeping 78
3.4 A closer look at two financial e-tools 81
3.5 Analysis 87
3.6 Conclusions 89
3.7 Bibliography 90
Box 3 Revenue models 95
Sustainability coaches 99
Scenario The energy dashboard 101
4 Sustainability coaches. A better environment starts with
your coach 105
Niels Compen, Jaap Ham and Andreas Spahn
4.1 Sustainability e-coaching in actual practice 105
4.2 Moral issues 109
4.3 Regulation and policy 114
4.4 Bibliography 118
Box 4 Privacy 121
Social coaches 125
Scenario: The info lunch at XSU 127
5 Social signals. E-coaches for social interactions 131
Joris Janssen, Mark Neerincx and Jelte Timmer
5.1 Introduction 131
5.2 Digitising behaviour 132
5.3 Changes in coaching 140
5.4 Issues 142
5.5 Conclusions 148
5.6 Bibliography 149
Box 5 Integrating e-coaching into an existing practice 152
Stress coaches at work 155
Scenario: Lisa and Matt go on a date 157
6 The digital stress coach. Total control over your mental health,
or ‘Big Brother is watching you’? 161
Marc van Lieshout, Noortje Wiezer and Elsbeth de Korte
6.1 Introduction 161
6.2 Digitising coaching 163
6.3 Exploring the societal impact of the digital stress coach 166
6.4 Policy implications 171
6.5 Conclusions 173
6.6 Recommendations 174
6.7 Bibliography 174
Box 6 Codes of conduct for professional coaches 177
E-coaching: from possible to desirable 179
7 E-coaching: from possible to desirable 181
Linda Kool, Jelte Timmer, Rinie van Est and Frans Brom
7.1 The advent of the e-coach 181
7.2 What is the e-coach capable of? 183
7.3 Reflecting on coaching practices 189
7.4 An e-coach without a code? 198
7.5 Recommendations 207
7.6 Final remarks 212
7.7 Bibliography 212
About the authors 216
Sincere support. The rise of the e-coach8
Rathenau Instituut 9
Coaches everywhere
Rathenau Instituut 11
1 Coaches everywhere
1
Jelte Timmer, Linda Kool, Rinie van Est
1.1 Technology as a helping hand
Modern life is demanding and complex. Keeping track of your finances can be
difficult in a world of digitised money. Making healthy diet choices is also a
challenge, given all the temptations that we face on a day-to-day basis. And
showering for one minute less may be a sustainable choice, that doesn’t make
it an easy one. It’s therefore not surprising that we sometimes need a bit of
help. That help can come from a friend or from a professional coach, but it’s
increasingly being provided by technology.
At Microsoft’s Faculty Summit in July 2013, Bill Gates argued that smart
technology can help us tackle many of these problems: ‘Software assistants
could help solve global problems’ (Simonite, 16July 2013). The way behaviour
can increasingly be tracked digitally makes it possible to analyse it with
computers, which can then help us understand that behaviour and improve it.
Beyond Verbal, an Israeli start-up, is working on software that identifies
emotions by means of speech analysis. This may help men finally understand
what their girlfriends are actually saying. ‘It’s time to understand emotions’ –
and Beyond Verbal can help.
2
‘Intelligent software assistants’ sounds too abstract, so we usually just refer to
apps’. The number of apps and devices on the market to help people change
their behaviour is increasing enormously (Research2Guidance 2013). In the area
of health and healthy living, there is now a flourishing market for wristbands,
scales, and apps for computers and smartphones. The widespread adoption of
smartphones (Conti et al. 2011), the falling cost of sensor technology, and the
increasing sophistication of data analysis have facilitated the advent of a new
kind of coach: the e-coach.
The use of e-coaches seems extremely promising. They can help us to lead a
healthier and more environmentally aware life, to relax more, and to under-
stand other people better. But the advent of the e-coach also raises questions.
Can apps and devices provide effective and reliable support for changing our
behaviour, and are they a possible solution to problems such as unhealthy
lifestyles or wasting energy? If coaching is offered in digital form, what does
that mean for access to coaching and how it is used? How does one deal with
the data that is collected digitally? Who profits from that data? What standards
1 This section is based on Kool, Timmer & Van Est 2013
2 http://www.beyondverbal.com/
Sincere support. The rise of the e-coach12
do e-coaches need to meet – are they the same as those for human coaches?
How far can we permit technology to go in influencing and changing our
behaviour and lifestyle? And finally, what do all these issues mean for regula-
tion and policy in the area of electronic behavioural support?
The Rathenau Instituut’s aim with this book is to clarify how e-coaching is
developing, and to instigate public debate on the social and ethical issues
involved. E-coaching is a relatively new technological development within a
much older tradition of coaching and support. We discuss the rise of the
e-coach within five domains: health, finances, sustainability, social behaviour,
and work stress. In each chapter, the key question is: What new digital coach-
ing practices are evolving, what changes and what social, political and govern-
ance issues do they entail, and what are the conditions that we should impose
for these new practices? The purpose of this study is to make recommenda-
tions on the best way of dealing with the various questions and issues related
to e-coaching so as to ensure that it is used in a socially responsible manner.
In section 2 of this chapter, we will define just what an e-coach actually is, and
what technological advances play a role. Section 3 discusses trends in the
actual practice of coaching. After all, when attempting to understand the
development of e-coaches we need to consider not just the technology but
also the social context within which that technology is developing. Section 4
outlines the approach taken in this book and provides a reader’s guide to the
whole volume.
1.2 What is an e-coach?
Digital coaches come in all shapes and sizes. It is difficult, for example, to keep
up with the number of apps for tracking and improving one’s health. In March
2013, there were estimated to be 97,000 different apps on the market meant to
support healthy lifestyle choices (Research2Guidance 2013). Wristbands
produced by such companies as Fitbit, Jawbone, or Nike+ have become
popular with people who want to get more exercise. These track physical
activity and sleep patterns, and they can be linked to a set of smart scales that
are connected to the Internet and that calculate weight and body fat
percentage. These devices can help people in their struggle against a
sedentary lifestyle. The e-coach uses social game mechanics, scores, statistics,
and right-on-time tips and suggestions – on your scales, wristband, or app – to
encourage you to be more active.
But it is not just in the field of health that coaching apps are available. A
number of banks offer an online housekeeping book to support financially
healthy behaviour, and companies such as You Need a Budget and AFAS
Personal deliver apps promising analysis, advice, and greater control of
finances. Smart energy meters such as the Wattson are intended to help us
reduce our energy consumption. In the field of social relationships and
Rathenau Instituut 13
interaction, the Time Out! app aims to prevent domestic conflicts from
escalating. The wristband produced by the Italian company Empatica can
relate stress to workplace activity, analysing which activities lead to stress and
whether certain work rhythm patterns are unhealthy. Users then receive tips for
tackling stress so that they can work more healthily and more productively.
1.2.1 Background to the e-coach
Although new technologies in the shape of smartphones, sensors, and smart
apps are playing a major role in the rise of the e-coach, people’s interest in
tracking their behaviour has not just come out of the blue. Measuring,
quantifying, and analysing our own behaviour and that of others is part of a
long scientific tradition. Down through the centuries, researchers have
conducted experiments in an attempt to understand their own behaviour and
that of other people. In the sixteenth century, the Italian physician Santorio
Santorio (‘Sanctorius of Padua’) kept track of his weight for thirty years,
weighing himself before and after every meal. He also weighed his food and
his faeces in an attempt to discover why they differed in weight. Early
researchers such as Friedrich Sertürner, the German pharmacist who
discovered morphine, also carried out experiments on themselves to
determine the effects of certain substances (Neuringer 1981). The Victorian
statistician and founder of eugenics, Francis Galton, made use of a little device
that he called his ‘pocket registrator, which allowed him to record
anthropological statistics among crowds of people without calling attention to
himself (Galton 1880).
