When Apple announced iOS 8 would arrive with a new Health app designed to aggregate data from fitness apps like Runtastic, MyFitnessPal, Up, and FitStar, it seemed like a canny business move. Fitness trackers are going mainstream (Gartner estimates the market will reach $5 billion by 2016), and by providing software and hardware—including the Apple Watch—the company could appeal to that market.
ReadWrite’s Owen Thomas was less than impressed with the initial version of Health, calling it “a sickly debut” and a “a crippled, useless piece of software.” He chided Apple for the confusing interface and ultimately useless data it provided. But Sarah Wanenchak, writing in Cyborgology, went a step further: “The Health app is literally dangerous, specifically to people dealing with/in recovery from eating disorders and related obsessive-compulsive behaviors.” Not only was it poorly designed, particularly for women, she wrote, but it was “an enabler of this behavior, a temptation to fall back into self-destructive habits.” That Health, as one of iOS 8’s preloaded apps, couldn’t be deleted only made the situation more galling.
Wanenchak’s critique implied a larger question: Do health apps and fitness trackers pose a danger to people with eating disorders?
Michele Kabas, a licensed clinical social worker who specializes in eating disorders, says she’s shocked that users don’t have a choice about installing the Health app. “That’s irresponsible—that’s not thinking about how this might impact some people, and how some people might not want it.” Millions of Apple products run iOS 8; the National Eating Disorders Association says that up to 30 million people of all ages across the U.S. have an eating disorder at some point in their life—and only one in 10 receives treatment.
For most users, it might seem easy enough to simply ignore the Health app. But for people with eating disorders and obsessive behaviors, it’s an automatic reaction to log diet information. “Most people who have healthy relationships with food and their bodies use these fitness trackers and know what the limit is,” says Dr. Rene Zweig, therapist at Union Square Cognitive Therapy. “Someone who has a more obsessive mindset or eating disordered mindset can easily get on that spiral of competing with themselves or other people.”
“Living a healthy lifestyle should be a balance between physical and psychological healthy, not a number on an app.”
She says almost all of her patients are using the apps; some use them in healthy ways, but many use them in rigid and obsessive ways to negatively compare themselves to others and reinforce unhealthy habits. Without the apps, Zweig says, those patients would be doing the same thing on paper.
Antonia Eriksson blogs about going from a hospital bed being treated for anorexia to becoming a self-described fitness freak. When she was sick, Eriksson wore a Polar pulse watch to monitor her heart rate and activity levels. She says that for most people, they are helpful tools. But anorexia sufferers don’t use them the same way.
“When you have an eating disorder of some kind … it becomes an addictive behavior where it’s all about pushing your body to [its] absolute max, which isn’t healthy at all—it’s more like a way of measuring the progress in your eating disorder,” she says via email. “Living a healthy lifestyle should be a balance between physical and psychological healthy, not a number on an app.” Eriksson takes care not to mention numbers of calories or weight on her blog, knowing quantifying data can be a dangerous trigger for some of her followers.
Health apps and fitness trackers provide just that data—and many users are able to interpret the numbers without falling into negative habits. But the same numbers can provide fuel for eating disorders, if not exacerbate them. And being able to trade and compare numbers can provoke a disordered sense of competitiveness. One pro-anorexia forum thread discusses consuming just 750 calories per day and walking a minimum of 14,000 steps, tracking it all with a Fitbit. On MyFitnessPal, people with eating disorders congratulate one another about under-eating or over-exercising—so often that other users have complained.
And while some devices and apps provide raw numbers that can be used to positive or negative effect, others—Carrot Fit, Nenshou, and the shock therapy wearable Pavlok, for example—are built around negative motivational tactics, shaming the user into meeting goals that may not be healthy. Zweig, the therapist, says the cruel, negative reinforcement of such systems may appeal to people who already have disordered eating. “It sets up a self-selecting group of people more likely to use it but would also be more vulnerable,” she says.
