Our bodies were designed to move. In today's world, many of us are moving less. According to the WHO, insufficient physical activity is a significant risk factor for heart disease, cancer and diabetes. They also state that more than 80% of the world's adolescent population is insufficiently physically active. You might expect this issue to be in societies designed around the car, such as the USA, but it's a concern around the world. In fact, according to data compiled by the Economist, rates of physical inactivity in adults from 2010 showed that countries such as Japan, Malaysia, South Africa, and Britain have higher rates of physical inactivity than the USA. A 2012 study looking at time use and physical activity in 5 countries (USA, UK, Brazil, China and India) and forecasting trends to 2030, concluded with "These forecasted declines in physical activity and increases in sedentary behaviour will have significant implications for the health outcomes, healthcare costs and overall functional well-being of societies across the globe." It makes for bleak reading and is a global call to action. As the world continues to modernize, is the price we pay for progress?
21st century lifestyles
Where is modern technology taking us? Take online shopping, which continues to grow, and whilst convenient, and cheaper for many, I do wonder what the impact will be on physical activity levels? There is rising interest in 'smart home' technologies. How about eliminating the walk from your bed to the kitchen to make coffee in the morning? That's right, control your coffee maker from the comfort of your bed using an app on your phone.
Perhaps tapping buttons on our phones is still too physically taxing for us. In the future, we may be speaking to our homes. At IFA (one of the leading shows in consumer electronics and home appliances) in Berlin last Friday, I wandered around the Samsung hall to explore their new products. One new feature seems to be the ability to adjust your 'smart home' from bed at night with just one phrase. I can see this technology could be tremendously useful for some people, but is this another modern convenience that ends up promoting an inactive lifestyle?
Samsung launched their new smartwatch, the Gear S2, and showed an application where you can control your car directly from the watch. That's right, turn on the air conditioning, stop/start the charging process, check if the doors are locked, from the comfort of your sofa. Take a look at the language used in the marketing material, "You don't need to walk back because you aren't sure you had locked the car doors." I can't help but think that a potential side effect of the Internet of Things is further reducing opportunities for us to move, because we can we do much more from the bed or the sofa. Perhaps this world of reducing activity from our lives is what we really want? A survey in 2014 by Lowe's found that 70% of Americans who own a smartphone/tablet wish they could control something in their home from their mobile device without getting out of bed.
Whilst housework may not be considered 'exercise', take a look at this robot vacuum cleaner I spotted at IFA. Control it using the app or the remote control. I'm not picking on Samsung particularly, but they did have a large presence at IFA with a focus on connecting various devices in our life, so it's interesting to see what they are pushing as the future of consumer electronics. Maybe this appeals to us at our very core? A study in Canada suggests that we are biologically wired to be lazy, although this is very early stage research.
Given the global call to action to get people moving again, how might policy makers regulate use of these new connected technologies? We hear about banning sugary drinks or placing extra taxes on foods and drinks associated with a rise in obesity, what if technologies that lead to you being less physically active are taxed at a higher rate?
Or maybe you can only buy them if you have a specific medical condition, and being able to control your home whilst lying in bed would improve your quality of life?
Now, there are two sides to every coin, and technology is also out there to get us moving again and to make being active a more enjoyable and engaging experience. We are starting to see our clothes getting smarter, equipped with sensors and connected to the internet. Do you run a lot? What if your socks could speak to you and offer real time coaching on improving your running style so you can avoid knee and back injuries? I don't run anymore due to an knee injury, but I was curious about the socks from Sensoria. The socks feel like regular socks, but contain textile sensors which relay data on your foot pressure as you run up to a plastic anklet that clips onto the top of the sock. The anklet transmits that data by Bluetooth to your phone, and you'll get real time feedback as you run from the app on the phone. I did try the socks out, and go out for a short run, and I found it quite remarkable. I had set my desired foot landing to 'ball', but I deliberately ran landing on my heel, and through my earphones, the 'virtual coach' reminded me to land on the ball of my foot or take a break. Whilst the socks are aimed at distance runners, it's interesting to note that Sensoria have a vision of 'The garment is the computer' and that they are exploring the world of healthcare. For me the socks don't just collect data about your activity, but are offering real-time feedback based upon that data, which I think is what we need more of.
