Scenic-Or-Not, combined with hundreds of image features extracted using the Places Convolutional Neural Network, might help us understand what beautiful outdoor spaces are composed of. We discover that, as well as natural features such as ‘Coast’, ‘Mountain’ and ‘Canal Natural’, man-made structures such as ‘Tower’, ‘Castle’ and ‘Viaduct’ lead to places being considered more scenic. Importantly, while scenes containing ‘Trees’ tend to rate highly, places containing more bland natural green features such as ‘Grass’ and ‘Athletic Fields’ are considered less scenic. We also find that a neural network can be trained to automatically identify scenic places, and that this network highlights both natural and built locations. Our findings demonstrate how online data combined with neural networks can provide a deeper understanding of what environments we might find beautiful and offer quantitative insights for policymakers charged with design and protection of our built and natural environments.Beautiful outdoor locations are protected by governments and have recently been shown to be associated with better health. But what makes an outdoor space beautiful? Does a beautiful outdoor location differ from an outdoor location that is simply natural? Here, we explore whether ratings of over 200 000 images of Great Britain from the online game  As indiWhile individual ideas of beauty are likely to be shaped by our personal cultural and social experiences, there is also reason to believe that our preferences for certain environments are shaped by evolution –5. Such Traditionally, small-scale surveys have been the most cost-effective method of gathering quantifiable data on what people find beautiful in outdoor spaces. Such surveys have provided important initial evidence that beautiful spaces may encourage physical activity ,13. HoweScenic-Or-Not, provided evidence that people who live in more scenic environments report their health to be better [The ability to crowdsource large amounts of data, coupled with recent advances in computer vision methods, is opening up a new avenue for research, allowing us to investigate visual perceptions of our environment. A recent analysis of over 1.5 million ratings of over 200 000 outdoor images taken across Great Britain, crowdsourced via the online game e better . Crowdsoe better . Computee better  and ‘bage better  have alle better  or visuae better . More ree better ,27, undee better ,29 and ee better ,31.Scenic-Or-Not, in order to develop a deeper and broader understanding of what beautiful outdoor spaces are composed of. We attempt to find answers to our question that go beyond the simple explanation ‘what is natural is beautiful’. Finally, we evaluate to what level of accuracy we can create a model to predict the beauty of scenes for which we do not have survey or crowdsourced scenicness data.We draw on this ongoing and rapid improvement in computer vision, particularly with CNNs. We use the Places CNN ,33 to ex2.Scenic-Or-Not, an online game that crowdsources ratings of the scenicness of outdoor images. Scenic-Or-Not presents users with random geotagged photographs of Great Britain, which visitors can rate on an integer scale 1–10, where 10 indicates ‘very scenic’ and 1 indicates ‘not scenic’. Each image represents a 1 km grid square of Great Britain, and is sourced from Geograph (http://www.geograph.org.uk/), an online documentation project encouraging users to submit geographically representative photographs of Great Britain. The Scenic-Or-Not dataset comprises 217 000 images covering nearly 95% of the 1 km grid squares of Great Britain. To date, over 1.5 million ratings have been submitted. We only include images in our analysis that have been rated more than three times.We explore data extracted from images from Scenic-Or-Not have previously been used to explore the links between scenicness and land cover [Scenic-Or-Not dataset to understand what characteristics beautiful images of our environment might be composed of. For each Scenic-Or-Not image, we use the Places205 AlexNet CNN [Ratings from nd cover , and scend cover . PreviouxNet CNN  that hasxNet CNN  to extraWe use the more recent Places365 CNN trained on the Places2 dataset (a repository of 8 million scene photographs)  to extraScenic-Or-Not on a per-pixel level, with each pixel being allocated to one of 11 colours that constitute the principal colours in the English vocabulary . More details of this procedure and the empirical data that support it can be found in the electronic supplementary material.We also explore the basic characteristics of photographs in our scenic ratings dataset, including their colour composition, saturation, brightness and colour variations. We examine each image from a). The sample of least scenic images suggests that such images are often composed of primarily man-made objects such as industrial areas and highways. However, images containing large areas of natural greenery can also be considered unscenic if they look drab, or if man-made objects, such as industrial plants, are obstructing the view (b).Visual inspection of a sample of the most highly scenic images suggests that they conform to widely held notions of beautiful scenery, comprising rugged mountains, bodies of water, abundant greenery and sweeping views a. The sathe view b.Figure25 m-resolution UK Land Cover Map 2007 (LCM) [We also look at a subset of images that are located in urban areas and do not consist primarily