15.1.1 A History of the Web & Fitness: Understanding Context

While wearable trackers and apps are somewhat new phenomena, there is a long history studying the relationships between food, exercise, and technology, even if “fitness” is a newer term. The extant research paints a landscape in which there are benefits as well as unintended negative consequences of the ways in which users utilize technology in accordance with their exercise and dietary needs. For example, studies have found that online health-related communities can be beneficial for users trying to lose weight and maintain weight loss [4]. Virtual forums can provide spaces in which users motivate one another and exchange information and experiences [5]. These interactive spaces allow users to find support in their journeys, share and receive information, while often having the option of anonymity. While these forums and communities may be beneficial to many users, there are also communities in which disordered behavior is promoted in the same ways as healthy behaviors. For example, there are numerous online communities devoted to eating disorders. While some users come to these spaces to aid in their recovery, some use them to perpetuate and exacerbate their conditions. There have been numerous studies exploring “pro-ana” (pro-anorexia) and “pro-mia” (pro-bulimia) communities that promote eating disorders as a lifestyle choice that values thinness, rather than a medical condition [6]. Within these spaces, users often provide one another with encouragement to lose or maintain a low weight and continue with their symptoms, which can range from and include self-starvation, severe calorie restriction, cycles of bingeing and purging, and extreme exercise. Out of these communities grew the term “thinspiration” (sometimes abbreviated as “thinspo”), which refers to content that inspires viewers to be thin and can take the form of text, photos, videos etc. One “thinspiration” slogan most commonly associated with the “pro-ana” movement is the phrase “nothing tastes as good as skinny feels.” Studies across decades depict a landscape in which users interact with one another via technology to encourage, motivate, and exchange information surrounding their nutrition and exercise habits and goals, which can range from healthy to disordered.

While there is this long history of users utilizing technology to discuss and monitor their nutrition and exercise, “fitness” is currently becoming an increasingly popular topic online, particularly on social media platforms such as Facebook, Instagram, YouTube, and Pinterest. A 2015 national study at Northwestern University in the Unites States found that teenagers look up fitness and nutrition information more than any other type of health information [3]. There is a current and evolving research stream explores the types of messages and content on the web (particularly social media and mobile apps) surrounding fitness [7–9] as well as how different groups are interacting with this content [10–12]. While this information is accessible to many and may help users live a healthier lifestyle, there are potentially negative and harmful messages often embedded within this content.

Within current social media research that focuses on fitness content, scholars discuss the similarities and differences between “pro-ana”, “pro-mia”, and thinspiration messages and new online movements. For example, when a user searches “thinspiration” on Pinterest, a link to the national eating disorder association's web page is made available. The term is not allowed as a hashtag on Instagram. Currently, however, there is a new movement labeled “fitspiration,” which is meant to inspire viewers to be “fit” rather than skinny by eating nutrient dense food and exercising regularly [9]. This search term does not come with a warning and is not banned on Instagram, yet scholars have found that content with this label is likely to contain messages that promote weight-related guilt, encourages food restriction [13] negatively affect body image [9], decrease mood and self-esteem [8]. These scholars point out that there are numerous similarities between thinspiration and fitspiration, yet the latter is portrayed as healthy, seemingly focusing on fitness rather than thinness. While the former is often associated with the slogan “nothing tastes as good as skinny feels,” the latter is often associated with “strong is the new skinny.” While the words and messages are different, both movements often include photographs of women with idealized, often unattainable body types. This growing research landscape presents a continued depiction from earlier research: a double-edged sword in which users are able to access fitness-related information via social media platforms and monitor their progress via mobile apps, but are also interacting with disordered content. The current state is complex and nuanced in that disordered content is not always clearly labeled, is often embedded with healthy information (making it difficult to discern between healthy and disordered), and is often masked as “healthy.”

This history of the ways in which users have interacted with technology to discuss and monitor their nutrition and exercise, in ways both healthy and disordered, is important to examine because it helps us understand context. While this long history exists, there are currently emerging topics across disciplines, such as “fitspiration” and other online movements that span across online communities, apps, and social media. This combination of rich history and emerging issues at the intersection of technology and fitness creates a larger narrative in which the WoT plays a pivotal role. If the WoT is to use the web and connect “things” in ways that are meaningful in a health and fitness domain, then it will do so within an already-existing context. Understanding this context is crucial if we are to consider the social implications of this new layer of application.