A smarter wardrobe
What about 'smart shirts'? I have tried out one from Hexoskin, which captures an array of biometric data on your activity (and your sleep). It's amazing to be able to capture that depth of data about your physical performance from a shirt (42,000 data points a minute!), and I could even see live data streaming from my shirt to my Apple watch. They are quite a snug fit as the fabric needs to be close to your skin for the sensors to work. Recently announced was a 'smart shirt' for men from Ralph Lauren, which won't just capture data as you exercise, but the app will also process the data in real-time to suggest workout options to you. At IFA, Samsung launched their platform brand for wearables, 'the humanfit' (which stands for Human Fashion in Technology). They demonstrated a research project, Body Compass, their take on a 'smart shirt' for fitness tracking & coaching. An interesting video demonstrating this shirt and associated coaching app can be viewed here. It appears inevitable that one day, all of our clothes will have some form of technology within them, especially now that Google have started Project Jacquard. I wonder, could we end up living in a world, where we are willing to pay MORE for a piece of clothing that isn't going to be monitoring us?
These advanced technologies are not cheap either. The Sensoria socks are $199, the Hexoskin shirt is $399, and the Ralph Lauren shirt is $295. Today, such inventions are the preserve of the rich but we easily forget that once upon a time, mobile phones were originally the preserve of the rich, but are now ubiquitous. On the plus side, you can chuck the socks and shirts in the washing machine like regular clothes.
What about 'smart hats'? In case you don't want to wear a chest strap to track your heart rate whilst you exercise. You know it's 2015 when you can connect your Lifebeam hat to your Apple watch and see your heart rate displayed on the screen of the watch. A lot of products produced so far that can track your activity levels seem to be great for walking, running or cycling. What if you want to track other forms of activity? Kudos to Misfit who just launched the Speedo Shine, a wrist worn device that can count your swim laps and swim distance.
Maybe you want to track how many push ups you do? An app called Fitocracy launched for the Pebble Time watch, which can automatically track how many repetitions of an exercise you do. I did try it in the gym, attempting both Russian Twists and Push Ups. I found in my test that the app consistently under recorded how many repetitions I did. I understand apps aren't perfect on the day of launch, evolve quite rapidly and I do think they are going in the right direction. Focus Motion who provide the algorithm used in the Fitocracy app do have a bold vision, "We're like Siri for human movement" is mentioned in their new video, and they are "building the world's most sophisticated database in human movement analysis." If they achieve what they are aiming to do, it would impact not just fitness, but physical therapy and corporate wellness too. I recommend viewing their video.
There are a plethora of fitness apps and wearables with features aimed at getting us active and keeping us active, and there is hope that these new tools are the solutions to many of our problems. We might believe that apps and wearable technology can't really do much for us. However, there are fascinating stories out there of how these new tools have transformed lives. For example, Dan Ziehm, who lost 126 lbs over 13 months with the help of an app called MyFitnessPal, or Federico Viticci who after being diagnosed with Hodgkin Lymphoma, turned to his iPhone to help him get in shape. The post covering his usage of different digital tools makes for compelling reading, and he writes, "Tracking my life with my iPhone makes my commitment real and the effects directly measurable. Being able to open an app and be coached through workout sessions or use my phone to track steps and runs is empowering. iPhone software has enriched my lifestyle and it has allowed me to be more conscious in my daily choices."
Another example is Graham Bower, who opens his series of posts with, "I was diagnosed with cancer in 2007. Technically, it was chemotherapy that saved my life, but fitness gadgets helped me put my life back together again afterward." These stories are not just occuring in rich countries like the USA, but elsewhere too. Take Deepak Abbot, in India, who used a combination of tools to lose weight, and mentions "Goqii is not just an App, but a combination of fitness band, tracking App & a personal coach for guidance. It has a big hand to play in my current weight/inch loss."
What about my own story? I have become more active this year, and given I work in front of a computer at a desk, then my Apple watch reminding me to stand up once an hour has probably been a useful tool. An app called Deadline, has shown me the impact on my life expectancy based upon the physical activity data captured by my Apple watch and stored in my iPhone. I understand it's not a regulated medical app with clinical validation, and we don't know how exactly it works, but the point is, that linking my activity with a perceived extension to my life expectancy was a feedback loop that made me feel really good about my choice to exercise at the gym that evening. Behavior change is complex, so rather than generic messages encouraging us to be more active, why aren't we using new technologies to enable 'personalised prevention'?