of natural land cover that might be associated with beautiful scenery. We differentiate urban areas from rural areas using area classification data from national statistics sources ,39. We u07 (LCM)  to identc). It appears that the most scenic images in urban areas consist not only of images that might be reminiscent of countryside scenery—such as beautiful canals and tree-lined paths—but of images that also contain man-made features such as historical architecture and bridge-like structures.The sample of images we inspect suggests that the definition of scenicness in urban built-up settings is more varied than in rural areas c. It appThe number of photographs in our dataset vastly exceeds a number that could be reasonably examined and characterized by a human encoder. In order to exploit the information contained in all of the photographs in our dataset, rather than a small sample, we build an elastic net model that considers the following features we have extracted from the images: colour composition, 102 SUN scene attributes and those Places365 place categories that are labelled as outdoor categories, of which there are 205. (Note that these 205 outdoor categories from the Places365 CNN differ from the 205 outdoor and indoor categories from the Places205 CNN.) We specifically choose to use an elastic net model as they have been shown to perform well even in situations where there are highly correlated predictors . ElasticFigures 3.We now check to what degree we can predict the beauty of scenes for new places for which we do not have crowdsourced scenicness data. We first build an elastic net model to predict the scenicness of images. This time we hold out 20% of our data to test our prediction accuracy. Our performance measure is the Kendall's rank correlation between the predicted scenic scores and the actual scenic scores. With our model applied to all images, we achieve a performance score of 0.544 for all images and 0.445 for our urban built-up images.As CNNs have shown tremendous progress in computer vision tasks –31, we aAs we have limited training data, we use a transfer learning approach  to leverScenic-Or-Not database contains only one image per 1 km2 grid square, and only in Great Britain. We check how well our Scenic CNN performs in an area where we do not have images at a high resolution from Scenic-Or-Not. Specifically, we investigate how our Scenic CNN performs for London by predicting the scenic ratings of 243 339 outdoor London images uploaded to Geograph. We use the Places CNN [Figure 6a demonstrates that parks known for their scenery, such as Hampstead Heath and Richmond Park, have large clusters of scenic imagery. We also see that areas around large bodies of water such as the Thames also seem to contain the most scenic imagery. The most unscenic images seem to be located in the city centre. However, a close-up view reveals clusters of highly scenic imagery in attractive built-up areas, such as Trafalgar Square. An examination of the photos predicted to be scenic indicates that while our Scenic CNN predicts high ratings for images containing primarily natural elements, images of man-made elements, particularly historical architecture around the city, including Big Ben and the Tower of London, are also predicted to be scenic (b). While our Scenic CNN in general predicts low ratings for images containing primarily man-made features, images containing large areas of drab or unmaintained greenspace and images with a restricted view are also rated as unscenic (c).Our aces CNN  to deteraces CNN . With a e scenic b. While unscenic c.Figure4.Scenic-Or-Not, combined with the ability to extract hundreds of features from the images using the CNN Places365, might help us understand what beautiful outdoor spaces are composed of. We attempt to find answers to our question that go beyond the simple explanation that ‘what is natural is beautiful’, and explore what features contribute to beauty in urban and built-up settings.We consider whether crowdsourced data generated from over 200 000 images from the existing online game We find, as expected, that natural features, such as ‘Coast’ and ‘Mountain’, are indeed associated with greater scenicness. However, in urban built-up areas, the definition of scenicness varies, and instead we see that natural features such as ‘Pond’, ‘Garden’ and ‘Trees’ are associated with greater scenicness. Surprisingly, we also find that man-made features can also be rated as scenic, in general as well as in urban built-up settings specifically. We find that historical buildings, such as ‘Cottage’ and ‘Castle’, as well as bridge-like structures, such as ‘Viaduct’ and ‘Aqueduct’, are associated with greater scenicness.What we find to be unscenic might provide the greatest insights. While, as expected, we find that man-made features such as ‘Construction Site’ and ‘Parking Lots’ are associated with lower scenicness, large areas of greenspace such as ‘Grass’ and ‘Athletic Field’ can also lead to lower scenic ratings. Evolution might have conditioned us to dislike certain natural settings if they have attributes that are detrimental to our survival . For exaFinally, we also explore to what level of accuracy we can create a model to predict the beauty of scenes for which we either do not have crowdsourced scenic ratings, or for which we require scenic ratings at a higher resolution. We modify the existing Places365 CNN in order to predict the scenicness of images and