A Review of Small Screen and Internet Technology–Induced Pathology as a Lifestyle Determinant of Health and Illness: A Commentary to Stevens and Egger (2019)

‘While once measured as television viewing, screen time now includes computer usage and, more recently, the use of mobile devices with screens.’

Without question, rapid and dramatic advances in automation and communication technology since the 1960s have transformed everyday life for most individuals in developed countries—particularly those countries recognized as leaders in the “information age.” These recent technologies have fundamentally changed the way that we interact socially, the way that we work, and the way that we learn. Ironically, while our access to information and ability to utilize automation technology would be inconceivable even 25 years ago, the available scientifically acquired information concerning the relationship between the evolution of the technology and its associated impact on human health is both sparse and contradictory. Stevens and Egger¹ have discussed a range of pathologies that have been associated, to some degree, with the dramatic expansion of internet technologies and increased screen time. While once measured as television viewing, screen time now includes computer usage and, more recently, the use of mobile devices with screens. The authors accurately describe the “uptake and impact” of new technologies as having “[redefined] our lifestyle behaviors and environment.” However, there are varying degrees of scientific substantiation of the association between technology usage and emerging health challenges—often the popular press dramatically overstates the evidence of technology-associated conditions. And, it is not at all clear what will be the best approaches to addressing the health challenges that are strongly associated with screen time and internet usage.

What is clear is that digital technology and mobile sensing devices have catalyzed a paradigm shift in health care toward what has been termed a “person-centered”² empowerment for participation by individuals in their health management. In this paradigm, individuals have real-time, or close to real-time feedback on their behaviors; convenient access to health promotion activities and health-related information, what are being called socio-technological drivers; and coordinated management of their health care through monitoring devices and online access to personal health information. These technological advances—many of which were designed and developed for marketing to the general public—have had the effect of making individuals active participants in evaluating their own health behavior and health care decision making.

Scientific Consensus on Technology Use and Associated Health Issues

There are a number of behavioral changes and health conditions that are associated with increased screen time with a high level of supporting scientific evidence. Of these, the population studies and clinical trials that show an association of increased screen time and a reduction in physical activity and increased prevalence of eye strain have reached a level of corroboration that is almost indisputable.

Declining Physical Activity

Numerous peer-reviewed studies have demonstrated a dramatic and inevitable reduction in physical activity with the rise of labor-saving devices, computerization, and automation. Using a community of Old Order Amish as representative of rural life before industrialization, Bassett et al³ demonstrated a very significant difference in activity levels of this community of Amish as compared with the average physical activity levels of populations across 12 industrialized nations. Amish men and women averaged about 15 000 MET-min per week as compared with about 2500 MET-min per week reported for the general population. In addition, the prevalence of obesity in the Amish community was about 4% as compared with more than 30% in the general population. This particular Amish population adheres to a physically demanding agricultural lifestyle and has rejected modern technology; thus, their occupational and household energy expenditure is comparatively very high. Studies examining population trends in the United States from 1960 to 2010 show that daily occupational energy expenditure declined by 120 to 140 kcals per day.⁴ Over the same 50-year period, the average weekly energy expenditure associated with household management among women declined by approximately 1800 kcals while screen time increased from 8.3 to 16.5 hours per week.⁵ These studies illustrate a small portion of the extensive scientific literature examining the decline of physical activity among adults in developed nations over the last half century. Stevens and Egger acknowledge the growing science-based evidence that supports an association among increased screen time, physical inactivity, and prevalence of overweight and obesity among children and adolescents. It should be noted that beyond childhood and adolescence, physical inactivity has been established as a major determinant of morbidity and mortality across the lifespan.⁶

Increasing Prevalence of Eye Strain

There is a growing body of scientific evidence illustrating the relationship between screen time and eye strain (reviewed in Sheppard and Wolffsohn⁷). For over a decade, a range of eye and vision symptoms, sometimes termed digital eye strain or computer vision syndrome, has been associated with the flickering and glare that is characteristic of computer screens, and with the repetitive eye motions of reading on-screen text. The prevalence of this syndrome among computer users has been estimated to be more than 60%.⁸

Objective measures in clinical trials have demonstrated increased eye fatigue—specifically a decline in the ability to distinguish flickering and nonflickering light—with prolonged screen usage.⁹ In addition, some but not all studies have shown an association between eye fatigue and common complaints of pain around the eye, heavy eyelids, and burning/itchy eyes.^9,10 Clinical studies^11,12 of pupal responses to screen watching have shown detrimental changes in characteristics that appear to be dependent on the type and level of demand of the visual task. While screen-related eye strain is not specifically addressed by Stevens and Egger, it has had a long period of recognition and study, is well established as an outcome for a significant proportion of chronic screen users, and has a number of interventions under consideration to address the condition.⁷

These are 2 well-documented examples of health challenges that have resulted during industrialization and now digital technology and automation. It is noteworthy that one health outcome, eye strain, results directly from the use of technology (long sessions of continuous screen watching). By contrast, the poor health outcomes associated with physical inactivity result from the lifestyle choices that come from using technology (eg, sitting on the couch and eating snacks while binging on Netflix). Since the etiology of these 2 examples are quite different, it follows that the solutions may well arise from very different strategies. In the case of eye strain, a solution may be automatic reminders to take intermittent breaks from looking at the screen and focusing on more distant objects for a short time. The reminders could be mandatory on work-related computer systems and default programming on personal devices. For screen-associated physical inactivity, the solution may be more multifaceted and require more complex behavioral change strategies that are accessed through computers and mobile devices. We discuss these strategies in the next section. While the solutions to these 2 health challenges may be quite different in terms of complexity and user interaction, we believe that they will emerge through imbedding innovative strategies into the devices rather than simply trying to limit screen time voluntarily or through regulation.