Furthermore, for me, the key factor this year has been my family & friends who care enough to have kept asking me, when are you going to get into shape, Maneesh? If a machine like the Apple watch kept asking me that question, I'd probably have thrown it out of the window pretty swiftly. Humans genuinely care, but machines are programmed to care.
The need for systematic evidence
Now these stories are inspiring and a form of evidence, but what does the latest research say about these new digital tools? A recently published study evaluated 30 free iPhone fitness apps, and compared the content against guidelines from the American College of Sports Medicine. One of the study's conclusions was, "Nearly all the apps, although technically well designed, did not meet the basic recommendations of the ACSM for exercise prescription, and therefore, would not be suitable for beginning exercisers." A small clinical trial in New Zealand tested two fitness apps to see they would increase fitness and physical activity levels in 14-17 year olds. They didn't find that these two apps made a difference as standalone instruments.
Some people rely on data from activity trackers to understand how many calories they are burning. Another recently published study found that some of the popular trackers are not as accurate as they could be. It's early days yet in the world of digital fitness and we desperately need more research to understand what actually works in the real world. The challenge is that many of these devices are evolving at such a rapid pace, that by the time research gets published, the technologies they evaluated may have moved on a version or two. Just like in the world of healthcare, methods of generating evidence need to adapt to the the blistering pace of change in the 21st century.
Having the option to collect all of this data about our activity is likely to be useful, but we must be mindful of the purpose they have been designed for, despite boundaries appearing to be blurred. I'm concerned that ordinary people could start relying upon the growing abundance of data from these fitness tools to medically self diagnose.
Marketing departments might position many of these latest technologies as the next big thing in getting us active, but we have to remember that promise does not equal proof. I'm hopeful that a greater focus on science driven innovation in years to come will lead to improvements in this arena.
Gyms & technology
When faced with the need to exercise, some of us turn to gyms & health clubs. I am curious to know if these organisations are taking these new trends seriously as I believe their revenue streams are at risk by some of these ‘disruptive’ technologies. I was invited by Fitness First (the largest privately owned health club group in the world, operating in 16 countries) to check out what they are doing in the area of Digital Fitness. I attended the Charing Cross branch and took part in a new form of group class, called BEAT, which uses heart rate based training. I was asked to put on a Polar chest strap before the demonstration, and whilst the class was on, I could see live data about my heart rate (as well as others) on the wall mounted screen. When the class finished, I got an email with a report summarising my activity, showing how long I spent in each of the 5 training zones. David Perrin, CustomFit Fitness Manager, told me that the BEAT classes have been well received by members. The BEAT concept is in 2 UK clubs right now. David also showed me their CustomFit app (in 8 UK clubs right now), which is powered by a clever fitness algorithm that can give members a bespoke workout. FitnessLogic is the “brain” that powers CustomFit. It builds workouts based on a member’s training goal, experience level and preferred training style through a combination of human expertise and smart technology. What I find interesting is that it’s device agnostic, so in future, Fitness First would be able to incorporate data from any device that you are wearing. These new products are part of a journey for Fitness First, which is expected to evolve and mature over time.
David Langridge, digital lead at Fitness First, told me, “There’s no doubt technology is changing the fitness and health world, but we believe tracking activity in isolation will not keep people motivated to stay active – already a lot of people stop using wearables and apps soon after purchase. Through working with behavioural psychologists at Fitness First we have developed a good understanding of how motivation is created and habits are formed, and evidence suggests devices on their own are not enough. People also need support and an emotional connection, sharing of the accountability for the data with someone else. This can be shared with family, friends or peers or dedicated fitness professionals. All of these people provide social recognition, a vital part in the creation of motivation and forming long term habits. “This is not the time to be cautious, it’s the time to embrace the disruption to our industry which is providing us with opportunities for growth in the coming years – we already think beyond the bricks and mortar of our clubs. We should welcome digital health with open arms, shaping our products and services ready to support the digital health users of tomorrow.” When I think about gyms, and my own experiences using them, cutting edge technology doesn't come to mind, so I was pleasantly surprised to hear that Fitness First are actively thinking about Digital Health.