Early in the twentieth century, scientific measurement and monitoring found
their way into the workplace when Frederick William Taylor introduced
‘scientific management. In the spirit of a remark by the eminent physicist Lord
Kelvin – ‘If you cannot measure it, you cannot improve it’ – work processes
were quantified and analysed, with the data generated being used to see how
they could be made more efficient. Taylor’s scientific approach to management
replaced the existing rules of thumb and intuitive knowledge by empirical
methods. Precise measurements became the basis for decisions on how the
work process should be designed. Although the way Taylor applied the
concept of scientific management has been discredited, the underlying ideas
are still very much apparent in modern management and elsewhere (Lepore
2009).
The legacy of these early attempts to measure, monitor and improve can
currently be found in the ‘Quantified Self’ movement. Central to that
movement is the aim of understanding ourselves better by using a wide range
of measuring instruments, under the motto ‘self-knowledge through numbers’.
Since Galton introduced his pocket registrator, the technology has really taken
off, fuelled in the first place by sensors that allow us to digitise and quantify
behaviour and in the second place by powerful computers with which we can
Sincere support. The rise of the e-coach14
analyse the data generated. In 2010, the technology journalist Gary Wolf – one
of the driving forces behind the Quantified Self movement – explained the
interest in self-quantifying and self-tracking on the basis of four trends:
1. Sensors are getting smaller and more powerful all the time;
2. Their integration into smartphones means that they have become
ubiquitous;
3. Social media have made sharing personal information something that is
broadly accepted and acceptable;
4. Cloud computing makes it possible to combine data on external servers
and to analyse it (Wolf 2010).
According to Wolf, one of the great advantages of quantifying is that
‘Numbering things allows tests, comparisons, experiments. Numbers make
problems less resonant emotionally but more tractable intellectually.’ Not only
can one say that ‘numbers don’t lie’ but the thinking behind scientific
management is also clearly apparent again. Spreadsheets, software, and all
kinds of gadgets make it possible to collect data ranging from emotions and
social interaction to brain activity and physiological signals. Proponents of the
Quantified Self use this data to analyse their own lives, discover new
connections, and take better decisions. This may involve, for example,
determining one’s ideal personal diet, the ideal dose of coffee one needs to
be most alert, or which books have produced the most positive emotions over
the course of the past year.
The Quantified Self movement has generated interest in measuring and
monitoring, but using some means of physical or behavioural self-surveillance
is not reserved exclusively for technology freaks. The Pew Research Center has
found that about seven out of ten American adults make use of some kind of
self-surveillance, with a fifth of them utilising technologies such as apps (Fox &
Duggan 2013). The business magazine Forbes (Clay, 1 June 2013) referred to
the 2013 Consumer Electronics Show (CES 2013) as ‘the Quantified Self edition’
because of the emphasis on self-tracking in many of the products presented
there, such as the Netatmo weather station, which measures air quality,
3
or the
Withings Smart Body Analyzer, a set of smart scales.
4
The increasing interest in self-tracking provides a significant social context for
the rise of e-coaching. Collecting data on one’s own behaviour is the first step
towards analysis of that data and the provision of well-founded advice by the
e-coach. Quantified Self has set itself the goal of using data collection to gain
new insights into one’s own behaviour; where the e-coach is concerned, the
aim is to digitise the process of monitoring and analysing, with the e-coach
3 www.netatmo.com
4 http://www.withings.com/nl/smart-body-analyzer.html
Rathenau Instituut 15
applying digitised coaching strategies to encourage the user to change his
behaviour. Quantifying and tracking have therefore had the coaching aspects
added on. In practice, the distinction between e-coaches and Quantified Self
gadgets will not always be clear. Some of the gadgets that are frequently used
within the Quantified Self movement in fact contain motivational and coaching
elements. The fitness trackers produced by Nike+, Jawbone, UP, and Fitbit
track the users activity but also provide personal feedback and tips to
encourage him to take more exercise.
1.2.2 Technological development of the e-coach
The first generation of e-coaching apps is on the market, but there are already
research projects aimed at producing the second generation of digital
coaches. These will feature even better, smaller sensors that can register
behaviour more precisely, more refined computerised data analysis, and more
subtle ways of providing personalised feedback. In the Netherlands, 2011 saw
the start of the Healthy Lifestyle Solutions partnership programme, in which
Philips Research, the STW Technology Foundation, and the National Initiative
Brain & Cognition (NIHC) are collaborating to promote research on the
development of computer-supported lifestyle coaching applications. The aim
of that programme is to create digital versions of proven coaching strategies
that will coach and assist people in making long-term changes to their
behaviour. Under the motto ‘measure, monitor, and motivate’, the parties
involved are working on sensors that can track the user’s behaviour, bodily
functions, cognition, and emotions as unobtrusively as possible. An e-coaching
device will then offer the user personalised feedback (Kool, Timmer & Van Est
2013).
The collaboration within the programme is indicative of the interaction
between industry, technology research, and cognitive science in the develop-
ment of e-coaches. Smart devices for quantifying and analysis are combined
with knowledge of cognition, psychology, and coaching in order to encourage
certain behaviour or the desired change in behaviour.
5
The e-coaches derived
from this combination feature three processes:
1. Data is collected via sensors or from other digital sources;
2. This data is analysed and the coaching strategy is decided on;
3. Persuasive, motivating feedback is provided (Purpura et al. 2011).
We will take a brief look at this process of data acquisition, analysis, and
persuasion (see Figure 1).
5 The evolution of e-coaching can be seen as part of a trend towards convergence between
Nanotechnology, Biotechnology, Information Technology and Cognitive Science (NBIC). In the
case of e-coaching, information technology converges with the cognitive and behavioural sci-
ences (Van Est & Stemerding 2012).
Sincere support. The rise of the e-coach16
Figure1.1 Technical description of the e-coach (Kool, Timmer & Van Est 2013)
Data acquisition – measure
The data that the e-coach collects on the user’s behaviour forms the basis for
analysing that behaviour and for the advice that the e-coach then offers. The
data is derived from self-reporting (for example filling in a questionnaire),
monitoring by means of sensors (for example cameras, accelerometers, or the
GPS receivers in most smartphones), or from other sources of data (such as
social networks, calendars, or digital bank statements).
Although a lot of monitoring still involves manual input– for example diet apps
that require one to enter meals manually – the aim is to automate data
collection and monitoring and have them operate as unobtrusively as possible
so that the user does not need to bother about them (Kool, Timmer & Van Est
2013). The use of sensor technology plays a key role in this, with an ongoing
trend towards miniaturisation, minimisation of energy consumption, and
continuous monitoring (Guardian Angels 2012). A smartphone such as the
latest iPhone already contains no fewer than nine different sensors: an
accelerometer, GPS, ambient light sensors, microphones, a proximity sensor,
cameras, a compass, a gyroscope, and a fingerprint scanner. Network
connectivity further increases the possibilities for using sensors (Apple 2014;
Conti et al. 2011, p. 9).
Rathenau Instituut
Source: Kool, Timmer & Van Est (2013)
Rathenau Instituut 17
Data analysis – monitor
The data produced by sensors and other data sources is generally unstructured
and does not in itself help to understand the user’s behaviour. In order to
generate information from this raw data, it needs to be analysed.
6
Sensor input
from accelerometers, for example, can be broken down into various kinds of
exercise (walking, cycling, running). Data on heart rate variability and skin
conductance can be combined to determine someone’s stress level. Data
mining techniques – combining IT and statistics – can be used to identify
patterns automatically or semi-automatically (Kool, Timmer & Van Est 2013).
Data analysis can also help explain the behaviour itself, for example by clarifying
someone’s pattern of expenditure (YNAB 2014) or by identifying the calendar
appointments associated with a high level of stress (Empatica 2014). The
Active2Gether research project – part of the Healthy Lifestyle Solutions
programme already referred to – incorporates data from social networks.