Technological Innovations That Promote Healthy Living by Providing Convenient Self-Monitoring and Social Support

A number of studies have demonstrated the use of “enabling spaces” as a foundational component of modern behavioral change strategies.^13,14 These spaces can be geographical or virtual, but the similarity among them is (1) the enabling spaces’ ability to provide access to information and support through peer interactions and (2) the spaces are outside of the traditional healthcare system structure.

The convenience and comfort associated with enabling spaces, in conjunction with sensor-enabled mobile devices that collect almost continuous data on activities, behaviors, and health outcomes, provide an opportunity for behavioral intervention strategies that can reach beyond the individual to the individual’s social network and living environment. These devices and the emerging technologies that collect, analyze, and contextualize the large quantities of data are already changing the relationship between patient and health care provider.¹⁵

Self-Monitoring

This key aspect of behavioral intervention strategies has been used extensively with a particular focus on monitoring and increasing physical activity, monitoring and adjusting eating habits, and addressing weight gain.¹⁶ One highly referenced randomized weight loss trial¹⁷ examined the effect of self-monitoring physical activity or diet with commonly used phone apps among overweight men and women. Most participants chose popular apps including RunKeeper, My Fitness Pal, and Fat Secret’s Calorie Counter. The results demonstrate that the participants who self-monitored their physical activity using a phone app reported significantly greater intentional physical activity and energy expenditure than those who did not. In addition, participants who self-monitored their caloric intake by phone app consumed fewer calories on average than did the participants who self-monitored by written journal. While adherence to all self-monitoring strategies in the study were low, the results reflect the convenience of real-time monitoring, ease of accessing complex calculations such as energy and nutrient intake and energy expenditure, and statistical analyses that can show behavioral changes over time.

Virtual Gaming

One innovative approach to behavior change through new technologies is the use of real-time activity recognition and contextualization in virtual game-based platforms accessed through the internet.¹⁸ Perhaps exercise through bicycle riding has been changed more profoundly by this approach with digital technology than any other mode of physical activity. Current online interactive websites for stationary cycling are now a multimillion-dollar business internationally. These sites provide a platform that combines social media and support groups, personal training, and aspects of computer gaming where the rider can interact with people or can use an avatar to ride through famous landscapes or imaginary bicycle routes. An important attribute of these systems is that the individual can ride in the safety and convenience of her own home and interact with others internationally at any time day or night. This technology, which allows collection of a wide range of physiological data from each session, has expanded beyond cycling to walking/running and even water-based activities.

Persuasive Technology

New strategies are exploring the use of data from mobile sensors and statistical modeling to evaluate behavior at the individual level and then predict the impact of specific behavioral change strategies.¹⁹ In essence, persuasive technology is exploring the capacity to take population-based behavioral strategies and apply them with adjustments based on individual characteristics and the ability to quickly adapt to dynamic changes in psychological status and environmental context. The use of persuasive technology is expanding rapidly with automated natural language processing and machine learning algorithms.²⁰ Through these advances in artificial intelligence, interventionists are now able to recognize emotional and social contexts in language—potentially enhancing the effectiveness of interventions by personalizing strategies that optimize the mode, timing, and intensity of the intervention interactions and messaging in almost real time.

The Future of Technology and Healthy Living

Modern digital technology has allowed us to communicate more efficiently, access expansive amounts of information, and experience new cultures and social networks. The technology has also been linked with social disconnect, mood disorders, and adverse physical health outcomes. It is interesting to note that a number of health conditions that have been associated, to some degree to the use of digital technology are due to the lifestyle associated with technology rather than the technology itself. This difference is illustrated in the comparison of the increase in sedentary behavior that is associated with increased screen time and automation, and eye strain that results from extended and uninterrupted screen watching.

As recognized by Stevens and Egger, great discoveries and inventions are by their nature socially disruptive. Certainly, there was a time when it was worrisome that the internal combustion engine was replacing the horse and the horse-based economy, and that the use of light bulbs was extending the workday into the evening and changing the population’s sleeping habits. While we still study the effects of automobiles and electric light on rates of morbidity and mortality, we no longer frame the discussion as “overuse” of the technology.

The use of mobile devices can be a very personal activity, and innovations for technology-based health interventions will continue to empower individuals to make informed healthy choices. Just as with the new technologies from a century ago, perhaps progress will come from embracing emerging technologies and continuing to create new and innovative ways to use the technologies to improve health and reduce the burden of disease. Depending on the situation, the solution may be programmed into the functioning of the application (such as built-in breaks to address eye strain) or person-centered persuasive language to promote healthy choices. In any case, future technologies will be required to successfully provide personalized, flexible, and motivational behavioral interventions while addressing the personal and cultural changes that we are currently experiencing due to technological advancements.