Who else in that industry is thinking about the future? Virgin Active is another international health club group, and their CIO, Andy Caddy sees data playing a crucial role in their future. In an article, he says, "They will have with them what I call the ‘database of you', this thing that defines you, and it will be up to [companies like Virgin Active], health insurance providers and hospitals to think about how they are going to interface and use that data. "People will arrive at the door of a business towing this information, and they'll be expecting companies to be able to work with it. If [companies] can't they will go somewhere else."
Whilst today, data about us and our health may be scattered around the globe, held in different databases by multiple providers, the status quo is overdue for disruption. Leonard Kish & Dr Eric Topol's bold commentary outlines the case for people owning their medical data, and outlines the path needed to create a very different future from today's world.
I'm writing this post during European week of Sport, which is working on building an active Europe. On their website, they've got some brilliant infographics which I found enlightening. Some of the highlights;
59% of Europeans never or seldom exercise or play sport
Where are Europeans active? 15% in a health or fitness centre
42% of Europeans don't practice sport due to lack of time
I didn't realise that so few people use health clubs & gyms, and I wonder how the industry will play a role in increasing physical activity, when so many people don't have time. The future poses huge challenges for health clubs & gyms, who may have to convince their senior leadership to foster a data driven business culture. Just as pharmaceutical companies are being forced to think ‘beyond the pill’, health clubs will have to think ‘beyond the gym’. They will have to offer a basket of digital services around their core product in order to survive and prosper. It will be interesting to see how organisations like Fitness First and Virgin Active adapt to changes in digital health over the coming years. As our world becomes more connected, I see numerous opportunities;
a) What if your health club had access to the data from the sensors monitoring your health at home? Imagine you had a group class scheduled at 6pm, but because the club knew you slept badly the night before, they sent you a message suggesting you reschedule the class, as you are at increased risk of an injury?
b) When you’re at the gym and lifting free weights, imagine there are sensors that can monitor how you are lifting the weights. A member of staff might get alerted that you’re using poor technique, and be prompted to walk over and suggest advice to reduce your risk of injury with that exercise.
c) With all that data available about members, could health clubs offer tiered analytic services to help you get insights about what that means for you and your training goals?
d) If doctors prescribed a patient a series of classes at a health club, the health club (with your consent) could insert data collected about you from each of your visits into your electronic medical record to prove to the doctor that you had adhered to the prescription which could also serve to record the intensity of your activity too.
e) Maybe you prefer to exercise when the gym is quieter. So why couldn't the gym use data from members swiping in and in out of the gym to monitor capacity levels, and send you a text message letting you know it's quiet, and it's a good time to come in?
I recently heard Misha Patel, an Experience Designer, give a great talk at Wearables London on the use (and non-use) of wearable technology in gyms. I asked her, What could gyms do with tech & data to retain members? She told me, "Gyms need to provide a more connected and tailored experience for their customers to allow people to achieve a holistic and comprehensive view of their fitness activity, both inside and out of the gym. Physical activity informatics acquired at the gym should integrate seamlessly with the individual’s fitness data history; exercise machines should be able to connect to personal devices to access individual’s fitness achievements and aims in order to suggest realistic and personalised training programmes and goals."
I'm curious, if you don't currently use a gym, would all of this new technology, data and connected devices convince you to start using one? If you've stopped using a gym, would these advances persuade you to start going again? Or maybe by embracing these new technologies, gyms will lose members who perceive all of these new technologies as distractions and disruptions?
A personal trainer in your pocket
What if you don't want to visit a health club or gym, or you can't afford it, or you travel a lot for work? Just like in healthcare where a multitude of apps offer access to a doctor from your smartphone, what if you could access a personal trainer from your smartphone?
There is Fitmo, an app that allows you to connect to a trainer and help meet your goals. Create a custom program using your activity history with the Fitstar app. 5 minute personalised mobile fitness is what the Fitnet app promises. An 'Uber for personal training', Handstand, offers a workout when you want it, with on demand personal training, where the trainer can meet you where you want!
It's fascinating to see how wearables are trying to get smarter, and do more than just collect data about you. Microsoft offered 'Guided workouts' with their wrist band, so you can turn the band on your wrist into a 'pro trainer and coach.' What about a wearable device that could track your activity but also coach you in real-time? That's what Moov plan to offer with their 2nd generation product. If this is what's here in 2015, imagine what we're likely to see in the decade ahead. Will personal trainers become unemployed by 2025? It would be unwise for people in this industry to believe their work is immune from rapidly changing technologies. Some people may prefer training with a 'virtual coach' or even a companion robot, because they know the machine would never judge them like humans sometimes can. Or will this smarter technology be the trigger to help 'inactive' people become 'active' again?