Smart analysis of the data means that the programme can make use of the
social context to encourage young people to participate in sports.
7
Feedback – motivate
In the feedback, the motivational aspect of digital coaching comes to the fore,
i.e. the way in which the e-coach suggests ways that the coachee can become
more physically active and helps him achieve his intended goal. Psychological
theories of behavioural change come together with computer science in what
is referred to as ‘persuasive technology’ or ‘captology, i.e.technology
deliberately designed to alter the behaviour or attitudes of users (Fogg 2002).
The purpose of persuasive technology is to develop systems that work on the
basis of information about the user and his response to feedback in order to
select precisely the right persuasive strategy for bringing about a change in
behaviour (Kool, Timmer & Van Est 2013).
1.3 Coaching practice
When attempting to understand the development of e-coaching, we need to
consider not just the technology but also the social context within which that
technology is developing. The e-coach is in fact becoming part of an existing
practice of coaching, behavioural support, and self-help. The developers and
providers of e-coaches, their relationship to the existing practice of coaching
and support, and users’ expectations all combine to create a social structure in
which the technology evolves and is applied. The figure below shows how the
e-coach is evolving. The coachee – i.e. the user – becomes digitised if his/her
behaviour is automatically recorded by means of sensors. Coaching is also
digitised if it can be provided by computers (in other words if they can analyse
6 This is based on Russel Ackoff’s popular hierarchy (1989) of human knowledge, commencing
with data that is analysed to produce information, which then forms the basis for knowledge and
nally for wisdom.
7 http://active2gether.few.vu.nl/ ; https://www.hersenenencognitie.nl/contents/887?locale=en
Sincere support. The rise of the e-coach18
user data and give him/her personalised feedback and advice based on that data).
The endpoint in this development is an autonomous digitised coach. But that
e-coach is not isolated from other forms of coaching; it is related to them and
can complement them, or can in fact open up a new market that traditional
coaches cannot serve. The role played by technology will not always be the
same as that played by human coaches. The question is therefore: what changes
take place within this process of digitisation, and what new practice of
coaching comes into being?
Figure1.2 Digitisation of coach and coachee (Kool, Timmer & Van Est 2013)
1.3.1 Existing coaching practice
The existing practice of coaching is very diverse. Coaching is offered in many
different forms – for example self-help books – and for a very wide range of
purposes, from career coaching and fitness coaching to relationship coaching
and debt relief counselling. Coaching can be used to help solve a particular
problem – for example taking control of one’s finances with the aid of a debt
relief counsellor – or to improve certain behaviour, for example getting more
exercise with the aid of a fitness coach. The methods that coaches use are also
very varied, ranging from recognised, protocolised cognitive behavioural
therapies to alternative therapies and methods of behaviour change. Although
the title ‘coach’ is not a legally protected one, there are professional
associations (such as the Dutch order of professional coaches NOBCO) that
provide training, codes of conduct, accreditation, and seals of approval so as
to monitor the quality of coaching (NOBCO 2013).
1. Traditional coaching
2. Digitization communication 4. Digitization coachee
3. Digitization coach
5. Autonomous e-coach
Coachee
Degree of digitization
Coach
eCoachee
eCoach
Degree of digitization
Rathenau Instituut
Source: Kool, Timmer & Van Est 2013
Rathenau Instituut 19
The element common to all these various kinds of coaching is that they all
provide guidance in changing a particular aspect of the coachee’s behaviour.
This often involves several face-to-face sessions with the coach during which
reflection, exercises, and advice are used to work towards the desired change
in behaviour. Data on the coachee’s behaviour is collected by means of self-
reporting, assignments, and observation by the coach during the sessions. It is
the coach who interprets the data and who determines the appropriate
coaching strategy and feedback. The coach is consequently aware only to a
limited extent of the coachee’s behaviour outside the sessions, and feedback is
provided only during the sessions.
1.3.2 Rise of e-coaching
Traditional coaching by a human coach is quite expensive and available only to
a relatively limited extent. Digitisation means that coaching can be made
scalable. Once developed, a digital coaching application can be replicated at
virtually zero cost. As long as the user ensures that his smartphone battery
doesn’t run down, the app can provide continuous support without the
intervention of a human coach (paid by the hour). This means that e-coaches
can reduce the cost of coaching and greatly increase its availability (STW 2011).
If all one needs for support is a smartphone and a coaching app, then coaching
can become a mass-market product. Alexa von Tobel, CEO of the company
that markets the LearnVest financial planning app, summarises this as follows:
We are making access to unbiased financial advice as easy as getting a gym
membership.
The e-coach is also causing various fundamental shifts in the way coaching
takes place, or in the approach and methods applied. The digital coach cannot
match the wealth of personal interaction offered by a human coach, but it can
fulfil a number of functions in a broadly accessible manner, enabling it to
provide the user with support and advice. E-coaches offer a number of important
new options for registering and modifying behaviour. Where the human coach
has to work on the basis of observation and reports, the e-coach uses sensors
to continuously monitor behaviour in the background. Responsibility for collecting
data is therefore outsourced to the technology, and at the same time the
e-coach can acquire real-time information about the coachee’s behaviour in
the context within which it occurs. The sensors can also be used to acquire data
that self-reporting is unable to uncover, for example physiological data (Kool et al.
2013). The e-coach also has the necessary computing capacity to process large
quantities of data and to discover connections within that data that would not
be apparent to human observers. The software can search for patterns within
the data and can generate projections regarding future situations. It can also
discover relevant correlations with other user activities for which data is
available. Finally, because it is actually worn by the user, the e-coach is ideally
placed to provide support when it is most needed, for example when the user
is about to break his diet resolution by going to eat at McDonald’s.
Sincere support. The rise of the e-coach20
The fact that coaching can be provided digitally by means of software and
devices means that new parties are entering the market to provide it. As we
have already seen in the section on Quantified Self gadgets, producers of
consumer electronics play a role in this, not just established corporations such
as Philips, Samsung, Sony, or Apple but also a large number of small new
technology and software firms. Cheaper versions of sensors and tracking
devices used in the medical field are now being offered on the consumer
market. The development of the e-coach therefore fits in with the trend
whereby the boundaries between the consumer and healthcare domains are
becoming blurred (Asveld & Besters 2009). The market for coaching is
changing due to the advent of e-coaches, with providers and their business
models also changing as a result. The context in which an e-coach is offered
can also play a role here. A third party can provide a coach because it has an
interest in the outcome, for example a public authority that aims to tackle the
problem of obesity, or an employer that wants its truck drivers to adopt fuel-
efficient driving behaviour. The data collected using the e-coach can play a
decisive role in the new business models thus created. These different interests
are shaping the new coaching practices that are emerging.
1.3.3 Prospects for autonomous digital coaches
The aim in developing the e-coach is to produce an autonomous system that
can take over as many tasks as possible from the human coach, and can
provide personal support for a large number of people. This means that the
processes of collecting and analysing data, and providing coaching feedback,
are being digitised. The e-coach keeps close track of the user’s situation in the
relevant context. Data analysis makes it possible to identify patterns, for
example that the user tends to eat unhealthily when stressed or after exercising.
Based on this information, the e-coach can assist the user by offering tips and
encouraging him to choose a healthier meal at just the right time. The e-coach
assigns the user to a particular personal coaching category (a profile) with the
most effective motivational strategies for that context.
Digitisation and self-empowerment are changing both the process and the
practice of coaching. There is a shift from simply collecting data towards digital
behaviour monitoring, and the coachee therefore has less control over the
information collected and what is done with it. Smart analyses are carried out
in real time, and coaching thus becomes a continuous process rather than
something that takes place at regular intervals during coaching sessions. New
parties are now providing coaching and new target groups are making use of
it. These changes raise new questions about the new roles, protocols, and
frameworks for the responsible deployment and use of e-coaches. This book
looks at those questions in various different ways according to the domains
within which e-coaching is applied.