Even for those without eating disorders, fitness apps often take a one-size-fits-all approach to defining what’s healthy. Body types, fitness levels, and metabolisms vary, and although many apps account for how frequently you eat and exercise, they fail to take in the fuller picture of individual health.
She was adaptable enough to redefine her sense of what constitutes “healthy,” but the Fitbit was unyielding.
Sara Watson, a technology critic and a Fellow at the Berkman Center for Internet and Society at Harvard University, wrote eloquently in the Atlantic about her experience using a Fitbit tracker while recovering from hip surgery. The device insisted on 10,000 steps a day; the day after her surgery, Watson took 48. She was adaptable enough to redefine her sense of what constitutes “healthy,” but the Fitbit was unyielding.
These devices provide quantitative data but fail to account for personal nuance, she says. For instance, Fitbit can’t attribute weight gain to hormonal changes or birth control, or know when weight loss is thanks to the flu.
For Watson, Fitbit is an awareness tool; it helps her better understand her behaviors. But she wouldn’t offer it to an anorexic friend, in part because the systems are designed primarily around losing weight. “In part, you design for the least common denominator,” she tells me. “Realistically, people wear them for two months and stop using them, and then there are people like me who wear it every single day.” Daily use will produce reams of data; users are on their own in deciding how to use them.
Owen Thomas noted this problem in his review of Apple’s Health app, saying it “doesn’t provide any kind of interpretation for what I’m seeing, or suggestions on what to do differently in terms of my exercise or nutrition.” And most apps seem to address the problem of interpreting healthy habits haphazardly, if at all. MyFitnessPal, for example, provides an “eating disorders resources” page and posted a blog from a licensed clinical social worker about overcoming binge eating. And the app will sometimes warn users if they appear to not be consuming enough calories. But is that enough?
In comparison, social networks Pinterest and Tumblr have programmed their apps to direct users searching for hashtags like #proana or #thinspiration to the National Eating Disorders Association. Those searches indicate someone who may have an unhealthy body image. By contrast, fitness trackers and apps can’t necessarily tell the difference between disordered eating and simply forgetting to log meals for a few days.
In building apps and services designed for a mass audience, tech companies often ignore or misunderstand mental illnesses.
Still, Zweig says, the apps could do more. They could use the available data to provide more contextualized feedback. “Take the responsibility to say, ‘Based on your body mass index, you should consult a physician as this might be too little of a body weight,’” she says.
In building apps and services designed for a mass audience, tech companies often ignore or misunderstand mental illnesses. But with the quantified-self market becoming more mainstream, and people sharing their personal experiences with disordered eating and fitness apps, perhaps designers will begin to think about not just a great undifferentiated mass of users, but also the minority who may use these apps in harmful ways.
And it should be noted: A number of apps exist to help users overcome their eating disorders. Recovery Record, for example, is marketed as a “recovery companion,” allowing users to enter both their nutrition and fitness information, as well as the urge to binge or purge. A Recovery Record app for physicians is designed to be used in tandem with eating disorder treatments.
Fitness apps and health trackers aren’t inherently bad or good. They’re tools that can used in different ways and come with their own built-in blind spots and biases. Apple’s decision to force Health onto iOS 8 devices could endanger those who have a compulsion to track themselves already. But for the great majority of people, monitoring their health should pose no harm. It can even do some good.
“I think in general, it would be misplaced to vilify these apps,” Zweig says. In the U.S., more than two in three adults are considered to be obese or overweight, according to the National Institute of Health; more than a quarter of Americans age 6 and over are “completely sedentary,” according to survey result by the Physical Activity Council.
“I think there are a lot of great things about them, and for most people they are helpful or benign, not to negate how serious eating disorders are,” Zweig says. “Most people in the U.S. aren’t struggling with an eating disorder. They are struggling with obesity or too little exercise.”
Illustration by Tiffany Pai