achieve the best performance using the VGG16 CNN architecture. As well as carrying out a quantitative analysis of the performance of our CNN, we present our predictions for images in London, and find that they are broadly in line with intuition. Our Scenic CNN predicts high ratings for images containing primarily natural elements, such as those located in parks in London known for their attractive scenery, such as Hampstead and Richmond Park, and also predicts high scenic ratings for beautiful buildings, such as the iconic Big Ben and the Tower of London.In order to improve the prediction performance of our model, we anticipate that further data to differentiate particular features of built-up areas are needed. For example, we note that while we find historical buildings (e.g. ‘Castle’) to be the most beautiful, this could reflect the fact that we do not have categories to describe modern types of architecture in our data. Future research could explore this further.In general, our findings offer insights which may help inform how we might design spaces to increase human well-being. It appears that the old adage ‘natural is beautiful’ seems to be incomplete: flat and uninteresting green spaces are not necessarily beautiful, while characterful buildings and stunning architectural features can be. Particularly in urban areas, features such as ponds and trees seem to be important for city beauty, while spaces that feel closed-off or those that are too open and offer no refuge seem to be spaces that we do not rate as beautiful and do not prefer to spend time in. This accords with research that investigates whether our preferences for certain environments might be shaped by evolution, which explains our attraction not only to natural spaces ,7 but alOur findings demonstrate that the availability of large crowdsourced datasets, coupled with recent advances in neural networks, can help us develop a deeper understanding of what environments we might find beautiful. Crucially, such advances can help us develop vital evidence necessary for policymakers, urban planners and architects to make decisions about how to design spaces that will most increase the well-being of their inhabitants.


Wasted, elaborating the ways Hornbacher offers a positive presentation of anorexia nervosa that may, intentionally or not, induce certain readers to “try it” themselves. This is followed by an exploration of how Hornbacher’s own reading praxis is implicated in a discursive feedback loop around anorexia narratives. It concludes with a discussion of disordered reading attitudes in relation to the emergence of the “pro-anorexia” phenomenon.This article explores the relationship between eating disorders and reading behaviors, arguing that there is a meaningful difference in a minority of readers' approach to and understanding of anorexia life-writing, and of literary texts more broadly. To illuminate this distinction, this article begins by considering the reported deleterious influence of Marya Hornbacher’s anorexia memoir,  Although the incidence of anorexia nervosa has been increasing since its identification in the 1870s, and particularly since the mid-twentieth century, it is only since the late 1990s and the advent of widespread Internet access that anorexia has seemed to transform conspicuously from an isolating, individualist disease to, as many view it, a communal activity and group identity. Pro-anorexia websites, which offer soi-disant tricks and tips to avoid eating or being found out and which recast the condition as an elite, ascetic lifestyle or even a religious cult, have generated widespread and enduring media concern, “revulsion [and] . . . morbid fascination.”3 On these sites, anorexia becomes “Ana,” a goddess figure to whom acolytes are encouraged to devote themselves; whose “thin commandments” they must follow; and whom they worship “with soul . . . heart and . . . bodily functions.”4 For many, one book lies at the core of their devotion: Wasted: A Memoir of Anorexia and Bulimia. Published in 1998 and written when Hornbacher was twenty-three, this text was part of a new trend in the United States for bold, provocative, and sometimes lurid accounts of young women’s psychiatric crises, ushered in by such memoirs Girl, Interrupted (1993) and Prozac Nation (1994).Anorexia nervosa, Joan Jacobs Brumberg argues, “has become Wasted to exacerbate their anorexic thoughts and behaviors. Nicole Johns, in her own eating disorder memoir, Purge, calls it the “preeminent” memoir, the “eating disorder bible,” describes its “cult following” amongst eating-disordered patients, and writes that “women attempted to smuggle Wasted into the treatment facility.”5 Similarly, reviews of Hornbacher’s memoir on bookseller Amazon’s website caution, “don’t say you weren’t warned”; “it is toxic to people who are sick”; it “is NOT a good book to give to a teenage girl or any person with an eating disorder.”6 Whilst it may seem a spurious suggestion that a book might trigger or encourage an eating disorder, Hornbacher herself explains how, upon reading The Best Little Girl in the World, 7 It is also not the first time such a claim has been leveled at a memoir written “to keep people from going where I went.”8 During the 1820s, for instance, Thomas De Quincy’s Confessions of an English Opium-Eater, presented as a “useful and instructive” record of the author’s addiction and the “horrors of opium,” received criticism for encouraging its readers