‘Digitising Fat’ – Digital technologies, Embodiment and the Governance of Fat DRAFT PAPER: DO NOT CITE OR CIRCULATE WITHOUT AUTHORS PERMISSION Dr Emma Rich Senior Lecturer University of Bath
[email protected] Twitter: emmarich45 2nd Annual International Weight Stigma Conference 24th June 2014, Canterbury, UK Session 2: iFat: On Screen, Online, and Coming to an App Near You 9:50-10:10
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Introduction Weight loss is not a panacea to complex health problems I wanted to start with a very simple statement that Weight loss is not a panacea to complex health problems. Yet, the imperative for individuals to take responsibility for their weight as a simple solution to a range of complex health issues reflects a shift in recent years towards a focus in health care on ‘personalised preventive medicine’ (Swann, 2012). This shift has been accompanied by the rise of digital health, which is being promoted as critical to solving public health challenges such as diabetes and obesity. Digital technologies are being seen to provide new means through which ‘preventative medicine may be realized through participatory health initiatives’ (Swann, 2012). A range of digital systems are therefore increasingly being utilized to predict, diagnose, treat, and monitor health, not just by health professionals, but increasingly by users themselves for purposes such as monitoring their weight loss. In 2008, I began writing about some of these trends with Andy Miah in the book The Medicalisation of Cyberspace (Miah and Rich, 2008). At that time, the entire infrastructure and culture of medicine was being transformed by digital technology, the Internet and mobile devices. Indeed, some 80% of the population in Europe has carried out a health-related search on the Internet (Mager, 2012). Cyberspace was regularly used to provide medical advice and medication and along with other scholars we offered an emerging and critical account of the implications of this medicalisation of cyberspace for how people make sense of their health, bodies and identities. Since then, one of the major trends and developments has been towards the utilization of mobile devices to navigate the Internet and the rise of social media. As users increasingly switch from mobile browsers and websites to mobile apps downloaded from google play and apple app store, a rise of mobile app usage has been registered (Arthur, 2014). The ubiquitous presence of mobile devices in this era of preventive medicine has secured their place as a core driver of health engagement, now recognised as ‘mHealth’ (Lupton, 2012; WHO, 2011). According to the WHO (2011), mHealth includes “medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants (PDAs), and other wireless devices” and is a major growth area of health. Partly, this is because they provide the relatively low cost means through which individuals can quantify and self-track their behaviours, monitor patterns of behaviour and act in accordance with that data as part of the preventive system of health care. Furthermore 52% of smartphone owners, have used their phone to look up health or medical information (PEW, 2013) and currently, there are 97,000 mHealth apps available - the mHealth market was recently estimated at $26billion by the end of 2017 (research2guidance, 2013). Understanding how people experience personal health through these digital encounters in the context of wider health care programmes is important. But, for the purposes of this paper, I was to focus specifically on teasing out the implications of mHealth in a socio-cultural and political contexts where ‘weight stigma’ is pervasive and damaging (Bombak, 2014). Indeed, as Burdard
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(2009: 42) argues ‘one of the most important inquiries within the new field of fat studies is the examination of the way that health issues have been used to oppress people of size’. To this end, I offer a developing critique of the role of these technologies in producing particular body pedagogies (Evans et al, 2008). I drawing from a critical framework of understanding digital health (Rich and Miah, 2014) through which people learn about their bodies, health and identities. Subsequently, I examine how weight and the body is being defined through quantification and self-management in ways that may reify normative ideals with particular implications for the discursive constitution of fat. I conclude by suggesting some questions for future research agendas.