Rathenau Instituut 21
1.4 Outline of the book
The Rathenau Instituut’s aim with this book is to increase awareness of the rise
of digital coaching and to investigate the significance of that trend for society
in general. E-coaching is still in its infancy, and it is difficult to estimate the
precise effects that it will have. This book therefore considers a number of
specific cases in order to determine the changes that e-coaches are bringing
about in certain coaching practices and the impact this is having on those
practices. The various cases reveal what we might expect from the next
generation of digital coaches, and what requirements we would like to see
them meet. We look successively at e-coaches in the fields of health and body
management, personal finance, sustainability, social behaviour, and work
stress. We then bring together the insights gained from these various cases in
a concluding chapter. That chapter discusses the main changes that can be
identified in all these cases, and we make recommendations as to what is
necessary in the development of e-coaching so as to ensure that digital
coaching takes place responsibly.
The cases and applications discussed in this book do not constitute an
exhaustive description of the evolution of e-coaching. There are in fact many
more aspects of our lives in which the relationship with technology is becoming
more intimate (Van Est 2014) and in which technology assists us by providing
advice and feedback (Van ‘t Hof et al. 2012). E-coaches are just the start of a
trend in which coaches and behaviour-changing technologies will become
ubiquitous, with those technologies being interlinked and becoming smarter,
subtler, and more regulating. The rise of the e-coach is therefore a phenomenon
that extends beyond the five domains dealt with in this book. The examples we
give are intended to clarify the dynamics within which e-coaching is evolving,
and to outline the opportunities and risks involved. In order to give readers a
glimpse of what e-coaching may come to mean in the future, the theme of
each chapter is introduced by a brief scenario. The authors have projected
situations that could arise in a few years’ time, extrapolated from the current
state of technology. The purpose of the scenarios is to get readers thinking
and thus encourage a public discourse on the rise of the e-coach.
1.4.1 Readers guide
It is in the field of exercise, health, and lifestyle that e-coaching is most
advanced. This book therefore starts with a contribution by Sander Voerman
(Eindhoven University of Technology) on the use of e-coaches in ‘body
management, which is how Voerman summarises the active alteration of one’s
eating behaviour and deliberate participation in a fitness programme so as to
get enough exercise (Chapter 2). Voerman identifies not only the social issues
that e-coaching raises but also the problems that body management practices
faced before e-coaching came on the scene. Many existing ways of achieving a
healthy lifestyle are unreliable, for example, and there are major differences of
opinion between researchers on just what constitutes a healthy diet. What
Sincere support. The rise of the e-coach22
significance does that have for the reliability of e-coaches, and how should
users, developers, and policymakers deal with it? Voerman also considers the
influence of e-coaching apps on our body image and body awareness, and
discusses which conditions are required to ensure that e-coaches respect and
promote user autonomy.
In Chapter 3, on financial e-coaches, Harro Maas (Utrecht University) looks at
the historical evolution of the financial coach, from housekeeping books and
moral algebra’ in the eighteenth century to modern budgeting tools and apps
that help users understand and control their expenditure. Modern electronic
housekeeping books enable users to act prudently and to optimise their
financial behaviour in various different ways. Maas examines to what extent the
provider of the electronic coach looks over the shoulder of the users, which
might raise questions about the neutrality of the financial e-coach.
In Chapter 4, Niels Compen, Jaap Ham, and Andreas Spahn (Eindhoven
University of Technology) clarify the development of persuasive e-coaches
aimed at influencing energy consumption and sustainability. Increasingly,
persuasive technology can be tailored to the individual’s needs. The authors
show that the rise of these e-coaches is allowing a wide range of parties to
exert influence. More and more parties are playing a role in influencing the
users behaviour, with each of them pursuing its own aims. The authors also
discuss the conditions for responsible use of persuasive e-coaches, respecting
the users autonomy as much as possible.
The final two chapters concern e-coaching applications that are still evolving
and have so far only been used in practice to a limited extent. In Chapter 5,
Joris Janssen and Mark Neerincx (TNO) and Jelte Timmer (Rathenau Instituut)
describe the rise of ‘social e-coaches’, which aim to improve the social
relationships between people. They describe three social contexts within which
social coaches are being introduced: (1) the clinical sector, for example for
children with ADHD, with e-coaching by a health care professional within an
existing treatment programme; (2) social work, for example aimed at
preventing the escalation of domestic violence, with e-coaching taking place in
consultation with the social worker and also being supported by a professional;
and (3) applications in the personal domain, for example for assertiveness,
dating and social interaction, with e-coaching focusing on self-help, without
the supervision of a professional.
In Chapter 6, Marc van Lieshout, Noortje Wiezer, and Elsbeth de Korte (TNO)
explore the social impact of the digital stress coach. They note that it is still
very difficult to measure stress digitally. For now, only a combination of various
different methods (physiological data, questionnaires, etc.) can produce
reliable stress measurements. Using digital stress coaches in a work situation
can also alter the relationship between employer and employee. There is a risk
Rathenau Instituut 23
of unwanted interference in the employee’s private life and erosion of his/her
autonomy. At the moment, Dutch legislation on data protection and working
conditions offers a sufficient framework for using stress coaches responsibly in
the workplace.
1.5 Bibliography
Ackoff, R. (1989). From data to wisdom. In: Journal of applied systems analysis
(15) pp. 3-9.
Apple (2014) Iphone 5s Technische Specificaties. Accessed 17-07-2014. https://
www.apple.com/nl/iphone-5s/specs/
Asveld, L. & M. Besters (2009). Medische technologie: ook geschikt voor
thuisgebruik. Den Haag: Rathenau Instituut.
Clay, K. (2013). ‘CES 2013: The Year of The Quantified Self?’ In: Forbes, 01-06-
2013. Available online at http://www.forbes.com/sites/kellyclay/2013/01/06/
ces-2013-the-year-of-the-quantified-self/ Accessed 17-07-2014
Conti et al. (2011). Looking ahead in pervasive computing: Challenges and
opportunities in the era of cyber–physical convergence. In: Pervasive and
mobile computing. (8) pp. 2-21.
Empatica (2014). Human Data in Real Time. Accessed 17-07-2014. https://www.
empatica.com/info.php
Est, R. van et al. (2014). Intieme technologie. De slag om ons lichaam en
gedrag. Den Haag: Rathenau Instituut.
Est, R. van & D. Stemerding (eds.)(2012). European governance challenges in
bio-engineering – Making perfect life: Bio-engineering (in) the 21st century.
Final report. Brussels: European Parliament, STOA.
Fogg, B.J. (2002). Persuasive Technology. Using Computers to Change What
We Think and Do. Morgan Kaufmann.
Fox, S. & M. Duggan (2013). ‘Tracking for Health’. Pew Research Center’s
Internet & American Life Project. Washington.
Galton, F. (1880). ‘On a pocket registrator for anthropological purposes’. In:
Report of the British Association for the Advancement of Science ( 50), p. 625.
Available online at http://galton.org/cgi-bin/searchImages/search/essays/
pages/galton-1880-rba-pocket-registrator.htm
Sincere support. The rise of the e-coach24
Guardian Angels (2012). ‘FET Flagships Pilot. Final Report. April 2012. http://
www.ga-project.eu/files/content/sites/guardians-angels-neutre/files/pdf/
Guardian_Angels_Final_Report_July_2012.pdf
Hof, van ‘t et al. (eds.) (2012). Voorgeprogrammeerd. Hoe internet ons leven
leidt. Boom Lemma: Den Haag.
Kool, L., J. Timmer & R. van Est (2013). Keuzes voor de e-coach. Maatschappelijke
vragen bij de automatisering van de coachingspraktijk. Den Haag: Rathenau
Instituut.