to try opium themselves.9 Going back a little further in time, we encounter the themes explored in other essays in this collection—suggestions that reading about particularly emotive subjects might prove a singularly harmful exercise, particularly for adolescent girls. For instance, the suggestion that Samuel Richardson’s 1747–48 novel Clarissa—wherein the eponymous heroine willfully starves herself to death and has been described by Maud Ellmann as a “literary anorectic”—harmed young women readers by “discomposing their stomachs” presents a curious similarity to contemporary concerns about the dangers of reading accounts of self-starvation.10Many anorexia nervosa patients describe using Certainly, it would be specious to posit that Hornbacher’s book is capable of spontaneously causing anorexia nervosa—it has not been established that any text can trigger the disorder in healthy individuals—but there does appear to be a special relationship between particular writing and reading practices and anorexia identity formation and maintenance for some readers with a predisposition to eating disorders. Certain experiences and accounts of anorexia  seem to rely upon peculiar ways of approaching, producing, and consuming written texts, and both anorexia memoirs and the pro-ana phenomenon 11 The underlying assumption, therefore, is that anorexia is a condition of superficiality, or of vanity. This understanding is inadequate for several reasons.Currently, anorexia is widely considered a sort of visual condition. The terms used to write about the disorder focus on sight, image, perception, looks, mirrors: we talk about people “looking anorexic”; our critical discussions center around obvious thinness and body image ideologies; we illustrate anorexia by showing someone gazing in a mirror and seeing a distorted reflection; and we witness and contribute to innumerable debates about how the ubiquitous visibility of thin celebrities  must be responsible for the increasing incidence of anorexia. This view sees anorexia as a kind of mimicry: the anorectic has seen thinness around her and attempted to reflect those images corporeally. Reflexively, we reach towards motifs from well-known stories to frame the disorder in these terms: even support websites and charitable organizations, and of course pro-anorexia websites, take names like 12 In this way the anorectic is held solely to blame for having become ill, yet her illness is also seen as an apparently inevitable product of visual culture (either way absolving anyone else of guilt or responsibility). Evidence suggests that this view of anorexia as volitional is quite common, and that it has a stigmatizing and ultimately harmful effect on attitudes towards those with anorexia. Several studies have highlighted the negative attitudes health care professionals hold towards anorexia patients, reporting, for example, that such patients are less liked, finding the prevailing opinion among caregivers is that anorexia nervosa is self-inflicted and willful, and that patients “have only themselves to blame” for their condition.13 Public attitudes towards patients with anorexia nervosa are similarly negative.14 Research by Arthur Crisp found that patients 15 In Crisp’s study, feelings of blame towards anorexia patients far exceeded those for depression or schizophrenia and approached levels directed at those with drug and alcohol dependence. This indicates a high level of public stigmatization of eating disorder patients. These studies are just part of a larger body of research which suggests that the view of anorexia patients as too-credulous (and implicitly vacuous) consumers of mass media contributes to attitudes of blame and stigmatization.This view propels pervasive beliefs about the influence of mass media on anorexia incidence or on “prospective” anorexia patients : the view, as Michele Crisafulli and colleagues put it, that anorexia nervosa is “a purely sociocultural phenomenon in which young girls succumb to the image of ideal beauty put forth in fashion magazines.”16 For these patients, and for others who in one or more ways challenge the predominant view—for boys and men, for older women, for people of color—their illness becomes doubly aberrant: since the dominant narrative of anorexia has converged on this teen girl/visual model, other narratives, other anorectics, become invisible, yet these patients are nevertheless subject to the same abiding social stigma that assaults all anorexia patients. Anorectics whose eating disorders are not accommodated by the prevailing narrative are less likely to seek help and are less likely to have their problems recognized as such if they do.17 Delays in diagnosis and treatment have known negative consequences for illness duration and recovery trajectory.18 Any anorectics for whom the visual model does not seem to fit suffer more and for longer while that model persists in determining the thrust of popular eating disorders discourse.A further problem with the visual model for conceiving of anorexia nervosa is that it leaves little room for alternative narratives, thereby marginalizing accounts of anorexia that do not fit this framework. Portraying anorexia as a so-called slimmer’s disease or as a celebrity copycat phenomenon among teens has meant that anorexia is increasingly not recognized when it presents differently. Recent work has found a significant portion of anorexia cases emerge without volitional weight loss or any attempt