Weight-related mHealth In these new territories of health engagement, there is a growing market in mobile health apps that relate to physical activity and lifestyle. Such apps, allow users to track their exercise behaviour, body weight, and food consumption, are the most downloaded health apps across devices (Fox and Duggan, 2013) and now represent a critical mass in the digital health landscape. These lifestyle apps (eg tracking weight loss) are not subject to regulation (Powell et al 2014) in the same way as mHealth apps that act as medical devices (e.g. suggesting insulin dosages). As such, their role in health care systems is in some ways less scrutinized. The influence of mHealth practices for those of us interested in critical weight studies, is also a pressing matter given that we are entering the phase of 4G networks and the capacity of smart phones is rapidly developing. More recently, technologies have developed further with the advent of web 3.0 and the ‘internet of things’ which include digital devices, often linked to each other. There is a growing market of wearable technologies like fitbit and polar wristband, and it includes those with sensors such as bands, patches and GPS technolgoies which enable users to record and log data on their bodies such as body mass index, calories burnt, heart rate, physical activity patterns. The tracking of this data reflect a movement called ‘the quantified self’ which involves ‘the practice of gathering data about oneself on a regular basis and then recording and analyzing the data to produce statistics and other data (such as images) relating to one’s bodily functions and everyday habits’ (Lupton, 2013: 25).
mHealth in a conext of neoliberal health care Whilst many of the technologies described in this paper are ‘new’ they exist within health assemblages which connect with our interest in the configuration of weight; ‘to explore the ‘truth effects’ of obesity discourse: how this discourse is translated into interventions that target how people relate to, and act upon, themselves and others’ (Clarke, 2014: 1). Their integration into health care systems evokes questions raised elsewhere in the work of Mol (2008) about what health ‘care’ is and how it should be practiced. In this sense, whilst these might be novel technologies, they are formed through complex inter-relationships that have a particular sociocultural history. In part, the context for their emergence is connected to the biomedical focus on obesity as a health crisis, often reduced to lifestyle issues such as diet and physical activity.
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Central to this neoliberal health discourse is the idea that fatness is the result of an individual’s lifestyle and issue of choice and responsibility of individuals (Halse, 2009). This neoliberal perspective dominants current public and scholarly debate about weight, fatness and health (Rich, Monaghan and Aphramor, 2008; Solovay and Rothblum, 2009), The rising appeal of digital health solutions to influence individual behaviours is therefore rationalised ‘against the backdrop of contemporary public health challenges that include increasing costs, worsening outcomes, ‘diabesity’ epidemics, and anticipated physician shortages.’ (Swan, 2012). Health agencies are embracing the capacity of digital technology to create a more cost-effective way of delivering health care. Policy investments in digital healthcare are therefore justified on the basis of greater efficiency of overburdened health care systems. In terms of how health-care is practiced, it therefore reflects a logic of choice (Mol, 2008) the concept of patient as customer or citizen and instrumental aspirations of digital interventions that transfer responsibility away from the state and onto the individual; an approach which aligns with the neoliberal health perspectives described above. Governments and health organizations are recognizing the opportunities - and additional responsibilities afforded by these technologies, as a means of delivering a more effective health care system (European Commission, 2014) and as a way of fostering a ‘digitally engaged patient’ (Lupton 2013). The focus on digital health is a priority focus in a range of UK and European policies (UK Government Digital Strategy, NHS digital Strategy, European Commission, 2014) and consultations (European Commission public consultation, 2014) and the digital agenda is seen as a flagship initiative for public health as part of the Europe 2020 growth strategy. iHealth - mHealth, body pedagogies and the ‘individual’ Against his socio-political backdrop, what does it mean to care for one’s body and be the healthy citizen? This, in turn means examining the health imperatives that govern individuals to use these self-tracking technologies in a process of ‘participatory surveillance’ (Abrechtslund, 2008). In other words, what are the power-knowledge relations (Focuault, 1977) that come to regulate our understanding of our bodies and of our subjectivities within these digital environments? What are these apps doing in relation to ‘weight stigma’ in ethical, moral, political and ideological terms in contexts where popular discourses constitute size as one of the dominant criteria through which bodies are read and judged (Van Amsterdam, 2013; Evans et al, 2008). There are a broad range of conceptual apparatus that might help us address these questions. In a paper recently published with Andy Miah (Rich and Miah 2014) we make a case for conceptualising what takes place online through the lens of public pedagogy. Whilst there is not space here today to talk about the specifics of public pedagogy, it advances a vision of education that recognises how learning—albeit about one‘s body and health in this case—can occur in sites and contexts beyond formal schooling: ‘In advancing a public pedagogy approach to theorising digital health, it is necessary to recognise how technology is inextricable from the manner in which people learn about
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health. Furthermore, these apparatus dictate conditions of self-tracking, collection of data, and monitoring, which have a bearing on what and how people learn about their bodies and health’ (Rich and Miah, 2014: 301) This, we argue, makes it possible to ask perhaps deeper, questions about individuals‘ engagement with digital health technologies that might have a bearing on understanding the stigmatisation of weight. These technologies are situated in an assemblage within which there is a particular logic of care (Mol, 2008) which is focused on increased responsibility. There is not time for a detailed review of the vast number of apps currently available in the marketplace. I focus my critical review here on some of the most popular apps as reflected in a search through Apple’s app store top 30 rated ‘health and fitness’ apps and via a search for apps using the term ‘weight loss’.