Lepore, J. (2009). ‘Not So Fast. In: The New Yorker, 12-10-2009. Available
online at http://www.newyorker.com/arts/critics/atlarge/2009/
10/12/091012crat_atlarge_lepore?currentPage=1
McCarthy, M. (2013). ‘How do we know whether medical apps work?’ In: British
Medical Journal 2013; 346: f1811
McLaughlin, P. & Crespo, M. (2013). ‘The proliferation of mobile devices and
apps for health care: promises and risks’. 21 May 2013, New York: Bloomberg.
Neuringer, A. (1981). Self-experimentation: a call for change. In: Behaviorism
(9(1)) pp. 79-94
NOBCO (2011). ‘Een zichtbare plaats voor coaching als professie. Beleidsplan
2011-2014’. NOBCO
Purpura, S. et al. (2011). ‘Fit4life. The design of a persuasive technology
promoting healthy behavior and ideal weight. In: Proceedings of CHI ‘11. ACM,
pp. 423–432.
RIVM (2012). Zorgkosten van ongezond gedrag. Centrum voor
Volksgezondheid Toekomstverkenningen.
Research2Guidance (2013). ‘Mobile Health Market Report 2013-2017. The
Commercialization of mHealth Applications (Vol 3)’. Accessed on 17-07-2014
http://www.research2guidance.com/shop/index.php/downloadable/download/
sample/sample_id/262
Schultz, D.P. & S.E. Schultz (2011). A History of Modern Psychology. Wadsworth.
Simonite, T (2013) Bill Gates: Software Assistants Could Help Solve Global
Problems. In: Technology Review, 16-07-2013. Available online at http://www.
technologyreview.com/news/517171/bill-gates-software-assistants-could-help-
solve-global-problems/ Accessed 17-07-2014
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STW (2011). Partnership Program Plan “Healthy Lifestyle Solutions.
Wolf, G. (2010). ‘The Data-Driven Life’. In: New York Times Magazine, 02-05-
2010. Accessed 17-07-2014. http://www.nytimes.com/2010/05/02/
magazine/02self-measurement-t.html?pagewanted=all&_r=0
YNAB (2014). ‘You Need A Budget. Accessed 17-07-2014. https://www.
youneedabudget.com/
Sincere support. The rise of the e-coach26
Self-tracking
The Quantified Self movement has grown in recent years from a small
group of geeks into a broad social trend. Popular apps like
MyFitnessPal (50 million users
8
) or Runtastic (30million users
9
) and new
generations of smartphones with built-in tracking functions (Samsung
S Health, Apple Health & HealthKit) show that more and more people
are getting interested in self-quantifying and self-tracking. Besides the
options offered via smartphones, there is also a flourishing market for
all kinds of ‘wearables’ and other tracking peripherals.
An important component of the Quantified Self movement’s philoso-
phy is the n=1 experiment: tracking your own behaviour, considering
the data collected, changing your behaviour, collecting new data,
considering that data, etc. While I was writing this report (as a re-
searcher at the Rathenau Instituut) I decided to try out a number of
gadgets myself, including the popular Fitbit activity trackers. The
Fitbit is a wristband that tracks how much you move around during the
day and how you sleep at night. The data is automatically synchro-
nised with your smartphone, and the Fitbit app allows you to add
information about your calorie intake. You can also set personal goals
for your weight or amount of exercise. The Fitbit then tries to help you
achieve those goals.
The interesting thing about the results of this n=1-experiment wasn’t
the scores and figures or the exercise targets that I did or didn’t
achieve but how it felt to use a device that measures and also ob-
serves you. As soon as you put on the wristband, you become more
aware of how active – or in fact, how inactive – you are. That is a
well-known effect of having somebody ‘looking over your shoulder’.
Followers of the Quantified Self movement say that it is precisely this
increased self-awareness that is such an important factor in changing
your own behaviour: you are more aware of what you are doing and
are therefore less likely to mindlessly reach for the biscuit tin, because
you then immediately realise that you will need to record that in your
app (at least, that’s what you have promised yourself).
Using the Fitbit also led to a certain amount of interaction between
me and the measuring device. The wristband attempts to track your
behaviour in a particular way, but how does it view that behaviour?
Do you get more points, for example, if you take shorter steps? If you
swing your arms vigorously, does that get registered? The Fitbit is also
8 Chapman (2014).
9 Pai (2014).
Rathenau Instituut 27
not a neutral observer; it has its own perspective on your behaviour. It
understands perfectly well when you go for a bit of a walk, but it is
less certain when you sprint up the stairs or go for a jog. After a while,
though, you get to know one another and you know what the wrist-
band does and doesn’t see (and you sometimes make sneaky use of
that knowledge).
When I get up in the morning, the FitBit app shows me that I woke
up fourteen times during the night. Fourteen times?!’
The movement sensor in the Fitbit can also measure your sleep
pattern during the night. All you need do is tap the wristband a few
times to indicate that you’re going to bed and then in the morning the
app shows you a graph of how deeply you slept and how often you
woke up. In this case, the Fitbit acts as a kind of extra sense that can
tell you something that you are only conscious of to a very limited
extent. This is where I really see the potential of quantifying: it
provides insights and information that I wouldn’t otherwise have. The
question is then what should be done with that information. I get up in
the morning, for example, and the FitBit app shows me that I woke up
fourteen times during the night. Fourteen times?! I have no idea
whether that is normal, but it doesn’t sound so great. The lack of
contextual information – whether that is in fact normal, what consti-
tutes a good sleep pattern – makes it difficult to assess the value of
the information or to do something with it.
I also came up against a personal stumbling block as regards sleep
pattern measurement. Because I forgot on a few occasions to put the
wristband into sleep mode, data for those nights is missing from my
graph. Although that wouldn’t make much difference in the long run, I
did notice my enthusiasm to continue tracking flag. After a few weeks,
I decided to stop wearing the wristband. I didn’t have any precon-
ceived goal that I wanted to achieve, and the data was not in itself
sufficient to sustain my interest.
The next generation of wristbands will attempt to strengthen the
relationship with the user by adding new kinds of interaction and
support. The Basis Band provides new kinds of rewards to encourage
the user to create healthy routines. This means that the focus of the
Quantified Self movement is gradually shifting towards coaching. A
number of speakers at the Quantified Self Europe Conference
(Amsterdam 2014) led sessions about motivation and behaviour
Sincere support. The rise of the e-coach28
change, while MyFitnessPal recently purchased the Sessions company,
which offers contact with human coaches via a smartphone app
(Chapman 2014). Nevertheless, the current generation of apps and
gadgets seems to focus mainly on making us more trackable and
helping us know ourselves better. Actual digital coaching still has a
long way to go.
Figure 2 The Fitbit activity tracker
Bibliography
Chapman, L. (2014). ‘Bringing Personal Coaching to the ‘Quantified
Self,’ MyFitnessPal Acquires Sessions’. In: Wall Street Journal Blog.
Accessed 22 July 2014. http://blogs.wsj.com/venturecapi-
tal/2014/02/19/bringing-personal-coaching-to-the-quantified-self-
myfitnesspal-acquires-sessions/
Pai, A. (2014). ‘Runtastic adds hydration tracking feature, now has 30
million registered users’. Mobi Health News. Accessed 22 July 2014.
http://mobihealthnews.com/31465/runtastic-adds-hydration-tracking-
feature-now-has-30-million-registered-users/
Rathenau Instituut
Rathenau Instituut 29
Health coaches
Rathenau Instituut 31Rathenau Instituut 31
Scenario: Exercising more with
MoreStuFit
By Gaston Dorren
2016. Four students in their early twenties are having a meal in their shared
kitchen.
Jennifer: ‘... so I’m now finally getting into exercise. Or in any case Im more
physically active. I’d never have thought that an app could get me to do that.
It’s MoreStuFit.
Caleb: ‘MoreStuFit? How do you mean?
Jennifer: ‘That’s what the app’s called, MoreStuFit. It’s an abbreviation for
‘More Students Fit, I think.