15.1.2 Framing This Chapter: Why Vulnerability Matters

This particular chapter is interested in the social impacts of WoT and fitness. This chapter explores both the potential positive implications, as well as potential challenges, when it comes to the WoT and public health within a particular emphasis on vulnerable populations. Vulnerability is essential to examine in this chapter for two reasons: 1) When considering unintended consequences of technology, it is imperative to consider those who are often overlooked during design and integration processes. Those who are not considered “typical” or “target users” are historically most often those who are disenfranchised or negatively impacted by technological advancement, 2) “Health,” and fitness in particular, as a context is fraught with inequality, especially for the “have-nots” of societies [14]. While this is often the case globally, this particular chapter will focus on the context of the United States. Within the United States, vulnerabilities exist in numerous ways across geographic and social dimensions.

This chapter explores both societal vulnerabilities as well as contextual vulnerabilities related to fitness (e.g. body image, disordered behavior, and eating disorders). Societal vulnerabilities refer to ways in which users are made vulnerable by larger systems in society (e.g. educational institutions, local economies, etc.). Contextual vulnerabilities refer to ways in which users are vulnerable based on the specific context of health and fitness. In other words, this perspective considers how users' negative relationships with food and exercise may affect their relationship to fitness information. The web is a space that researchers consistently paint as a double-edged sword when it comes to health and fitness, especially for vulnerable populations. How can WoT alleviate this tension and accentuate possible benefits while mitigating potential unintended consequences? This chapter explores how the WoT impacts these vulnerable populations as shown in Fig. 15.1.

15.2.1 Societal Vulnerability

When exploring the social implications of technology, whether it be a singular device, algorithm, or a technological movement, it is important to examine how these relate to, impact, and affect not just the dominant populations but minority and vulnerable populations and users as well. While there are a myriad of dimensions in which populations are made vulnerable, there is a significant number of studies that explore the relationships between socioeconomic status (SES) and health. Researchers often refer to this relationship between SES and health as “the gradient.” This term describes the well-documented phenomenon in which the more privileged or “better off” a person is, the better their health [14,17]. In their 2012 review of the extant literature exploring the gradient, Evans et al. explain that this phenomenon exists across all countries and nearly all ages, yet the cause of disparities in health are not clear. Cutler et al. [14] explore this lack of clarity, arguing that SES consists of several dimensions that all have relationships with health, including “income, education, occupation, race, and ethnicity,” (pg. 2).

The WoT has the potential to ease this gradient. Evans et al. [17] discuss income as one of the dimensions of SES, indicating that this can affect the quality of medical care and food, along with types of housing, toys, childcare, and neighborhoods (pg. 23). In terms of costs, the WoT may be able to alleviate some of the costs often associated with healthcare by connecting them to 1) professionals with lower costs, 2) digestible information. Visiting a healthcare professional requires both time and money in numerous ways. Doctors' offices are often open during working hours, which means that to keep an appointment requires adults or parents to take off work (which can be financially devastating). Visiting a doctor or specialist can also require travel, which demands time and money for transportation (gas, car payments, public transportation); for those who do not live close to a professional in general or one covered by their insurance, this may be a several day affair. Similar to time commitments, many jobs do not offer health insurance or pay enough to supply individuals and/or families with insurance. Even those who do have insurance often have to pay pricey co-pays and deductibles. In addition, many healthcare plans do not cover preventative, nutrition-based, or exercise-based healthcare. While poor diet and lack of exercise are linked to numerous diseases and conditions, gym memberships, nutritionists, personal trainers, and access to other types of dietary or fitness expertise are all often considered luxuries. Those between jobs or unable to find employment also experience tremendous hardship with these issues. The WoT may be able to ease the financial burdens of healthcare if they can connect with professionals digitally, either synchronously or asynchronously. By connecting asynchronously, this could ease the financial burden of time and travel. For those who offer synchronous, digital connection this could afford families to establish a relationship with a healthcare professional without the same monetary costs. Similarly, if a patient with a serious condition was able to monitor and log their relevant information (e.g. heart rate, blood sugar levels, emotional health, etc.), then having this information connected to their primary physician or caretaker may be able to alert them if something is wrong. This may decrease the need for expensive checkups, but increase quality of care. WoT stands to increase the connection to healthcare providers in affordable ways that give users the tools to learn and apply healthy strategies.