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These feature a variety of functions, such as self-tracking, goals, diet and physical activity advice, social media connections and reward systems. Furthermore, many prescribe exercise in the broader context of the battle against obesity, encouraging users to measure their physical activity and become active subjects.
For example, the Obesity Terminator app, includes ‘personal hypnosis session, BMI calculator, BMR calculator, exercise calorie calculator and affirmation video will help you get that nice, sexy figure that you’ve always dreamed of’.
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These apps allow people to monitor and measure weight loss, diet, physical activity and other body data, and produce quantifiable digital data; a process known as self-tracking or ‘quantifying the self’. Whilst many of these apps are worthy of individual empirical exploration,
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my intention here is to offer three key observations about the characteristics of these apps and the kinds of practices that people undertake through these technologies. 1. Body Data: Simple solutions to complex health issues Firstly, Ruckenstein (2014: 68) observes that ‘smart phones and tracking device have created a field of personal analytics and self-monitoring practices’. Users learn how to look after themselves via the disciplining regularity of the device‘s presence and regular notifications to maintain their good behaviour; a trend that has been depicted in the popular press as ‘nag technology’. This involves the trend towards ‘self-tracking involves collecting, charting and sharing data’ (Lupton, 2012) for example calorie intake. In this vein, these apps have significant implications for subjectivity and embodiment in ways that might further enhance the conditions within which stimgatisation of fat flourishes. Whilst engagement with apps might be a voluntary practice, it also involves a form of ‘participatory surveillance’ (Abrechtslund, 2008), involving self-surveillance and modification. Using self-tracking devices for monitoring and self management of one’s weight constitutes what Foucault (1988) terms technologies of the self. In this way, the imperative to use these technologies to track and monitor the users bodies, weight, physical activity and other behaviours and conceptualised as self disciplinary mechanism, enabling the governance of weight and fat. The app Calorie Counter and Diet Tracker by MyFitnessPal utilises the functions typically available in many of these apps. Users can upload information about their dietary habits, track their weight and view charts of their progress ‘for motivation’ (App descriptor).