Reinier: ‘Why do you want to exercise? You don’t need to, do you?’
Jennifer: ‘You mean I can still get into my bikini?
Reinier: ‘You fill up your bikini just right.
Jennifer: ‘Yes, you naughty boy. But if I don’t exercise now and I keep eating
as much as you – that’s just a random example, of course! – then in ten or
fifteen years I’ll look like my mother.’
Reinier: ‘In fifteen years? Wow, and you’re already worried about it? Incredible.
Are you also saving for your pension and stuff?
Abby (ignores Reinier and addresses Jennifer): ‘So you’re more physically
active now?’
Jennifer: ‘Yes. I make sure that for at least half an hour a day I don’t just sit around
on my lazy butt. Well…almost every day. The activity meter tracks that and
sends the info to my mobile phone. And I’m not eating as many sweets either.
Abby: ‘More active and fewer sweets too? So what kind of creepy thing is this
app? How are you managing to behave so weirdly and unnaturally?
Jennifer: ‘Well, I’ve been able to choose the weirdness for myself – that makes
it different. Listen, I’ll explain. The app first gives you a questionnaire to fill in
so that it gets to know you. General stuff like your age, height, weight and so
on – figures. But you also have to fill in the sports that you like, how active you
are already, whether you’re healthy, and various other things. After that I had to
fill in my targets. I want to make sure I exercise for half an hour, five days a
week. And I also want to move to music once a week.
Reinier: ‘I think that’s called dancing!’
Jennifer: ‘Dancing counts too, but I mean at the gym. And I don’t want to eat
sugary food more than twice a day.
Caleb: ‘But it’s easy to cheat, isn’t it?
Jennifer: ‘You can cheat almost anything. But this thing isn’t like a boss who
gives you orders, it’s more like a coach who helps you.
Sincere support. The rise of the e-coachScenario32
Abby: ‘But is it working? So you’ve set your goals, right. Then what?
Jennifer: ‘Well the app gradually gets to know me, my habits and so on. It
knows that I’ve got a lecture on Monday morning, ’cos it keeps track of where I
am. So it sends me a message, like: “Hey Jen, if you go by bike, you’ll have met
half your activity target for today.” Or it tells me: “So-and-so is at the gym.
Perhaps you can go with her next time?” And what’s fantastic is that if it sees
on the Weather Channel that it’s going to rain, it sends me a warning.
Reinier: ‘Not that the Weather Channel’s always so accurate….
Jennifer: ‘No, not always, you’re right. Nowadays I also look up at the sky. Grey
means rain, haha!’
Abby: ‘Is that all it does?’
Jennifer: ‘If it sees I’m in a lift, it sends me a message saying “Maybe take the
stairs next time?”
Caleb: ‘So it’s a real busybody! Can’t I just get the stats? Like “cycled 12.38kil-
ometres today at an average speed of 22.3 kph, “total calories burned in past
24hours: 1978” and so on?
Jennifer: ‘You’re a sports fanatic and a statistics fetishist, mate! I just want to
keep fit. And Im studying French, not applied physics.
Caleb: ‘Boring! For me, performance and competition are the only way to keep
up my interest in sport.
Jennifer: ‘I compete with myself – I get a bit better every week.
Abby: ‘But surely you don’t need those tips, because you already know them,
don’t you? I mean, do you really need an uPhone 2 and an app to remember to
climb the stairs instead of taking the lift?
Jennifer: ‘No, not to remember but to actually do it. Remember what they say:
“The spirit is willing but.... How does that go again?
Abby: ‘But I do think Caleb has a point. There’ll come a time when you’ll get
tired of the app. Or it’ll be exam week and you’ll get less exercise any way, so
you’ll get discouraged. You’ll totally forget about the app, just you mark my
words.
Jennifer: ‘Well thanks for being so encouraging. Ever heard of good habits? I
just hope that exercising will become a habit, like cleaning my teeth or eating
lots of veggies.
Caleb: ‘Listen to you preaching!’
Jennifer: ‘As for you, you need to make sure you don’t get another sports
injury again. Last year it looked like you’d end up in a wheelchair. That’s not
gonna happen to me.
Reinier: ‘Did you lot know that there are already sensors that can track what
you eat, drink, and smoke? They install one in your throat and it records
everything. When you get smashed, you can check the next morning to see
just how smashed you were. Pretty useful when you’ve been on a binge with
your mates!’
Jennifer: ‘Bloody hell, you’re on your way to becoming an alcoholic.
Reinier: ‘OK, Miss Preachy, lets be serious. When I graduate and Im a GP, it’ll
be very useful to be able to call up data from a patient’s file and say “Well
Rathenau InstituutRathenau Instituut 33
MrJansen, I think there’s a direct link between your liver problem and the fact
that you drink 6 units of alcohol a day.” Or if I want to make sure someone
sticks to his diet, I can get in touch myself.
Abby: ‘Hang on a minute – the app doesn’t send the data to your doctor, does
it?!’
Jennifer: ‘I don’t think so... it won’t, will it?
Reinier: ‘I don’t think so, but technically it’s perfectly possible. And it would be
a pity not to make use of the possibility. People wouldn’t need to visit the
doctor so often, and I could monitor them remotely.
Jennifer: ‘Listen, I’m not one of those exhibitionist bimbos in a reality soap – I
want a bit of privacy. Before I know it, the GP will be able to see how often I
sleep with Jeroen.
Reinier: ‘But why not? If your GP asks you, you tell him anyway, don’t you? As a
matter of fact, I think the app should track who you go to bed with, and it
should be able to check his data too. Then it can send you a warning if you’re
mucking around with somebody who has a nasty disease where it hurts most.’
Jennifer: ‘You’re disgusting!’
Reinier: ‘Come on, I’m just thinking out loud.
Abby: ‘Well, I think that apps like this will soon be competing with GPs like
you. The more we patients get to know ourselves, the less we’ll need you
doctors. You can find out all about your syndrome on the Internet, you can
collect the personal data yourself... the patient will be able to treat herself. You
know, Reinier, you med students are really just training to sign referral notes.
The door opens and Noura looks in.
Noura: ‘Hey Jen, it says on Facebook that you’ve done 2 hours and 23 minutes
of sport this week. Impressive!
Reinier, Caleb and Abby laugh, Noura looks puzzled, Jennifer blushes.
Reinier: ‘So much for privacy, Jen! On Facebook, no less! Just the kind of
discreet site where your information is absolutely secure!
Jennifer: ‘I only put the information on Facebook because me and some
girlfriends want to keep track of how much we’ve exercised. Its so we can egg
one another on a bit.
Caleb: ‘Performance and competition. The only way to keep up your interest in
sport. Didn’t I just say that?
Abby: ‘The guys have got a point, Jen. But Id still like to try that app. After all,
it’ll soon be bikini weather again.
With thanks to Saskia te Velde (VU University Medical Centre, Amsterdam),
who is involved in the Active2Gether project. This research project is develop-
ing an app to encourage young people to get enough exercise. The above text
does not necessarily represent her own views.
2 Tackling your lifestyle with the
body coach
10
Sander Voerman
2.1 Introduction
‘Man is what he eats’, wrote Ludwig Feuerbach (Feuerbach 1866, p. 5), and
what we eat really does have a major effect on our physical and mental
condition. Eating habits are also often typical of the culture or zeitgeist to
which one belongs. Contemporary Western society is highly remarkable in that
respect. In large parts of the world, famine and food scarcity are still among
the most pressing problems, but the West is struggling with health risks
because we eat too much. The make-up of our diet is also remarkable.
Whereas in other parts of the world this may be restricted by insufficient
availability, the choice of foods in the average Western shopping centre is
overwhelming. Even so, we still eat too many high-sugar and high-fat products
and not enough fruit and vegetables.