What about Virtual Reality? Widerun's use of VR is interesting. Bringing the outdoors to indoor cycling. Perhaps it's snowing in Scotland, yet you can from home, use Widerun to cycle in sunny San Francisco? How about a strenous workout at home using VR and some basic equipment? A prototype from Icaros in Germany shows us what might one day be possible. Maybe the use of VR to offer 'immersive fitness' will make group classes at gyms more attractive? Given Oculus Rift VR is set to launch in 2016, will we be adding VR headsets to our bags when visiting gyms in the future?
What if we could understand the best type of physical activity based upon our genes? Or how our genes impact our ability to recover from exercise? That's what DNAFit offers, and even allows you to get reports by linking to the data about you already captured by 23andMe.
As we technology plays a bigger role in physical activity, we may find us postponing taking part in an activity because our wearables need to be recharged first. Will a simple walk in the park be considered boring and unattractive if we're not monitoring, measuring and scanning every minute aspect of the walk? In the future, some of us may not have that choice if it becomes compulsory for others to know what we are doing 24/7. Should parents have the right to access activity data on their children? Would you want a daily email with details on the activity levels of your spouse? The ability to remotely track activity levels of family members in real-time may be reassuring for many. For example, if you have an elderly parent/grandparent living alone or in care. You might be halfway around the world, but you'll be able to find out if they've gone for their daily walk, simply by opening an app on your phone.
What lies ahead
I'm cautiously optimistic about the use of emerging technologies to get us moving again, and that collectively we can work with these new tools to enable as many of us to live healthier lifestyles. We have to ensure that these new digital tools don't inadvertently widen health inequalities. Perhaps we should focus on building technology to get specific groups of people active? Next month, Sport England is hosting a sports technology hackathon with the aim of developing apps to get a specific demographic more physically active. It makes me think, given ageing populations, are we doing enough to cater for the needs of people 65 years and up? Are we blinkered by stereotypes that old people are always weak and frail? How do we help the 'sandwich' generation to stay active? I believe time is going to be increasingly cited as a barrier to staying active. Maybe technology can evolve to help more people be active on their terms and conditions.
Whilst the focus of this post has been looking at technology and physical activity, I fully appreciate that technology alone cannot meet all the challenges that lie ahead of us. There are structural changes that are likely to be required across society with regard to how we live, work and play. On the other hand, redesigning how our cities are planned, reformulating public health policy and revising incentives in healthcare systems can take a long time, and technology is relatively easier to develop and implement. It's encouraging to read in NHS England's Five Year Forward View the recognition that more needs to be done in preventing people getting sick. This week at the National University of Singapore, during an event discussing the future of healthcare, there was also a call to shift focus onto preventative strategies, with a great analogy from Professor Wong, "It’s much better to build a fence to prevent people from falling into the river, rather than fishing everyone out to do CPR." Can simple changes reframe the entire conversation? It's remarkable to read about Dr David Sabgir, who couldn't seem to get his patients to be more physically active. In the end, he started going for walks with them, which prompted him to start a nonprofit, Walk with a Doc.
Maybe the biggest change required is changing our attitudes, beliefs and mindsets. "My doctor is not responsible for my health, I am" is emblazoned onto the t-shirt worn by personal trainer, Shawn McClendon. Not everyone thinks that way though. For example, a UK survey asked adults who was responsible for their health and wellbeing. The results are fascinating, with 14% believing they have little or no responsibility for it, 19% believing it's the duty of the government and 39% believing their GP is responsible. Is Canada moving in the right direction given the federal government is launching an app that will reward Canadians for making healthier lifestyle decisions?
I sincerely believe it's critical to ask ourselves, how do we prevent the children of today from becoming the patients of tomorrow? Our leaders will need to find the courage to plan for a better future, even if that means making changes today which make some of us uncomfortable. As Dr David Agus said back in 2013 on the danger of our sedentary society, "Yet we've engineered our society to sit. We need to change that."
[Disclosure: I have no commercial ties to any of the individuals or organisations mentioned in the post]