Another dimension of SES outlined in the literature is education. While education is an expansive topic, some scholars suggest that there may be a relationship between SES and the ways in which users evaluate the health information they interact with online. For example, in their review of extant literature surrounding youth and Information Quality, Gasser et al. [18] suggest that there may be a relationship in young users' “evaluative ability” and SES, particularly when it comes to education. While young people of lower SES are less likely to use the internet for information [18–20], they are more likely to use social networking sites than their higher-income peers.

While there is a cost barrier to accessing nutritionists, gym memberships, and personal trainers, users are turning to and utilizing technology to search for, interact around, and monitor their diet and exercise. As discussed in the introduction section, there is an increasing amount of fitness-related content on social networking sites (SNS). While this information is easily accessible for those who have the access and skills to navigate such sites, these spaces are not monitored by experts or healthcare professionals. These spaces have several benefits to users (lack of medical jargon may be perceived as more approachable, photographs and blogs may be more entertaining, perceived freedom of expression, lack of judgment, etc.). While there are significant benefits, the absence of a “traditional gatekeeper” on these sites means that disordered content is readily available, and sometimes it is difficult for users to discern between healthy and disordered messages [21]. If these SNS and devices through which users are interacting with this information were also connected to healthcare professionals, users could ask experts or share with their providers the spaces they most often search for and interact with health-related information. For instance, a person with diabetes could share where they most often find recipes with a nutritionist, who would be able to screen ingredient lists and teach their client how to do the same. A person recovering from an injury may be able to share a workout plan with a physical therapist, who can discuss or share a checklist as a means of evaluating a plan for re-integrating exercise. Users can learn through these connections and become empowered in ways that they define and can control. While income and education are only two of several dimensions of SES, examining them in relation to the WoT helps illustrate how this notion of connection and application may help ease the SES health gradient (see Table 15.1). The WoT has the potential to ease barriers that perpetuate the SES health gradient, as well as empower users to manage and make decisions about their health.

15.2.2 Contextual Vulnerability

While the WoT may be beneficial to those who are made vulnerable by the SES health gradient, it may also be beneficial for those who are contextually vulnerable (see Table 15.1). That is, those who suffer from disorders or conditions directly related to our context of fitness.

The Diagnostic and Statistical Manual of Mental Disorders (DSM), which is the standard classification of mental disorders used by mental health professionals in the United States, provides standard criteria for the classification of mental disorders, including eating disorders [22]. According to the DSM-V:

“Eating and feeding disorders are characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning” (p. 329) [22].

Eating disorders provide an interesting health example because they encompass not only aspects of mental health, but also nutrition and fitness. Not only do eating disorders deal with behaviors associated with food, but they also are related to behaviors associated with exercise. For instance, with restricting type of anorexia nervosa, individuals lose weight through dieting, fasting, and/or excessive exercise [22]. Exercise may also be used as a compensatory behavior to avoid weight gain, such as in the case of bulimia nervosa [22]. Users with eating disorders are particularly important to study given that these conditions affect roughly 30 million people. Twenty million females and 10 million males in the United States have an eating disorder, and many more have unhealthy eating behaviors [23,24]. These numbers are concerning and the prevalence of these eating disorders has been continuously increasing [23]. Approximately 1 in 200 females will develop anorexia nervosa, and 1–3 in 100 will develop bulimia nervosa [25]. Since 1930, the rate of anorexia nervosa has increased each decade for 15–19 year olds, and between 1988 and 1993, the rate of bulimia nervosa has tripled for 10–39 year olds [26]. Anorexia nervosa can lead to serious medical conditions, such as heart failure, loss of bone density, malnutrition, and depression [22]. Similarly, bulimia nervosa can lead to heart problems, other psychological disorders, and suicide [22]. There is increased risk of mortality with anorexia and bulimia nervosa either from medical complications or suicide [22].

