An educational tool addressing health literacy, education, awareness and advocacy

How might we reduce problems of health literacy and obesity by engaging individuals, family, communities and society in impacting the eating habits of young people and their parents?

The Story

Fitwits was created by Kristin Hughes, a communication designer at Carnegie Mellon University. The program did not begin with a big vision to impact the eating habits and health of children and their care-givers — it started with one small assignment to observe a badly failing online approach intended to entice kids to record their own food intake. Fitwits grew from Hughes’s insights into the gap in communication between doctors, young patients and their families — when she asked the doctors involved if they used the word obesity during well-child check-ups, they admitted that “talking obesity was challenging.”

The Fitwits program addresses the growing issue of obesity in children, with an emphasis on health and nutrition education as well as on disease prevention.

Fitwits provides an interesting solution to the problems described above, largely through a strong emphasis on service design. The service Fitwits offers is multi-fold. First, it is basic nutrition education, made attractive to children through the use of a thoughtfully designed toolkit based on didactic play. The design process employed allowed the team to consider the experiences of its participants first and foremost in its implementation. Participants’ experiences, whether child, doctor, parent, and teacher, were considered with equal levels of attention, with the understanding that engaging these audiences would require a comprehensive communication approach addressing individual learning styles and interests.

As understanding of the issues grew, the entire team began to map the ecosystem involved in children’s access to and knowledge of food and health. Eventually, Fitwits became what Hughes calls an “ecological model” of social design, wherein a strong emphasis is placed on the confluence of the individual, family, community, and society in approaching public health interventions. For example, the 6-month Fitwits school-based game operates at the various levels where obesity related health decisions are shaped. At the individual level, the game is designed to teach children about nutrition, and increase physical activity. Children received a wristband with tokens added as the child meets challenges, thus increasing and sustaining motivation and play. At the interpersonal family level, challenges were sent home to inform and motivate families to engage in healthy eating and physical activity. At the interpersonal level, classrooms compete with other classrooms keeping teachers and children engaged and motivated. At the organizational level, the Fitwits challenged school administrators to implement policies that encourage healthy nutrition and physical activity (i.e. Nitwit Free Tuesday, a day when Chips and/or soda were not allowed on school grounds). A community scoreboard and “Wall of Champions” in schools encouraged everyone to participate in Fitwits competition.

At the time of its launch in 2007, the program was housed within the Carnegie Mellon University School of Design. Since then, numerous components have been deployed in schools, physicians’ offices, community organizations, restaurants, and homes. All components were successfully piloted in various locations throughout the US and several have been implemented multiple times in different settings—all resulting in changed eating habits. In 2014, when Fitwits left the University, it formed an LLC, but did not secure the funding required to become an independent entity. Key stakeholders are still researching Fitwits in their locations.

Hughes says it was the process of design that made the Fitwits project unique. The products and services were carefully planned with all stakeholders in mind; the system was flexible enough to adapt to diverse and evolving needs; the immersion supported going deep where traditional approaches and time constraints don’t typically allow. Participatory design sessions were carefully planned, often spending weeks alongside the community, getting to know them—carefully co-designing a solution that would work for them. The design team was able to gain empathy and build trust with people who are never asked to be part of the solution.

Process and Measurement

Amount of Design: End to end

Title: Cycle of Service

Over time, people’s’ involvement and understanding strengthened and loyalty deepened to the point where the team realized that the language in cycle of service model didn’t describe what we were doing.

Title: A model that reflects the shift in focus to relationships
Service Design Network, Birgit Mager, Kaiser Permanente: 2013, Service Design Network 2010.

This model helped the team reflect upon a very important design consideration–the expectations and emotions people collectively bring to the experience. As designers we have to take time to know, engage, connect, encourage and celebrate each person who’s part of this process and then it became clear that not only the language had to shift so did the way these phases occur and play-off one another.

Title: Expanding to engage community

When the design process was put to use with a community seeking change, the team observed new types of social networks and exchanges grow and evolve as communities identified the changes of which they were capable. These networks function as a means of communication between the individual and the community. Together, this collaborative system of relationships started to rely on and care for itself. It is these relationships and self-reliance that grow and sustain change over time.

Title: Community changing themselves, their families and community.

The description for the model above:

Know what change I want to make.

Exploratory design to identify problems with the goal of re-framing them. Participatory design to measure understanding, and observe level of enjoyment and learning styles.

Engage with me.

Co-design with a community to purposefully influence, educate or inspire action.

Connect by letting me share my own story of success.

Allow for new experiences and unplanned interactions start to unfold simultaneously. If process is successful networks of stakeholders will begin sharing resources to catalyze healthy community change.