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The use of such devices align with the etiology of obesity is often reported through an individualistic framework (Puhl and Heuer, 2010) As noted by a growing body of work in critical weight studies, obesity studies/research is portrayed through a discourse which does not convey the uncertainty, complexities and ambiguities of the relationship between weight and health (Gard and Wright, Evans). Furthermore, Bombak (2014: 3) argues, ‘as this work is generated from within a biomedical institution, it is presumed to be unquestionably objective… disqualifies concerns of how this research may affect or be affected by anti-fat bias’. The implication of ‘lifestyle’ in the etiology of obesity therefore invokes a moral framework through which to read fat which contributes to the stigmatisation of fat; a framework through which personal responsibility is dominant (Lawrence, ). Weight loss apps and trackers reflect these prevailing discourses of neoliberalism and healthism where practices of self-care and individual
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responsibility are encouraged. For example, the app Weight Watchers Mobile UK enables users to ‘track propoints values for food and activity, track your weight and see your progress in an interactive chart, track your daily recommended healthy checks, get inspired by success stories, find tips and helpful articles, make smarter food choices with interactive cheat sheets’ (see Clarke, 2014 for a fore detailed examination of this particular app). Through these public pedagogies, the knowledge that is derived through these apps is predominantly through quantification and the reduction of complex health issues to body data. These processes contribute to a ‘new body ontology [...] that redefines bodies in terms of, or even as, information’ (Van der Ploeg, 2003: 64). These technologies ‘capture’ complex flows of body information and ‘reassemble’ (Haggerty and Ericson, 2000) them into individualized and simple readings of health. Furthermore, as Lupton (2014: 7) argues ‘the quantification of self through these technologies is portrayed as contributing to their objective neutrality, supposedly removed from the subject actions of humans’ (see also Ruckenstein, 2014). Digital solutions such as these, contribute to the discourse that weight is a matter of personal responsibility that can be controlled by individual; a simple matter of overeating and exercise. The implications of this relationality of power-knowledge have long been established in the literature where there are strong connections between assumed levels of personal responsibility of health conditions and high levels of stimatization (Weiner et al, 1988; Puhl and Heurer, 2010). As Carels et al (2009) suggest ‘While the etiology of weight stigma is complex, research suggests that it is often greater among individuals who embrace certain etiological views of obesity or ideological views of the world’. The logic of self-tracking and self-care is commensurable with the etiological perspectives of individual control of health: ‘This focus on control and responsibility in relation to body size categorizations magnifies the stigmatization and discrimination of fat subjects compared to other marked positions’ (Van Amsterdam, 2014: 164). These mHealth lifestyle apps are not neutral technologies (Feenberg, 2002) but are constituted partly through broader discourses of culpability, responsibility and even military metaphors as helping individual to take responsibility and tackle ‘the war on obesity’ (Monaghan, 2008). So the user of the app is positioned both as a subject that is ‘at risk’ and to be managed but also as a subject that is to be held accountable as ‘the individual’ within a neoliberal reading of enterprising selfhood. Exercise, weight loss are therefore mobilised as moral practices of the disciplined self through these technologies. 2. Public facing health experiences Secondly, the data that one collects on ones body, activities or behaviours can be shared with others through social media. To this end, mHealth does not simply respond to a vision of health, but can also be considered characteristic of a ―’confessional society’ (Bauman, 2007) With their accompanying processes of surveillance and evaluation, these technologies imply certain expectations of control, which are to be learned but also publicly displayed for evaluation by others. In this way, in the era of mobile health, these encounters with our bodies, weight and health have become more public facing, social experiences. To this end, a further characteristic of these apps, and their pedagogical functions, is the connectivity through social media which produce forms of ‘Lateral surveillance, or peer–to–peer monitoring, understood as the use of surveillance tools by individuals, rather than by agents of institutions public or private, to keep
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track of one another’ (Andrejevic, 2005). For example, the app Calorie counter and diet tracker by MyFitnessPal has a social feature to ‘connect with friends and easily track and motivate each other’ (App Descriptor).
This can intensify the processes of surveillance and regulation of people’s everyday lives. Devices such as wristbands and apps build a profile of the users lifestyle including calories consumed, activities undertaken, steps walked during the day. The app Carrot Fit utilises this surveillant approach:
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Carrot Fit - 7 minutes in hell workout and weight tracker ‘CARROT is a sadistic AI construct with one goal: to transform your flabby carcass into Grade A specimen of the human race. She will do whatever it takes - including threatening, inspiring, ridiculing, and bribing you - to make this happen … you will get fit - or else. This diabolical interval workout can be completed anywhere, at any time, so you have no excuse not to be in fighting shape when the Robopocalypse begins. Lose weight in style Are you ready to have so much fun tracking your weight that you’ll actually look forward to hopping on your scale? All you have to do is punch in your current weight, then sit back and let CARROT pass judgement upon you. Claim your reward If you work out and slough off those extra pounds, CARROT will reward you with fabulous prized like app upgrades, cat facts, and permission to watch your friend eat a bag of potato chips. Track your awesomeness- Because math is hard CARROT will do all the numbercrunching for you. See how your weight loss is coming along on a pretty graph, view your workouts on a calendar, and check your BMI.