These statistics demonstrate the importance of considering users with eating disorders as we move forward in the ways we connect health and technology. The WoT can be especially helpful to users with eating disorders. Having connected devices can improve access to healthcare resources and support for eating disorder recovery from not only other users, but also healthcare professionals. Technologies that can be used for eating disorder recovery and support include internet-based recovery programs and telemedicine, online communities, forums and blogs dedicated to recovery, social media platforms, and health apps for eating disorder recovery. These can allow easy and often cheap (or free) access to help and support [27]. Additionally, these devices can also allow different types of healthcare professionals (such as nutritionists, therapists, and primary care physicians), fitness instructors, and parents/significant others/other family members/friends to communicate with one another and the user in order to provide the best course of treatment. The internet has given us the ability to access novel treatment programs. Internet-based interventions, including both synchronous and asynchronous communication tools, have been shown to have positive effects on a number of mental health outcomes [28] and may have advantages over face-to-face therapy [29].

Internet-connected technologies that allow users to interact with one other can provide social support to their users and offer users a space to express their thoughts about eating disorders, diet, and fitness. Some studies have considered the use of mobile technology for treatment [30–35]; however, there have been mixed findings on the development and effectiveness of such technology. A quick search on the Google Play or iTunes reveals a number of eating disorder recovery apps. However, many of these apps do not take advantage of smartphone capabilities and do not adhere to evidence-based principles [30].

One exception is Recovery Record (see [36]), which is one app available on the App Store and Google Play. Developed by a team of psychologists, engineers and entrepreneurs, Recovery Record builds on cognitive behavioral therapy and self-monitoring techniques and also compliant with The Health Insurance Portability and Accountability Act of 1996 (HIPAA) [37]. In the United States, HIPAA defines privacy rules that protect the confidentiality, integrity, and security of protected health information and includes penalties for violations of the rules [37]. Recovery Record begins to take advantage of the WoT because unlike many apps, it connects to healthcare professionals, such as psychologists, medical doctors, nutritionists, licensed clinical social workers, dietitians, counselors, psychiatrists, and nurse practitioners, so that users can get access to needed healthcare and tailor their treatment plan to their specific needs. Healthcare professionals have access to a different interface than users but can deliver care directly through the app.

Some researchers have focused on online communities for eating disorder recovery and support [38–50]. Online communities have the potential to be therapeutic for those with eating disorders [41]. The main function of these communities is often to communicate encouragement, promote self-esteem, and provide information and support related to diagnosis, treatment, and interaction with healthcare professionals and other users [44]. Research has shown that online communities can provide new information about health conditions, concerns, and treatments and give users the ability to help others with the same condition or issue [51]. Online spaces can be safe spaces for discussing or finding information about stigmatized conditions, such as eating disorders [51–55]. With more connected devices, the opportunity to receive and give support grows.

While some of these online communities have expert moderators and healthcare professionals who may specialize in eating disorder recovery and support, one concern is that these professionals do not always play an active role in the forums [42]. WoT can potentially help address this concern by providing healthcare professionals technology that easily connects to and communicates with the technology users are already using. This would also help make the technologies more personal and relevant to each user's unique needs.

Much of the research on eating disorder recovery technologies has focused on technologies intended specifically to help users with eating disorders. However, users may be using technology not specific to eating disorders to aid in their recovery. That is, some users are employing technologies to help them recover that were not designed for that purpose. To date, little academic research has examined how users trying to recover from eating disorders are using these types of technology. There is a recent initiative to address this gap, exploring how women with eating disorders are utilizing non-eating disorder-specific technology, such as mobile weight loss and fitness apps, to aid in their recovery [56]. While this topic is newly emerging in an academic space, several popular media sources have discussed how some users are using social media to recover from eating disorders [57,58]. Some teens and young women have turned to Instagram in search of a support and recovery community. For example, an article on BuzzFeed.com explained how a 16-year-old with anorexia nervosa uses Instagram to document her recovery [57]. She largely posts images of food she consumes to promote others to eat a balanced diet instead of heavily restricting both amount and types of foods. Currently, she has over 1,000 followers. These types of communities can offer support to users with eating disorders while still offering a degree of anonymity. With the increasing prevalence of smartphones and mobile devices, accessing these communities is becoming easier and easier.