at dieting. In these cases, patients develop anorexia nervosa having unintentionally lost weight .19 There are thus multiple reasons to conceive of anorexia differently. This is not to say that anorexia is not at all concerned with visual culture or body image—it surely can be—but conceiving of anorexia nervosa as a condition for which interpretation, rather than perception—reading, not seeing—is a more important factor may begin to answer, in a way that other conceptual models are unable to, some of the questions raised by the growth of pro-anorexia texts and the charge that anorexia may be a textually transmitted disease.Finally, this predominant conceptual position on anorexia as a visual phenomenon requires a concerning and persistent focus on the strictly visual-corporeal elements of the condition. That is, seeing anorexia as the pursuit of socially idealized thinness yields treatment narratives which focus on correcting extreme thinness, holding reversal of emaciation as the primary marker of health. Using weight as the main measure of illness severity leads to enormous gaps in care provision  and disordered modes of reading, whereby innocuous or cautionary texts are co-opted, take on new meaning, or are transformed into compelling role models. The Minnesota Starvation Experiment was a 1944–1945 medical study designed to investigate the physical and mental effects of extreme caloric restriction and dramatic weight loss and to assess the effects and effectiveness of weight restoration strategies. Participants were recruited from a pool of conscientious objector volunteers in the Civilian Public Service. The healthy male participants had their caloric intake reduced by half for twenty-four weeks. Over the course of the study, the men exhibited a range of obsessive and compulsive food-related behaviors, including hoarding not only food items but recipes—almost one hundred cookbooks, which they would read obsessively.21 Anna Bardone-Cone and Kamila Cass found that healthy “participants who viewed a pro-anorexia website had greater negative affect, lower social self-esteem, and lower appearance self-efficacy” following the viewing than those who were exposed to a comparison website.22 This research presents a conflicted picture of the factors driving disordered eating, and how, or how far, pro-anorexia might fit into this: Bardone-Cone and Cass’s results imply a direct link between cultural messages and body image and eating attitudes, while Harper, Sperry, and Thompson’s findings note a similar correlation among regular consumers of pro-anorexia discourse, although they do not suggest causality. In any case, widespread concerns about the harmful influence of pro-anorexia seem justified, and these findings reinforce the urgency of questions raised about the origins of anorexia nervosa and the salience of pro-anorexia rhetoric in anorexia illness experience.More recent studies have examined levels of eating and body image disturbance in those who frequent pro-eating disorder websites and the effects of viewing pro-anorexic web content. Harper, Sperry, Wasted—and disordered eating. Noting the wealth of criticism attesting to the anorexogenic influence of Hornbacher’s memoir, one 2006 study measured the memoir’s effects on readers’ eating attitudes and behaviors.23 The study, crucially, found that participants—healthy women college students—showed no significant changes across three separate measures of eating behaviors and attitudes after reading the text.24 These findings directly contradict testimony from eating disorder patients at a variety of sources, suggesting that there is an interpretative gulf between certain readers’ (and eaters’) approaches to and understanding of the text. Indeed, Jennifer Thomas et al. suggest that readers who “vary in their underlying predispositions for disordered eating may also differ with regard to the salience, encoding, and retrieval of memoir information.”25 From a literary standpoint, we might view this as a diversity of interpretative engagement with narrative: vulnerable readers differ in their approach to close reading practices and discursive involvement with texts . Considered together, the above studies also suggest, in the relationship between reading disturbance and eating and body image disturbance, that there may be a method, peculiar to readers with or predisposed to eating disorders, of interpreting texts in a maladaptive way. Indeed, this way of reading could constitute a precondition for many cases of anorexia nervosa.We may find clues as to why some people are more susceptible to anorexia nervosa than others by looking more closely at what appears to be a significant relationship between reading particularly (sub)culturally important texts—like 26 It also denotes the processes by which other texts (for instance novels and self-help books) and other practices  transform and are transformed by the anorexia illness experience. Using this conceptual model to describe the peculiar intertwinement of narrative behaviors with anorexia need not impute direct etiology: that is, disordered reading is presented as a measure of propensity, not a measure of causality. Moreover, in the term “reading disorder” I intend to point not only to the relatively direct process of reading as simply receiving (or even consuming) a text, but to hold on to the numerous and complex meanings under the broader sense of the term: “reading” here is a conscious invocation of