To some extent, this can be explained by evolution: our body and brain are
simply not adapted to an abundant supply of food rich in saturated fats and
artificially added sugars (Lieberman 2013; Heitmann et al. 2012; Bellisari 2008).
But habits also play a role, and the way people in Western society deal with
food. If we want to eat more healthily, or if we want to lose weight by eating
differently, we also need to actively change our eating habits.
Something similar applies to physical activity. Various technological achieve-
ments – for example sewerage, water purification, and medication – have greatly
increased our health and life expectancy (Colgrove 2002). On the other hand,
technological progress has structured our activities in such a way that many of
us spend most of the day sitting down (Capon 2007, McCrady & Levine 2009).
The human body is not designed to be sedentary for long periods, however
(Stamatakis, Hamer & Dunstan 2011; Van der Ploeg et al. 2012). Ideally, we
ought to move around more while working but in practice, at least for the
present, many people don’t actually do that, or find it difficult to integrate
physical activity into their work. So they end up needing to exercise simply for
the sake of exercise, finding time in their busy schedule to take part in sport or
go to the gym in order to get enough exercise. Thats fine if you like that kind
of thing, but otherwise you need to find the discipline to be consistent.
10 This chapter was written with the support of both the Rathenau Instituut and the Netherlands
Organisation for Scientifi c Research (NWO) in the context of the Responsible Innovation (MVI)
project ‘Medical Trust Beyond Clinical Walls’.
Sincere support. The rise of the e-coach34
Rathenau Instituut 35
Exercise has in fact become a goal in itself: we don’t need to walk anywhere,
and if it’s raining we drive to the gym to spend time running on a treadmill.
In this chapter, I refer to both these practices – actively altering your own
eating behaviour and deliberately engaging in fitness activities so as to get
enough exercise – by the term body management. One can speak of body
management as soon as the effect on your body plays a role in deciding on a
particular diet or a particular sport. This does not, therefore, include nutritional
choices based on ecological production methods, animal welfare, or fair pay
for farmers; it does, however, include choices with an aesthetic rather than a
health objective. In actual practice, the desire to lose weight involves both
aesthetic and health reasons. The same applies to exercise: I do not categorise
taking part in sport for purely recreational reasons as body management, but
bodybuilding and jogging so as to fit into certain clothes, for example, can be
categorised in that way.
An increasing number of Web applications, mobile apps, and portable devices
have come on the market in recent years that are intended to help people
improve their eating habits, get more exercise, or get fitter. The core question
in this chapter is how the advent of such e-coaches is changing the practice of
body management, and what normative challenges this is creating. I shall focus
not only on the new societal issues that e-coaching may raise but above all on
the significance that the e-coach can have for the problems associated with
body management before e-coaching came on the scene. Many popular
weight-loss methods, for example, are extremely unreliable, particularly in the
long-term, and there are also major differences of opinion between university
researchers on what constitutes a healthy diet. What does all this mean for the
reliability of e-coaches, and what should users, developers, and policymakers
do with this information? Current practice is also permeated by social and
aesthetic norms that are problematic from a moral perspective. Partly for this
reason, many people in the West have a difficult relationship with their own
body. How could the advent of digital quantifying and tracking affect that
relationship? Finally, the e-coach also brings with it entirely new challenges, for
example guaranteeing privacy and the risk of improper use of large quantities
of intimate and medical data.
This chapter is structured as follows. In section 2.2, I discuss the current
practice of body management and how it is changing due to the advent of
e-coaching. My analysis is partly based on a study of the literature and partly
on personal experience of a number of the systems discussed, in some cases
my own experience and in others that of a number of users whom I interviewed
in the context of my study at Eindhoven University of Technology. In section
2.3, I then deal with the normative and societal issues raised by these changes
and how one can take account of them, basing my discussion on philosophical
and ethical work that focuses on trust, healthcare, and autonomy. I summarise
Sincere support. The rise of the e-coach36
a number of conclusions as design goals for responsible e-coaching. These are
rules of thumb, however; provided we have an understanding of the issues,
they can serve as basic principles but not as full-scale specifications. Finally, in
section 2.4, I discuss the implications that these issues may have for policy-
makers. How can the authorities contribute to the responsible use of
e-coaching in the field of body management?
2.2 Changes in actual practice
In section 2.2.1 I survey the practice of body management without the inter-
vention of e-coaching. Although e-coaching is becoming popular, many of
those who engage in some form of body management make little or no use of
it. In section 2.2.2, I then explain just what e-coaching means in the field of
body management, distinguishing between the various different functions or
components of the coach. I give a number of practical examples for each
component to show what applications are already available and how they are
leading to changes in actual practice. In section 2.2.3, I discuss how the
practice of body management continues to change as e-coaching creates new
opportunities for other parties, such as health insurers and food producers.
2.2.1 The ‘analogue’ practice of body management
11
The actual practice of body management – before the advent of e-coaching –
is extremely varied. It may involve coaching, for example when people are
being instructed by a dietician or a physiotherapist, but it can also involve ‘do-
it-yourself’ body management without such instruction, for example dieting
according to methods found in books and magazines. Some activities can be
categorised as involving limited coaching. Group lessons in spinning or zumba
do involve instruction and a form of motivation – both by the instructor and by
the social aspect – but there is often less individual instruction (with a coach
setting and evaluating personal goals together with the client).
11 For lack of a better term, I use the word ‘analogue’ here in a metaphorical sense for methods of
coaching and body management that the present chapter does not categorise as ‘e-coaching’.
This is comparable to the way in which the ‘e’ in ‘e-coaching’ is also used metaphorically, with-
out referring to everything that is ‘electronic’ (after all, watching a TV programme about dieting
can also be called ‘electronic’ but it does not constitute ‘e-coaching’).
Rathenau Instituut 37
F igure 2.1 Levels of body management practice
To understand the practice of body management better, we can divide it into
four levels (Figure 2.1).
12
At the top is the level of scientific research on the
relationships between nutrition, exercise and health, in particular relating to
mediating physical characteristics such as weight. We can also include research
on the effectiveness of specific diet and exercise methods in this layer.
However, our scientific understanding of the causes and effects of eating
habits and physical activity varies enormously. There is consensus on some of
the health risks of serious obesity, such as cardiovascular diseases, on the
importance of various nutrients, and on the effect of exercise on people’s
physical fitness. But that consensus quickly breaks down when the composition
of a healthy diet comes up for discussion. At the moment, for example, there is
controversy as to whether a healthy diet should include a large quantity of
cereal products or only a small quantity (Brouns, Van Buul & Shewry 2013;
Haywood & Proietto 2012; Davis 2011; Mudde 2013; Verburgh 2012, 2013).
More generally, researchers are still uncertain whether weight changes are
almost exclusively associated with the difference between energy intake and
energy output, or whether the effect of carbohydrates and hormones on our
metabolism is also decisive (Delbridge et al. 2009; Claessens et al. 2009;
Lejeune, Kovacs & Westerterp 2005; Bravata et al. 2003; Foster et al. 2003;
Baba et al. 1999; Skov et al. 1999).
12 This does not an exhaustive survey, of course. The focus is on the path from theory to practice.
It does, however, give us a fairly ‘power-free’ picture, in which, for example, the interests and
infl uence of the health insurers and commercial companies (including the diet industry) are not
made explicit. I return briefl y to the role of health insurers in sections 2.2.3 and 2.4.
Controversy
Non-
scientific
Consumers Patients
No
recognised
training
Protected
(para)medical
Evidence-
based
Consensus
Scientific research on health and effectiveness
Development of diet and
fitness methods
Coaching and treatment
Users
Rathenau Instituut
Sincere support. The rise of the e-coach38
The biggest controversy concerns the effectiveness of specific weight-loss
methods and whether it is feasible to achieve permanent weight loss at all.
