An app can track the calories you consume. A wearable monitors your step count, urging you to get active if your number is too low. That same watch might be able to evaluate your sleep too, even monitor your blood oxygen levels.

With a variety of methods on the market to track and measure your body, when is fitness-tracking and calorie-counting, especially for weight loss, too much? In the midst of a larger discussion on body positivity, body neutrality and diet culture, some argue too much counting, tracking and monitoring could exacerbate eating disorders.

“It's not just unhealthy for people with eating disorders, but it's not healthy for anyone to be tracking the amount of calories that they're eating,” said Dr. Cheri Levinson, an associate professor at the University of Louisville and the director of the Eating Anxiety Treatment Laboratory and Clinic.

“Unless somebody has a very specific medical problem, and it's prescribed by a physician, but for most people in the general public, tracking calories is not healthy.”

Nine percent of the U.S. population, or 28.8 million Americans alive in 2018 and 2019, will have an eating disorder at some point in their lifetime, according to a report by the Strategic Training Initiative for the Prevention of Eating Disorders at the Harvard T.H. Chan School of Public Health, the Academy for Eating Disorders and Deloitte Access Economics.

The report attributes more than 10,000 deaths per year as a direct result of an eating disorder, around one death every 52 minutes.

The connection between tech and negative mental health outcomes is front of mind this year, especially for teens. Last month, The Wall Street Journal published an in-depth piece on Instagram’s effect on teen girls and how parent company Facebook downplayed that connection in public. Concerns include body image issues and eating disorders.

“[Eating disorders] were already on the rise before the pandemic. I think, again, that is a product of our overall society's attitudes towards eating, weight, shape and health,” Levinson said. “And a lot of this messaging is starting to get targeted at younger and younger ages. So it used to be that we would really see eating disorders start between ages 13 and 15.  And now we're starting to see them start between ages eight and 11.”

Keeping count

In 2017, Levinson co-authored a small study on individuals attending an eating disorder clinic. The research found that 75% of all participants with an eating disorder used popular calorie-tracking app MyFitnessPal, and around 73% of app users reported the app had at least somewhat contributed to their eating disorder.

Other studies have found connections between calorie tracking and eating disorders as well. Another study from 2017 published in Eating Behaviors found college students who reported using calorie trackers had higher levels of dietary restraint and concern around eating, while fitness tracking was associated with eating disorder symptomatology.

A 2019 study published in the Journal of Medical Internet Research found around half of young adult participants said they had some negative experiences or behaviors using healthy eating or fitness apps. And the study found about a fifth of apps researchers reviewed allowed underweight goal setting.

“I think apps that are focused on weight goals, like entering a certain BMI typically, are also associated with increased weight stigma and shame, which can set someone up to fail and feel increasingly dissatisfied with their body,” said Jenna Tregarthen, cofounder and CEO of Bright Therapeutics. “And that is associated with increased restrictive eating, which is also associated with increased binge eating.”

Tregarthen, whose company makes apps like Recovery Record for eating disorder treatment and Nourishly for nutrition and dietary management, said calorie counts can vary a lot based on individual needs, like what kind of activities they’re engaged in. 

Though Recovery Record and Nourishly involve meal tracking, Tregarthen said those apps take a different approach, like encouraging users to consider the context of their food choices. That means keeping track of how sleep patterns and feelings affect what you’re eating, when you take time to snack or make a meal, and tracking hunger and fullness.

“I think it's very healthy for people to want to examine their relationship with food and their body and make changes. And that can be done in a way that doesn't increase their sense of shame and increase extreme dieting behaviors,” Tregarthen said.

And though body mass index is still commonly used in healthcare, the metric for measuring obesity is increasingly derided as being unhelpful for determining the health of an individual, especially as BMI was largely developed and tested for white men.

Meanwhile, long-term weight loss is difficult to achieve, and many dieters gain the weight back over time.

“One of the things that we know about the pursuit of weight loss is that when people are able to lose weight, they are not very likely to maintain that weight loss,” said Dr. Cara Bohon, a clinical associate professor at Stanford and vice president of clinical programs for Equip, a virtual and family-based eating disorder treatment program.