the literary, and in particular of the hermeneutic: of teasing out arcane, profound, perhaps broadly bewildering meaning—and of the anorexia memoir as scripture. Of anorexia nervosa as a type of close reading, even. Thus, “reading disorder,” as I conceive it, encompasses both the conventional and the multiple, expansive senses of “reading,” to include approaches to, understanding of, engagement with and responses to textual artefacts. Here I would reiterate that disordered reading, rather than being a condition of extreme impressionability, sees readers privilege their interpretation of certain textual events over any number of others that may contradict it. This position aligns with Thomas et al.’s suggestion of differences in information salience and encoding across reading behaviors, particularly concerning the subject of anorexia. Presented with a text, the (reading) disordered reader’s analysis will, thus, reflect only their reading of themselves. The reading disorder hypothesis resists and poses a direct challenge to the implicit conclusions of the visual interpretation of anorexia and thereby avoids the negative consequences of framing the illness as disorder of superficiality.I suggest the term “reading disorder” to describe this phenomenon and activity at work; it denotes the reading (and writing) practices by which textual artefacts—first among them case histories and personal narratives, which are normatively construed as negative and cautionary—are reinterpreted or repurposed as aspirational.This understanding of disruptive and non-normative responses to textual matter as a type of reading disorder allows, I believe, for closer and keener analysis of the processes and rhetoric behind the growing eating disorder cult and its anorexic discourse—that is, the looping effect illustrated by the synthesis, incorporation, and regurgitation of pro-anorexia content within and between online communities.This paper, then, is concerned with life-writing rhetoric, anorexia as a reading disorder, and the development of anorexic discourse. In the following analysis, I explore links between disordered eating and disordered reading and examine pro- anorexia as an alternative interpretative mode, outlining and analyzing the rhetorical mechanisms at work within the discourse that reveal anorexia as a reading disorder and anorexia memoir narratives as particularly revelatory in this understanding. Considering texts and their reception and deployment in this manner will offer a fresh, literary-analytic perspective on the experience of anorexia and the burgeoning pro-anorexia cult.Wasted, in particular, both illustrates and participates in the reading disorder phenomenon. In the next section I elaborate on the ways Hornbacher’s memoir offers a presentation of anorexia nervosa vulnerable to being read as positive and may, intentionally or not, influence certain readers to “try it” themselves. This will be followed by close textual analysis and exploration of the way Hornbacher’s own disordered reading suggests the reality of anorexic discourse or anorexia as a reading disorder. I conclude with a discussion of disordered reading attitudes in relation to the advent of the “pro-anorexia” cult.Wasted. Prior eating disorder memoirs, particularly the earliest published texts, which appeared in the United States during the 1980s, do not seem to generate this type of criticism or attention at all. Other eating disorder memoirs such as Puppet on a String or Joan Johnston’s Feast of Famine, and semi-autobiographical first-person works of fiction such as Second Star to the Right, were not criticized (or praised) for being dangerous, triggering, or motivational.27 Indeed, Second Star to the Right advertises itself as a “moving, perceptive and gripping book . . . that all young people should read.”28 Thus it seems that not all acts of reading, or perhaps not all texts read, are as prone to the alternative interpretative processes involved in disordered reading. So what might explain this difference? How does disordered reading transform texts like Wasted, and what is it about those texts and not others (like Feast of Famine) that fit the disordered mode so well?When considering anorexia memoirs’ involvement in eating disorder acquisition, it becomes clear that not all anorexia life-writing is charged with the same “toxic” influence as Wasted and its apparently harmless predecessors is that the majority of the earlier anorexia memoirs are heavily religious, and thus present the condition as a tragic affliction— that is, as utterly extrinsic to identity. Moreover, these texts portray recovery from anorexia as an often instantaneous product of faith or trust in God. In Feast of Famine, for instance, Johnston pinpoints her recovery quite literally to the minute: a religious epiphany reached while volunteering for a Catholic Apostolic charity.29 Hornbacher instead presents anorexia as an integral part of her identity and reveals her recovery, absent any deus ex machina, to be far less absolute or easily resolved—a precarious position, her world seemingly always in thrall to a persistent anorectic drive: “It’s never over. Not really. Not when you stay down there as long as I did, not when you’ve lived in the netherworld longer than you’ve lived in this material one, where things are very bright and large and make such strange noises. You never come back, not all the way” (285). Hornbacher’s position fundamentally transforms