WoT can not only provide more access to eating disorder care, but it can also help reduce the stigma around eating disorders. Having these various devices connected to one other can help shed light on how many people are struggling with disordered eating behaviors. While it is estimated that 20 million females in the United States have an eating disorder, this number is far larger considering many more have unhealthy eating behaviors [23,24]. These technologies can allow users to connect with one other, as well as healthcare professionals without ever leaving their home. This ability to increase access to needed healthcare resources and support has the potential to reduce stigma by making these issues less “taboo” to discuss. Through technology, we can encourage more people to talk about eating disorders and thus perhaps reduce the feelings of isolation often associated with eating disorders.

Another advantage of connecting different technologies (i.e., health apps, activity and heart rate trackers, connected medications, connected food and weight scales, internet refrigerators, online forums, social media accounts) is the potential for users and healthcare professionals to get a more holistic understanding of the user's health. Each of these connected devices in the WoT provides different types of information and data about a user and her experiences.

Imagine a young woman may use a variety of technologies, each of which shows something different about her life. On her health app, she may record her calorie intake and her exercise, but because she feels guilty when she overeats, she does not always record her binge episodes or her weight. With a connected refrigerator, however, there is data on the foods she has consumed. Her medicine cabinet and medications are also connected, so there is data showing she has been using laxatives frequently, especially after she has not recorded any foods in her health app. Her wearable activity tracker and heart monitor shows that her heart rate has been lower than normal. Her connected scale tells us she has weighed herself a lot lately and has lost weight. It also has data on her bone density and muscle mass, which has been decreasing over the last year. She also uses an app to track her moods as well as Instagram to search for fitness information. When all of this data comes together, we can see a larger picture of her behaviors and her health. While some of these devices' data alone may hint at a health problem, in isolation, the data does not show a full picture of her health. For instance, you look at her Instagram account; it is full of fitness information and inspiration. It looks like she is trying to be healthy. But you look at her activity and heart rate monitor. Does she have a heart problem? Her medicine cabinet and medications indicate she may have a digestive issue. Together, though, the data tells a different story and may indicate that she is suffering from an eating disorder.

15.3.1 Societal Vulnerability

As scholars consider this application layer, it is also important to discuss how to avoid exacerbating existing divides. As previously discussed, there is a divide in access to and quality of healthcare based on socioeconomic status. The WoT may lessen the disparity between the “haves” and “have nots” in terms of health, but we must consider another type of disparity: connection. While the WoT may aid in easing health disparities, these same groups are also often under connected which may block access to these connected “things” in the first place.

For decades, technologically-centered research has explored differences between populations and subpopulations with and without access to technology, the internet in particular. Often referred to as the “digital divide,” this research has evolved from exploring those with and without access to now exploring differences in use, skills, and connectivity [61,62]. In many developed nations, the divide surrounding internet access is diminishing, while the gaps in knowledge, types and use, and continuous connectivity persist and become more pronounced [61].

In their nationally representative survey of 1,191 US low-income parents with children ages 6–13, Rideout & Katz [62] found that the question of a “divide” extends beyond internet access and instead falls on a spectrum of connectivity. While 94% of the families had some kind of internet access, many of them were “under-connected.” This spectrum of connection depends on several factors, including: sole internet access via a mobile device, interrupted service, sharing devices with others and thus having limited time with connection, slow internet access, service cut off as a result of non-payment, and reaching their data limits.

If all applications and stakeholders are connected via the web and that becomes the standard for health-related interaction, what happens to users when their connections are interrupted, unreliable, or erratic? How is their care, which may be reliant on access and connection, affected? What happens if they are on a dietary or nutrition plan that requires access to record, monitor, or complete? What happens if they are monitoring or tracking a condition? Will irregular connection prevent some users from knowing about and/or pursuing these options in the first place?

In order to empower users who are made vulnerable by the SES health gradient, as well as avoid exacerbating existing divides, we must consider how to manage connectivity issues. While in an ideal world this connectivity spectrum would be dismantled, it is crucial to consider how intermittent or unreliable connectivity could negatively impact access to or quality of care users who are already disadvantaged by the SES health gradient experience. Similarly, while individuals and families may have smartphones or computers with internet connection, they may not have other expensive health-related devices (fitness trackers, heart-rate monitors, etc.). An expectation that all users can record this type of data may negatively impact those who cannot do so and ultimately discourage them from monitoring their health. Similarly, education needs to be considered. While these connections may empower users to seek resources, where are they learning to do that? Are these devices and connections available and taught in school? Do they have practice using it? Or do only the wealthiest users learn how to operate and maximize the potential of the WoT?