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Hello, chubby Human! Fitness overlord CARROT here with phase II of my plan to science your lazy carcass into a form more consistent with what celebrity magazines say you should look like. The power of such peer-to-peer monitoring is captured in one of the ‘review’ comments: ‘The Shaming really works! I made a deal with a friend to post to facebook each week I weighed in. Being told off by CARROT makes the guilt unbearable. Love it!!!’ Further research is needed as to the impact of being subject to such processes of evaluation and peer surveillance on users bodies, lifestyles and identities. 3. Imagining the new you: Visualisation and ‘Gamification’ (Whiston, 2012) Thirdly, and relatedly, users learn not only about ‘healthy’ activities, but of what and whose bodies may be valued, given status and meet the expectations of particular body pedagogies (Evans et al, 2008). As Gaztambide-Fernandez and Arraiz-Matute (2014: p. 57) argue, conceptualising technologies as pedagogical means taking ―account of the desires, intentions and conditions that produce them as such. The imagery of these apps often draw on ideal bodies, but accompanied by discourses of responsibility and choice. For example the Jillian Michaels Slim-Down: Weight Loss, Diet and Exercise Solution ‘no more excuses its time to thrive’ and ‘TVS toughtest trainer, Jillian Michaels, created this killer exercise app to help EVERYONE transform their lives’.
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Other weight loss apps now focus on the individual exercising control of their bodies through hypnosis. The app Weight loss hypnosis by mindfi - Lose Fat with Better Health and Meditation. ‘We invite you into our specially designed hypnosis program, which tackles the first and foremost important road bloc… YOUR MIND’. This includes audios such as ‘Master your knife, Master your life - Tricks to use to control how we eat’ ‘Move it and lose it - Increase your desire and motivation to become more active’.
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Another function in some of these apps is the process of visualising a future body. For example, weight loss for women (Visual Motivation) - Pacific spirit Media - See your weight loss in a visual way, see a model of your today’s weight, your heaviest weight and your goal weight. Review comments: ‘This basic, blinking figure mirrors your journey to the perfect shape. It is preferable to an emotionless graph’ ‘It really helps me keep on track. If I want a cookie or something, I just pull this up and look at it and go for something healthier. ‘Let this visual tool help to empower and motivate your weight loss journey. Download and start losing pounds now’.