anorexic subjectivity; this establishment of anorexia as a condition of being marries anorexia nervosa to personality, seeing it less as an illness and more as an almost inevitable behavioral manifestation of global character attributes. In this way, whereas Johnston’s memoir depicts anorexia as a departure from virtue, an absence of faith, and as symptomatic of a profound lack of a higher power, purpose, or meaning, Hornbacher’s account of her journey to and tentative return from the anorexic “netherworld” reveals anorexia to provide meaning for enduring “anorexic” personality traits.One key difference between 30 Hornbacher’s perspective on anorexia is largely ambivalent and often reverential. She writes of her anorexia as pure, focused ambition (107); “success” (19); an addiction which vitalizes, making her “high as a kite, sleepless, full of a frenetic, unstable energy” (105): to Hornbacher, the anorectic is able to experience life as though standard human physiological limitations do not apply. She describes the “very, very intense” power of starvation (105). And while Wasted, immediately marries her depiction of eating disorders with the image of intoxication, and her further characterization of her experiences with anorexia and bulimia nervosa as addiction (on nine separate occasions) seems to point towards the harms of these endeavors, depicting her eating disorder as an addiction does not necessarily act as a warning. Rather, it downplays its seriousness, its life-threatening dangers. Hornbacher writes of her trial of and addiction to various narcotic substances in her early adolescence, including heroin, with a surprisingly low affect and blasé attitude (72); consequently, her subsequent addiction to starvation becomes similarly mundane. Certainly, Hornbacher equates the dangerousness of anorexia nervosa to the dangerousness of intravenous drug injection in the mid-1980s—but as she presents heroin use in a thirteen-year-old as mundane, so she leads the susceptible reader to understand anorexia as such.Indeed, not only does Hornbacher create room for understanding anorexia as an identity category, but also this category is subject to particularly persuasive rhetorical management. A large part of the criticism leveled at her purportedly cautionary tale of addiction concerns her consistent association of both the central behavior (barely eating) and the disorder as a whole (anorexia nervosa) with positive personality traits and beneficial social or emotional side effects, from ideas of purity and perfection to intelligence, social standing, and liberty, while also presenting the text as something “to keep people from going where I went.”already perfectionistic, intelligent, incredible state of being: an elite, enviable endeavor. Hornbacher’s presentation of anorexia as a marker of distinction implies that, under competitive circumstances, the disorder is a way of setting oneself apart from the rest, as superlative—from “more” to most. Hornbacher’s writing of anorexia nervosa  embodies the epitome of success. While for some readers the ability to identify her position here as non-normative will remain intact, Hornbacher’s favorable framing of her anorexia means that the possibility of remaining neutral and detached is a greater challenge, and assimilation to her values and identity the more likely consequence.Hornbacher also relates anorexia to intelligence and abnormally high scholastic achievement—“anorexia,” she writes, is a “more cerebral” form of eating disorder (202), and “people with eating disorders tend to be both competitive and intelligent. We are incredibly perfectionistic. We often excel in school, athletics, artistic pursuits” (136). Thus, anorexia is a more cerebral subset of an 31 Employing a religious vocabulary in this fashion highlights the author’s reverence for her eating disorder and suggests not only its intensity but also its merit: consistent devotion to one’s religion (or cult) and adherence to its doctrines of faith will be rewarded with eternal life. This transformation of addiction to devotion is a rhetorical device frequently employed by pro-eating disorder websites for this very reason. Hornbacher describes her desire for faith: “Had we a god, it might have been Dionysus. We, his followers, imagined ourselves maenads, half-believing in divine possession, half mocking it. . . . We wanted to be that genius, that idiot mad with the world of his mind. A thrum of self-destruction, and a joy all tangled up. . . . We were very hungry” (104). This passage reveals, in addition to the religious elements of her disorder, the equation of its obsessional, dysfunctional behaviors with productivity, a theme that reverberates throughout the memoir.Whereas other writers have emphasized the involvement of religious belief in their recovery from anorexia, Hornbacher expresses concern about the tendency to surrender responsibility for illness and recovery to a higher power. Discussing the restrictive tenets of 12-step addiction programs, she writes: “There is a tendency to say: I have an addictive personality, I am terribly sensitive, I’m touched with fire, I have Scars. There is a self-perpetuating belief that one simply cannot help it, and this is very dangerous. It becomes an identity in and of itself. It becomes its own religion, and you wait for salvation, and you wait, and wait, and wait, and do not save yourself. If you saved yourself and did not wait for salvation, you’d be