15.3.2 Contextual Vulnerability

In the same way there are potential unintended consequences for those who fall on the lower end of the socioeconomic spectrum, WoT poses potential challenges for users with eating disorders. While the WoT may amplify the benefits of monitoring weight, food consumption, and exercise, with these affordances also comes a potential to also exacerbate obsessive and disordered behaviors. Obsessive and compulsive behaviors are central components of eating disorders, both traditional and emerging. For example, one eating disorder currently receiving a lot of attention is “orthorexia,” which health professionals define as an obsession with eating foods a person considers “healthy.” While considering which foods are the most nutritious is often encouraged by experts, these considerations can become disordered when they monopolize a person's thoughts and actions. Similarly, there is an emerging focus on excessive exercise and the extreme bodily harm it may cause.

Debates about the line between healthy fitness behaviors and obsession (as well as the role technology plays in disambiguating the two) are emerging across disciplines, particularly when it comes to social media. Over a decade ago, scholars discussed the ramifications of online communities that are devoted to encouraging anorexia (“pro-ana”) and bulimia (“pro-mia”) as a lifestyle choice, rather than eating disorders [6]. In the last two years, this conversation and research space has expanded to explore how harmful messages promoting obsessive, disordered behavior are subtler. Messages once clearly labeled “pro-ana” (pro-anorexia) or “pro-mia” (pro-bulimia) are now mixed amongst general content and labeled “healthy” on popular social media sites [8,63]. Often called “fitspiration” (inspiration to be “fit”), users without professional training are posting nutrition and exercise tips that range from “healthy” to dangerous.

Information Communication Technology (ICT) users, especially youth, carry around mobile phones and interact with these messages all day long, regardless of physical setting. Conversely, a recent Buzzfeed article featured interviews with young women across the world who are using these same platforms to overcome and recover from their eating disorders [57]. Research and popular culture show us how these spaces can be used to exacerbate disordered behavior, but also to aid in recovery and improved health. Exploring these trends across social media helps us understand how these dichotomies emerge. While social media is the connection of people, the connection of things (i.e., web of things) may (or may not, with interventions) reproduce the same patterns.

Unfortunately, with great potential comes a number of challenges. Although WoT can help provide a more holistic view of a user's health, there are many privacy and ethical concerns around having that much information about users. Do users want all of their data linked? How much do users want to reveal about themselves? Who gets to view and use this data? How is this data going to be used? What happens if their data is leaked? These are important questions we need to address as the WoT becomes more prevalent.

Returning to the aforementioned hypothetical user, assume a holistic view of her data across devices suggests she may have an eating disorder. Now imagine her data is reported directly to her physician. Her physician recognizes that her behaviors may be indicative of anorexia nervosa, but the user does not want treatment. What obligations does the physician have? Would the physician be required to send her information and data to a specialist? Would she be forced into treatment? Would this information have to be relayed to her insurance provider? How would that impact her life? The lives of her loved ones, especially if some of them are dependent upon her (ex: children, elderly parents, etc.)?

There are numerous dangers in having all of this information and these systems connected for users with eating disorders. As more technologies are connected, more data is available on users, reducing their anonymity. If this information is revealed, then it is more easily tied to an individual and may have real consequences (such as impacting their mental health, job, personal relationships, etc.) As mentioned before, there is stigma associated with eating disorders and other mental health conditions, and many people suffering from eating disorders experience other mental health conditions, such as depression [22]. Users may worry that others will perceive them differently based on their eating disorder, which could result in feelings of deeper isolation and separation as well as anxiety about others knowing about private aspects of their lives. There are also often real consequences to revealing this type of information about themselves. For instance, what if employers get access to this information? An article published in the Daily Mail in 2015 highlighted some of the potential negative consequences of employers having access to this information. The article details the story of one woman who said she was fired from her teaching job after staff realized she had anorexia nervosa [64]. These reports are not uncommon, in which people with eating disorders have said they have been bullied, passed up for promotions, and fired from their jobs once their conditions became common knowledge in the workplace.