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These visualisation mechanisms govern users by subjecting their body to visual forms of evaluation and eventual modification to imagine not only a future body, but a future self. This technology thus encourages users to not only imagine a different body, but to conceive of themselves as specific subjects where a ‘self-fulfilment’ will be achieved. This involves a process of governance through ‘the regulated choices of individual citizens, now constructed as subjects of choices and aspirations to self-actualization and self-fulfilment’ (Rose, 1996: 41) These apps supply individuals with technologies to participate in this process of selfactualization, encouraged through the visual imaginings of what their bodies might look like if they adhere to these discourses. MHealth is positioned as a means through which to realise this future self and achieve self-fulfilment (Rose, 1996). These apps form part of the landscape of what Monaghan et al (2010: 38) describe through the concept of ‘obesity epidemic entrepreneurs (and entrepreneurship)’ that ‘signifies a concern with the varied actors, interests, practices and manner of constructing medicalized fatness as a social issue or crisis’. Positioned as ‘consumers’, users are encouraged to navigate their way through the app market place, as a passport to self-fulfillment and the ‘good life’ (ibid; 41). Functions such as visualisation of alternative bodies reflect a process that Whitson (2012) describes as ‘gamification’ involving the combination of the quantification of self with creative
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and game play scenarios. A particularly alarming example of this is a mobile app that required users to carry out plastic surgical interventions to an avatar. As one tech magazine writes: ―”The game...rated for children 9 and older...walked players through the graphic steps of liposuction that must be performed on an ―unfortunate girl to make her ―slim and beautiful” (Bell, 2014)
I Such an example raises a number of ethical questions about how, increasingly, younger people are learning about health and weight and the value and status given to particular normalised bodies over others. The removal of adiposity through these practices of self reflect a process through which fat is ‘classified as expendable waste; a waste that must be purified or hidden if society is to be maintained as a realm of order and productivity’ (Shilling, p. 3) In this, and other apps, fatness is depicted ‘as matter out of place’ (Dougas, 1966) to be modified via weight loss programmes, physical activity or through more extreme forms of modification such as liposuction. Via mHealth define, fatness is defined as ‘a correctable health problem’ (Monaghan, Hollands and Pritchard, 2010). Fat is thus governed through the management of bodies in relation to data norms, as either acceptable or abject. Users thus gather ‘sociotechnical feedback’ (Monahan and Wall, 2007) not only about health, but information through which they learn to delineate particular bodies (their overweight bodies) as particular subjects (lacking control, in need of repair). From a pedagogical perspective on digital health technologies these mobile apps therefore constitute particular kinds of desires and embodiment that may also work to stigmatise fat. Some of the imagery in these digital spaces plays a powerful role in this process of governance, invoking pedagogies of disgust (Lupton, 2014; Leahy 2009) to encourage individuals to take action in accordance with self-tracking practices. Stigmatising is therefore underpinned by this assumption of ‘choice’, that we are all in a position to choose to modify our bodies freely. Complex health issues are thus reduced to data that can be compared with others, monitored and visualised, reinforcing for example the quantified norms of ideal weight. These discourses produce limited ways of understanding the body, linked to ‘performative health’ (Rich and Evans, 2009) through which comparative and performative visions of health emerge.
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In Weight Loss, by ModiFace, the application ‘consists of a weight loss simulation (on your own photo!) a personalised BMI chart, and progress tracker all in one app’ (App descriptor). Also involves keeping track of your progress and reaching your goals with challenges. The visualisation techniques on a photo you upload. Drawing on work on contemporary surveillance by Aas (2006: 154), draw on techniques that translate the collection of body data ‘into information patterns’ - flows of information are thus fixed to an abstracted ‘future image’ through which one can visualise a different body as part of their weight loss goals. In terms of stigma, one might ask how embodied experiences are being produced through these technologies and the implications for subject positions. What if there are no improvements in the performance and measured aspects? For instance, if one follows a particular programme but does not lose weight, particular where visualisation techniques are used? What do these apps do to us as subjects? Are we left feeling stigmatised, deficient, failing within systems of categorizations on ‘both the marked (disadvantaged) and the unmarked (privileged) positions’ (Van Amsterdam, 2013: 156) What if one does not feel the way one is expected to in the normalised imagery accompanying the promotion of these apps? In other words, what if this form of exercise is a burden? Feels hard? What is the effect on one’s subjectivity if one fails to achieve the ideals of these apps? What of those individuals who chose not to engage with these practices of self surveillance? Concluding comments: Weight stigma and the future of mHealth “The public emphasizes the presumed causal role of the individual