Simplify and make it fun for me to try-on small changes that will lead to bigger success.

The designers deepening understanding of community often requires you to pivot. Sequential planning, collective action, reflection, evaluation before moving forward is key.

Guide me by providing necessary tools to develop a shared, actionable plan.

Anticipate participants’ mastery in re-designing content with the help of others, but not you—this is the birthplace of sustainability and improved outcomes.

Encourage and help me build self-efficacy.

Communities begin to reuse, replace, master and advocate from within.

Celebrate by allowing time for people’s own understanding of advocacy to internalize and evolve into new outlooks and behaviors.

The Role of Measurement

The Fitwits intervention tracked the relevance and uptake of the learning directed at children, including what information was retained and levels of accuracy; changes in eating habits; levels of physical activity (number of steps) and physical changes, including body mass index (BMI), waist size, and reduction in obesity. The team observed changes in the way parents approached food purchases in the home, explored the effect of the school-based intervention and the confidence among doctors to deliver Fitwits’s messaging. However, a formal evaluation was not conducted, because there was not sufficient time (estimated at three to five years) to follow participants and the program lacked sufficient funding to field an evaluation.

One published study of the effect of Fitwits reported the results of a non-randomized intervention study focusing on the office and games for obesity discussions with 9 to 12-year-olds. The study used pre and post assessments in two residency programs. Overall, experience using Fitwits improved residency-based physician comfort and competence in obesity prevention and treatment, portion size, BMI, and “obesity” discussions with preadolescents. A second study aimed to assess the effectiveness of Fitwits on children’s knowledge and beliefs related to obesity and nutrition. The pre–post intervention study surveyed fifth graders (aged 9–12) from five urban schools one week before intervention, immediately after intervention, and 1 week after intervention. The percentage of correct answers to questions focusing on obesity, disease, nutrition, portion sizes showed significant improvement. The study concluded that there was compelling evidence that the Fitwits tools were an effective method to promote knowledge about obesity.

Team Structure and Dynamics

An ecosystem model, in which communities, families, schools and teachers, families, children are all engaged.

Geography and Reach

Pennsylvania, Ohio, West Virginia, Maryland, Louisiana, Texas, California


Increase literacy and improve eating habits of children in socially, economically disadvantaged communities that lack good examples of healthy living.

  • Improve food and nutrition practices, attitudes, and behavior
  • Increase individual and group health literacy, awareness, attitudes and behavior
  • Ensure children, young people, and their families adopt practices to stay healthy so that they achieve their full potential in life
  • Work to develop a thriving, replicable service network
  • Help individuals identify and change unhealthy eating habits
  • Make available up-to-date tools and resources that the community can use in order to self-sustain their involvement (i.e., hand-portion guide)
  • Effect changes in school/community/state/federal policies that directly affect
    childhood obesity

Dashboards and Documentation


Studies to Address Residency Training, Physician Competence, and Patient BMI Understanding. Poster #: R-347, staffed September 29, October 1-3, 2015 AAFP Family Medicine Experience, Denver, Colorado. Laura Maus, MD, presenter, Ann McGaffey, MD presenter, Winfred Frazier, MD presenter; Elaine Boron, DO, Frank D’Amico, PhD, Hanna Xu, MD, Linda Hogan, PhD, Kristin Hughes, MFA.9-October 3, 2015 “Two Steps with Fitwits Childhood Obesity”

Hughes, Kristin, and Peter Scupelli, Collaborative Design Strategies: Helping to Change the Practice of Care. Public & Collaborative: Exploring the Intersection of Design, Social Innovation and Public Policy, DESIS Network Press, New York, August, 2013.

Wislo, VMP, McGaffey A, Scopaz KA, D’Amico FJ, Jewell IK, Bridges MW, Hogan L, Hughes K. Fitwits: Preparing Residency-based Physicians to Discuss Childhood Obesity with Preteens. Clinical Pediatrics.  First published June, 2013 doi:10.1177/0009922813492012.

McGaffey, Ann, Abatemarco D, Jewell I, Fidler s, Hughes, K, Fitwits MD™: An Office-Based Tool and Games for Conversations about Obesity with 9-12 Year old Children. Journal of the American Board of Family Medicine November-December 2011; 24(6):768-71.

McGaffey, Ann, K. Hughes, S. Fidler, F. D’Amico. “Can Elvis Pretzley and the Fitwits Improve Knowledge of Obesity, Nutrition, Exercise, and Portions in Fifth Graders? Journal of Pediatrics. May 2009. International Journal of Obesity (Lond) 2010; 34(7): 1134-42.