While Bohon can’t say definitively if fitness trackers contribute to eating disorders, she has seen patients who have used trackers to enable their eating disorders.

“A common symptom in eating disorders is a compulsive exercise or very driven exercise that is intended to affect body shape or weight, or counteract the effects of binge eating, for example. And so fitness trackers can definitely become an aspect of that compulsive exercise where now, instead of just compulsively doing the exercise, they're also compulsively checking the exercise, or setting targets and goals for themselves with regard to the exercise,” she said.

But some studies have shown using an app to track diet can increase vegetable consumption and that using digital health monitoring tools more frequently was linked to weight loss in behavioral obesity treatment.

“There's a saying in behavioral circles: What can be measured, can be moved,” said Dr. Sherry Pagoto, a professor at the University of Connecticut and director of its Center for mHealth and Social Media.

“And so we always want, as a first step, we need to measure your behavior, so we can figure out how much you're doing it. And then we can make a plan to try to change that behavior, but it's hard to change if we don't have any way of measuring it.”

Pagoto doesn’t think fitness trackers contribute or cause eating disorders any more than other fitness tools, like a treadmill. But those tools could become a part of an eating disorder for some individuals. 

“You might encounter people who have an eating disorder who are using apps and wearables. But I wouldn't assume that it’s the app or the wearable that is contributing to the eating disorder. It might be another tool that they use to either compensate for overeating or to play out their eating disorder symptoms,” she said.

Pandemic accelerates "serious national crisis"

The COVID-19 pandemic negatively impacted many Americans’ mental health, and disordered eating seemed to increase as patients were isolated and cut off from their everyday routines. 

One study from 2020 found over one-third of participants in the U.S. and the Netherlands reported worsening of dietary restriction and compensatory behaviors. Around 23% of U.S. survey respondents reported regular binge eating on stockpiled food.

Tregarthen said Bright Therapeutics saw a 35% spike in use of Recovery Record during the pandemic.

“The demand for eating disorder treatment has never been greater. There has definitely been an increase in eating disorder development, as well as those who have eating disorders are seeing a worsening of their symptoms. It's a serious national crisis right now,” she said.

Bohon noted that parents and teens put off trips to pediatricians, and many children weren’t in schools. Both are places where eating disorder symptoms could be identified. 

Meanwhile digital options for eating disorder treatment could also be a necessity during the pandemic when many types of healthcare shifted to telehealth to decrease in-person interactions. One small study published last month found that providing eating disorder treatment via telehealth resulted in positive outcomes and high-quality reviews from patients.

For Equip, the virtual model allows more people to access family-based treatment, which Bohon said has generally been available at academic institutions with eating disorder clinics. 

“When Equip started, the idea was really to think about access to care in terms of why we went virtual, thinking that if someone lives far away from an in-person clinic, then we will be able to provide virtual treatment,” she said. 

“But probably if someone lived near an in-person clinic, we would have said, ‘You know what, go for in-person. It's going to be better than the alternative.’ But since Equip has been treating people now for over a year, what we've really seen is a lot of benefits of the virtual treatment in terms of allowing people to stay involved and integrated in their daily lives.”

Tregarthen said the Recovery Record app gives people a first step to take if they’re concerned they have a problem, as well as a way to keep track of their progress during teletherapy. 

“Around 30% of our users have never told anyone they have problems with disordered eating. If you think about that, the first thing they've done is install an app, or search on the App Store and find out,” Tregarthen said.

“So, for a lot of people, they may not even be sure if they have a problem. And they're installing this app just to see what's happening.”

As more people return to in-person interactions, there are still hurdles for those who struggle with disordered eating. Headlines about watching for pandemic weight gain may be triggering, and some may be dreading in-person experiences where others might notice physical changes they couldn’t see over Zoom.

“I think one thing as we start to get back to ‘normal’ interactions is that it will be so important to not make comments about body changes, not make comments about weight, not make comments about, honestly, even hairstyle changes, things like that,” Bohon said.

“Instead being able to focus on things that bring joy, things that bring laughter, ways that you get to experience life, rather than the changes in anyone's appearance.”