in developing obesity, and this was the single strongest predictor of possessing a stigmatizing attitude.” (bombak 2014, citing Sikorski et al, 2011) Whilst it is important to acknowledge at this juncture that there are many benefits to mHealth, for example in terms of novel patient engagement, this paper has begun to explore some of the potential ramifications of the rise of mHealth in socio-cultural contexts where weight stigma is pervasive and damaging (Bombak, 2014). As the above quote reminds us, technologies that focus on individual behaviours as the presumed causal role of weight gain, have a strong relationship with the increase in weight stigma. The reduction of weight, health and the body to ‘body data’, in the context of a neoliberal politics and logic of choice, emphasising personal responsibility and self-responsibility which further contribute to those discourses of obesity that assume an etiology of ‘lifestyle’. It highlights the role of the individual, which as the above quote makes clear, is one of the strongest predictors of a stigmatizing attitude towards weight. Physical activity and weight loss are seen to be simply a matter of individual choice in the quest to regulate bodies to normalised ideals. This understanding of health ignores the power relations that affect different individuals and identities – including those where weight may come to be stigmatized as outside the norm. Moreover, this overlooks the complexity of health and the interrelationships that come to constitute health and within which health practices and choices are made possible (Mol, 2008) which ‘not only position individuals as blameworthy, but moralize and decontextualize health inequalities by glossing over the social and structural contexts that come to bear upon this’ (Rich, 2011: 16). There is little space within these systems
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to address the material, affective and discursive basis of health. What is missing in these representations of the body are people’s everyday lives, embodied expeirences and social contexts. I have of course only touched upon some of the socio-cultural, ethical and moral implications, in terms of how bodies are being configured within and through these digital environments. Research is needed which explores how individuals negotiate and manage these digital environments and how this contributes to ‘embodiment, selfhood and social relationships’ (Lupton, 2012: 299). Drawing from the work of Van Amsterdam (2013) this means being attuned to the nuances of the ‘intersections of body size with other axes of signification such as gender, social class, race/ethnicity, sexuality, dis/ability and age’. The impact of body image and eating habits of girls and women (e.g. Bordo, 1995; Orbach, 1978; Rich and Evans, 2009; Wolf, 1991). In addition to this, there are some obvious challenges brought about by the growth of mobile health apps related to lifestyle. What might be the implications of this in contexts where stigma of obesity is already apparent (for example GPs, workplace). In the UK, the NHS has launched the ‘Health Apps Library’ to help individuals ‘manage their health’ and in 2012 the UK Department of Health suggested that GPs should start prescribing health apps to their patients. Despite this policy terrain, there is lack of research on the way people get informed about health through digital worlds and how this shapes their health practices and behaviours (Mager, 2012). Indeed, the volume and diversity of apps ‘has made it difficult for clinicians and the public to discern which apps are the safest or most effective’ (Powell et al, 2014). There is also a distinct lack of empirical data against which the efficacy of digital health-based interventions might be evaluated and the policy implications highlighted; a crucial concern given emerging evidence that a third of user who own a wearable health device stop using it within six months (Pai, 2014). Moreover, as health care increasingly shifts towards a reliance on digital platforms, what might be the implications of this in terms of disparities, inequalities and differential access to technologies. As noted elsewhere, the emphasis on personal responsibility in obesity discourse masks health disparities between populations from different social classes and ethnic backgrounds and the reliance on digital platforms for monitoring health care could exacerbate these disparities. Future research might also focus on the role of these technologies in families, given that within neoliberal models of governance families are often recast as responsible for the weight of a child (Zivkovic et al., 2010: 378). The linking of data to health services, employers and insurance companies, contexts where obesity is already stigmatised, could be a particularly concerning issues in the era of big data and neoliberalism. In 2013, a report by think-tank Demos made the headlines in the UK after it advised that ‘people who who lead healthy lifestyles should be rewarded with easier access to healthcare. The report, which was sponsored by a private health insurance company, explores the impact of having a more 'responsible' population, and is largely focused on public health (NHS, 2013) The report was sponsored by an insurance company and perhaps gives some indication of the discourse of responsibility which come to frame risk, weight and responsibility
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and which might further serve as the possible basis for exclusion and discrimination of those individuals who do not conform to particular disciplinary practices of the body. Finally, These are just some of the many questions that we might need to address as mHealth continues to grow in popularity amongst both users and health providers.
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