Various studies have shown that in the long term, many people’s attempts to
lose a substantial amount of weight are doomed to fail (Sumithran & Proietto
2013; Sumithran et al. 2011; Anderson et al. 2001; Leibel, Rosenbaum & Hirsch
1995). Various factors play a role in this, including genetic, hormonal, and
emotional aspects. Both diet and exercise have been called into question as
long-term weight-loss strategies (Thomas et al. 2012; Westerterp 2010;
Westerterp & Plasqui 2009). The question, of course, is what most people can
reasonably expect in the long term. No one denies that some people do in fact
succeed. What remains unclear, however, is which factors play a decisive role in
their success. Moreover, some studies show that people who have slimmed
down find it much more difficult to maintain their new weight than those who
were never overweight (Phelan et al. 2007, 2008; Hill et al. 2005). In the context
of health risks, this might be a reason to shift the focus from losing weight to
preventing weight gain.
13
Another development – which does focus specifically
on treating obesity – involves combining normal dieting methods with
cognitive behaviour therapy so as to tackle the emotional aspects of eating
behaviour (Werrij et al. 2009).
The lack of scientific consensus on the above questions expresses itself in
great diversity within the second level of the figure. This comprises the variety
of methods that have been developed to ensure a healthy lifestyle, a stable
weight, or weight loss. This level can also be taken to include advisory
organisations that provide general nutritional recommendations, for example
the version of the ‘food pyramid’ published by the Netherlands Nutrition
Centre [Voedingscentrum]. One good example of the conflicting diversity of
opinion is that the Nutrition Centre recommends eating a lot of cereal
products, in particular bread, whereas in his current diet bestseller The Food
Hourglass, the Belgian doctor Kris Verburgh asserts that we eat far too many
cereal products and that this is extremely unhealthy. Moreover, it is
questionable whether a lot of popular methods – such as those found in
magazines, diet books, and TV programmes – have any scientific basis
whatsoever. It is therefore difficult for lay people to decide, on the basis of
correct information, what method is the most reliable.
The third level comprises instructors
in the most general sense, ranging from
medical or paramedical professionals with a degree in their subject to coaches
who operate on a different basis. Organisations such as Weight Watchers also
fall into this category.
14
Finally, the fourth level consists of the users. As the
figure shows, users can receive instruction, follow a method by themselves, or
13 This would also mean that the users in question would shift from the patient end of the user
spectrum to the consumer end.
14 As a developer or sponsor of weight-loss methods, Weight Watchers can also be categorised as
belonging to the second layer.
Rathenau Instituut 39
– without adhering to any specific method – work loosely on the basis of their
own knowledge of scientific findings. It is also important that users may be
patients with a medical problem or consumers who wish to engage in body
management without a medical indication, doing so for health or other reasons.
S trictly speaking, the extent to which a method has been substantiated
scientifically or to which an instructor has had professional training is separate
from the extent to which the approach to body management is medical: if
somebody wants a more muscular body purely for aesthetic reasons, he or she
can also attempt to achieve that on the basis of scientific findings; conversely,
somebody with health problems due to obesity can also tackle matters
unscientifically. Nevertheless, in actual practice the two variables are
associated because medical institutions are subject to more stringent
requirements as regards their scientific nature and the training involved,
whereas producers in the consumer market have greater freedom to operate
on the basis of their own ideas.
The diagram can also be extended by considering not only the method or
practice of body management but also the reasons that people have for
managing their body. One important factor is society’s ideal of beauty and the
image created by the media regarding success and attractiveness. Because
this is directly associated with societal and normative questions regarding
body management, I shall discuss these aspects in section 2.3.
2.2.2 The present functions of the e-coach
In a previous study by the Rathenau Instituut, e-coaching was analysed in terms
of three connected processes, namely data collection, data analysis, and
feedback (Kool, Timmer & Van Est 2013, p. 19). The first of these processes
comprises, broadly speaking, the sensors or the data entry interface, the
second the algorithms and thus the application of the knowledge assumed in
those algorithms, and the third the reporting to the user, but in particular also
any feedback intended to encourage the user to engage in the desired
behaviour in the light of that analysis. Of course, this immediately raises the
question of what behaviour is actually desired. Because that is a crucial issue
specifically in the case of body management, I make use of an extended model
here, one which also explicitly includes the processes of evaluation and goal-
setting (Figure 2.2).
Sincere support. The rise of the e-coach40
1
Data collection
2
Data analysis
5
Feedback
User
3
Evaluation
4
Goal-setting
Rathenau Instituut
Fi gure 2.2 Five subprocesses within e-coaching
An instrument that reports only neutral data – for example the number of
calories someone consumes or burns, or the number of paces he takes – can
omit the goal-setting and evaluation phases. But as soon as the feedback also
has a motivational aspect, this presupposes that the monitored behaviour is
evaluated, and therefore that there is a goal or standard against which the
analysed data is evaluated. When this evaluation process applies an implicit or
generic goal, then the system has not been personalised to any extent, and
there is no question of fully fledged coaching. A fully fledged system enables
the user to translate his personal wishes or values into a specific goal on the
basis of which he can receive personalised feedback. Ideally, the goal reflects
both an evaluation by the system of feasibility and health and the personal
wishes, interests, and circumstances of the user.
Where data collection and analysis are concerned, the currently popular
systems are largely comparable. The market for e-coaching in the field of
exercise is dominated by ‘wearable technology, for example wristbands and
armbands, or meters that can be attached to clothing at hip height.
15
These
systems are broadly similar in the way they collect and analyse data; they
measure wrist or hip movements and analyse them in order to calculate the
number of paces taken. In addition, some systems include altitude sensors so
as to recognise when someone is going up stairs,
16
or they collect data on
night-time movement in order to analyse the wearer’s sleep rhythm.
17
Advanced armbands also measure heartbeat, temperature, and perspiration.
18
15 Examples of armbands: Nike+ FuelBand, Jawbone UP, Fitbit Flex, Fitbit Force, Basis B1, Body-
Media Fit Link. Example of hip clip tracker: Fitbit Ultra.
16 Fitbit Ultra.
17 Fitbit Flex, Jawbone UP.
18 BodyMedia Fit Link and Basis B1.
Rathenau Instituut 41
There are apps for joggers that track the distance covered by using GPS.
19
In
addition to these mobile devices and applications, the traditional set of
bathroom scales has been upgraded electronically. Modern ‘smart’ scales
utilise an electronic current to measure not only the users weight but also his
body fat percentage, and they can synchronise with apps on the mobile phone
or in the cloud, using Bluetooth or WiFi.
20
Systems that focus on nutrition also
use comparable methods, with a database listing products, from which the
user, with an app, can select what he eats or drinks throughout the day.
21
Some
systems make it possible to scan codes on packaging. Finally, there are
integrated systems with which the data collected from various different sources
or manufacturers can be synchronised in order to generate a more or less
complete picture, for example by linking calories consumed and burned with
changes in weight.
22
For all these systems, it should be noted, however, that the margins of error
can be very large and that they also differ greatly from one person to another
depending on their pattern of behaviour. Pedometers may count the wrong
kinds of movements as paces, sleep trackers may miss periods when the user is
awake but hardly moves at all, and calculations for the number of calories
consumed or burned actually provide only a rough estimate. The body fat
percentage measured by smart scales can also be significantly incorrect
because the margin of error differs from person to person and is also
influenced by how much water he or she has drunk. When registering the
amount of food consumed, there is a clear trade-off between precision and
ease of use: if someone really wants to know how much energy he is taking in,
it is not enough to just select a standard serving size from the database (a
sandwich, a glassful, a plateful etc.); one in fact needs to estimate the weight of
the serving each time or weigh it on a pair of kitchen scales. But estimates also
involve margins of error, and they also introduce the risk of a bias towards small
quantities. There are in fact users who consistently weigh everything that they
eat, but such an approach is unlikely to conquer a large part of the market.
Besides generating information for the evaluation component, recording
behaviour can in itself lead to the user becoming more aware of what he eats
or of how much exercise he takes.
23
That effe