One way to address these concerns is to provide users with the option to record and link this data and the ability to decide who accesses it. Imposing data sharing may be problematic, especially in areas of stigmatization. Whether or not it is positive or negative, the user should have the power to decide. Otherwise, we risk users not trusting and ultimately not using these technologies, which may be providing them some form of help and support for their eating disorders and other conditions. By not giving users agency to make their own decisions about their data, we may actually negatively affect these users.

As WoT becomes increasingly popular, the opportunity for unintended uses and unintended negative consequences increases. When considering how technology may be used in unintended ways or result in unintended consequences, scholars are encouraged to consider what is already known about these types of technologies individually.

There has been a great deal of research on how users have created blogs, websites, and online communities to enable, promote, and maintain eating disorders. Traditionally, much of this research has focused on pro-eating disorder sites and communities, such as “pro-ana” and “pro-mia”. On pro-eating disorder sites and forums, users share information on how to lose weight and essentially maintain the symptomatology of eating disorders [6]. While pro-eating disorder communities can offer emotional support and a sense of community, the messages and content focus on sustaining disordered eating not recovery [6,65]. Many researchers have found that pro-eating disorder communities have negative effects on their users. Some researchers believe that these sites are a façade of “support” but actually are anti-help-seeking and anti-recovery [66]. These communities actually exacerbate their symptoms [65,66] and perpetuate unhealthy habits, such as extreme food restriction and purging [67].

While these spaces were once the primary spheres promoting disordered behaviors and content, extant literature suggests that the line between “healthy” eating and exercise content and disordered content is continuously becoming less distinct [8,63]. This means that “health” technologies (i.e., health apps and diet and activity trackers) and even technology not specific to health and fitness (i.e., Instagram, Facebook, Twitter) may negatively impact users.

Although there is limited research on the use and misuse of health apps in relation to eating disorders, some popular media articles report that health apps and diet and activity trackers can be dangerous [68–71]. Currently, some academic research aims to examine how using mobile health apps impact women with eating disorders [56,72]. As part of this work, healthcare professionals are explaining how health apps can trigger and feed into eating disorders by focusing too much on the numbers and data around calories and weight [72]. Users may be intentionally using these types of technologies to enable their eating disorders. However, even when users have intentions of utilizing health apps in a healthy way, they may go too far and develop disordered eating behaviors [72].

Other types of technology, such as social media, may unintentionally negatively impact users' body image and disordered eating behaviors [73–77]. For example, Kim and Chock [78] conducted an online survey to examine Facebook's impact on drive for thinness. They found engaging in social behaviors such as checking friends' profiles, leaving messages, and commenting on profiles is correlated with drive for thinness in both females and males [78]. Fardouly et al. [74] studied the effects of Facebook on female university students' body image and found frequency of Facebook use was related to body image concerns. Other researchers have studied hashtags and photos on sites such as Instagram and Twitter. For instance, Tiggeman and Zaccardo [8] discuss how “fitspiration” can have unintended negative effects on college-aged girls. In her analysis of fitness blogs and media culture, Stover [63] argues that “fitspiration” is dangerous in that the images and text are more “culturally acceptable” than those that showcase emaciated subjects.

In addition to concerns about the effects of connected systems, WoT increases the amount of data available, and in the context of health, this may be problematic. From health apps and activity trackers to self-diagnosing online, users play a bigger role in their health than ever before. With more and more connected “things” in the WoT, an abundance of user data is created. While all of this data may reveal important health information, healthcare professionals' time is already limited. More physicians are explaining how WoT is impacting their work and their interactions with their patients. In many cases, physicians may only have 15 minutes with their patients, and the amount of data patients want to go over is just too much. So how can we possibly interpret all of this data? Although automation and machine learning methods may reduce the burden, we still face a huge challenge in being able to use all of this data in a meaningful way. Yet with all of this data, the context may still get lost, resulting in misunderstandings about what the data actually means.

Although WoT can provide a number of benefits to users, caution should be taken, especially when thinking about vulnerable populations, such as people with eating disorders. In addition to examining the privacy issues surrounding WoT, researchers need to continue to study unintended uses, unintended users, and unintended consequences (both positive and negative) of different types of technology in order to understand how they will impact users. Before connecting devices and integrating different forms of data, it is important to know not only potential effects on users but also how to use the data in a meaningful and ethical way. Ideally, WoT can help users, and we can empower users by giving them the choice to record, connect, and use data pertaining to their health.