Internet and smartphone application usage in eating disorders: A descriptive study in Singapore
Graphical abstract
Introduction
Eating disorders are associated with significant morbidity and mortality (Arcelus et al., 2011, Harris and Barraclough, 1998, Smink et al., 2012) and have been identified by the National Institute of Mental Health (NIMH) as a priority area for adolescent and adult mental health (Chavez and Insel, 2007).
However, in this current age, the increased ease of access to the Internet and social media platforms has given individuals with eating disorders a medium to share their emotions, experiences and illness-related information. Pro-eating disorder websites perpetuate eating disorders as these websites encourage the achievement of low body weights, and also provide “tips and tricks” on weight loss, such as vomiting and fasting (Borzekowski et al., 2010). Additionally, these websites also place an emphasis on “thinspiration”, which are motivational quotes and images of thin celebrities (Borzekowski et al., 2010, Norris et al., 2006, Rouleau and von Ranson, 2011). A more recent worrying trend is the shift in the online presence of pro-eating disorder groups, with many of them favouring social networking websites such as Facebook. Since then, hundreds of pro-eating disorder communities have appeared on these social networking websites (Teufel et al., 2013), increasing their accessibility to vulnerable individuals.
Facebook has garnered global popularity since its founding in 2004. With over one billion users, it is the most widely used online social network at the current time (Hummel and Smith, 2015, Thackeray et al., 2012). As Singapore is a multi-ethnic society known for its unique blend of Eastern and Western cultural and media influences (Future Ready Singapore, 2014), it is thus not unexpected that there are an estimated 3.22 million Facebook users, with a penetration level of 62.2% of the population (Infographics, 2015). It is likely that a large proportion of individuals with an eating disorder in Singapore are users of these social network sites, and that this would have an influence on their illness and patterns of behavior, as shown in previous studies (Becker et al., 2011, Cohen and Blaszczynski, 2015).
The available literature on the influence of Internet usage, in particular, social media and smartphone applications (“apps”), on eating disorders is scarce. Previous studies in this area had focused on pro-eating disorder websites. It was found that these websites can have negative effects on users (Bardone-Cone and Cass, 2007, Csipke and Horne, 2007, Smith et al., 2013). A pilot study on 76 adolescents undergoing treatment for eating disorders found that 35.5% had visited pro-eating disorder websites, with 96% of this group learning new weight loss or purging methods from these sites (Wilson et al., 2006). Following that, a cross-sectional, Internet-based survey of adult pro-eating disorder website users found an association between heavy pro-eating disorder website usage and more disordered eating behaviours and a poorer quality of life (Peebles et al., 2012).
There is a gap in knowledge on the usage of social media in individuals with an eating disorder. This is an important area of exploration given the popularity of social media, its ease of use and accessibility and the shift of pro-eating disorder groups to social networking websites.
Smartphone applications have also proliferated. There are now apps that calculate food caloric content, apps that monitor activity levels and apps for sharing photos of food. The use of these various applications may play a role in perpetuating illness in individuals with eating disorders.
Elucidating this information is valuable in guiding future research and development of intervention options, which would include education to raise awareness amongst medical professionals, individuals with eating disorders and the community at large. Identification of factors which trigger and/or perpetuate eating disorder symptoms, would allow for development of targeted intervention programmes that are more up to date in this age of widespread smartphone application usage and ready access to the Internet.
The aim of this study was to assess a group of patients with eating disorders in Singapore who presented for treatment. Using a self-reported questionnaire, we would look at the pattern of usage of smartphone applications, Facebook and YouTube usage and whether usage is correlated with severity of illness. We anticipated that those with higher usage of Internet and smartphone applications would have a greater severity of eating disorders and more psychosocial impairment, which would suggest an area of targeted intervention when treating patients with eating disorders.
Section snippets
Methods
The Singapore General Hospital (SGH) is the largest tertiary acute hospital in Singapore, with the SGH Eating Disorders Programme being the national treatment and referral centre for eating disorders (Singapore General Hospital, 2014). We looked at individuals diagnosed with an eating disorder who presented to the SGH Eating Disorders Programme from 13th June 2013 to 20th December 2013. The inclusion criteria for the study were as follows: (1) individuals aged 12 and above, with no upper age
Results
Although 56 participants were enrolled in the study, 1 participant was excluded due to the absence of an actual eating disorders diagnosis. Thus, 55 participants were included in the final analysis (see Fig. 1).
Demographic results showed that 94.5% of participants were female. There was also an under-representation of Malay and Indian populations (1.8% and 5.5%, respectively), and an over-representation of other ethnicities (21.8%). This is in comparison to the Singapore Department of
Discussion
The purpose of this study was to determine the Internet usage of participants with an eating disorder, in particular social media and smartphone application use. Eating disorder severity of individuals with an eating disorder was also assessed.
Despite the small size of this study, the demographic results corresponded to those obtained by Kuek et al. (2015) in their descriptive study of patients with anorexia nervosa in Singapore. The profile of participants in this study emphasizes the need for
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