self-sufficient. per se, along with her academic talents, is a success. Hornbacher here encourages her readers to covet her illness as well as envy her ability. The disordered reader feels that, unless she becomes as successfully anorexic, that is, as sick as Hornbacher—sleeps less, eats less, weighs less—and achieves more, she will fail. Hornbacher repeatedly underscores the hyperactive workaholic tendencies that accompany her anorexia. Relating the initial stages of the disorder, which occurred when she was aged fifteen and at boarding school, Hornbacher boasts, “I was running twenty-five miles a day on a knee that was beginning to split” (110). At seventeen: “I stopped sleeping. . . . I brought a stack of books and a notebook, packs of cigarettes, and sat coiled in a chair in the corner, rubbing my eyes, red in the almost tangible haze of smoke, swallowing coffee so thick it left sludge in the bottom of the cup. Reading Bertrand Russell and John Stuart Mill and Marx” (218). At nineteen she recalls sleeping less than three hours a night, “eating 320 calories a day” (247); “writing a weekly column” and “sidelining as a freelance research hack for a couple of papers” (248); “going to school full-time [and] pulling a 4.0 grade average” (248)—and weighing about 80 pounds.Hornbacher’s understanding of her achievements as the fruits of her deep entrenchment in her anorexia suggests that the disorder of her behavior to present anorexia nervosa as a positive condition. But my argument is not only that Wasted presents a non-normative reading of anorexia in which the condition is suffused with positive meaning and associations, but also that Hornbacher’s writing reveals her own disordered reading behavior. Exploring this phenomenon in closer detail provides a useful route to understanding anorexia as a reading disorder. I shall show how reading practices are involved in Hornbacher’s anorexia, and suggest that her expression and explanation of this  closeness between ways of eating and of reading discloses as well as participates in a peculiar and intimate relationship between anorexia and reading.Hornbacher exploits an idiosyncratic writing style and her own disordered reading Wasted was written as an intentionally pro-anorexic text. It is not the aim of this paper to apportion blame to Hornbacher (or her readers) for their involvement in these rhetorical processes; the hope is to shed some light on this hitherto little-explored relationship between reading behaviors, narrative engagement and anorexia nervosa. Wasted and Hornbacher have a central role in this epiphenomenon but it is unlikely to have been a deliberate or welcome one. Indeed, responding in an interview to a question about the intended audience for the book , Hornbacher said, “I will honestly say I did not write this for people with eating disorders. . . . Did I write it to help others? Yes. I wrote it so their mothers, husbands would put them in the hospital.”32 She states in the introduction to Wasted that she wrote it “to keep people from going where I went” (7), yet her prose seems at odds with these apparent intentions: she consistently addresses the reader as a confidante, a fellow anorectic—beckoning to readers with her extensive use of the second person  and confirming a shared identity by using “we” addresses throughout (“we have to choose sides” [154]). I believe the necessarily introspective direction of memoir conspired with what I shall show is her own disordered reader, the potential interpretation of her words as promotional may not have seemed possible or plausible, or have occurred at all to her during the writing process.This section first addresses how Hornbacher’s distinctive writing style works to promote anorexia nervosa in the disordered reader; it then turns to Horbacher’s testimony of her own disordered reading to discuss the way she ties together reading and anorexia. Finally, I explore the implications of my method for understanding reading disorders and anorexic discourse. Here I must state explicitly that I do not believe 33 Some of these passages work to induce a “disordered” identity in the reader. For example: “The problem in your life is your body. It is defined and has a beginning and an end. The problem will be solved by shrinking the body. Contain yourself” (42), and “You will lift the toilet seat, carefully slide your fingers inside your mouth and down your throat, and puke until you see orange” (61). Ordinarily, being forced to assume such an identity is alienating, foreign, uncanny; it coaxes from readers a dysphoria between mind and body, a corporeal sense of wrongness. A reader made to throw up vicariously through a text will be, like Marya’s (non-disordered) friend who tried it, “gripped . . . by a sudden sense that what [they are] doing [is] wrong. Not wrong in the sense of sinful, but wrong in a human sense—a crime against nature, the body, the soul, the self” (123). Yet since Hornbacher consistently, almost conspiratorially, invites her readers to identify with her, passages such as these have no room for alienation. Hornbacher’s prose thus skillfully guides the reader towards painlessly, perhaps even imperceptibly, synthesising her own thought patterns, beliefs, and perhaps even behaviors.This apparent gulf between the expression and reception of memoir information emerges in the myriad foibles in Hornbacher’s writing. What may be self-conscious attempts to locate herself at some remove from her more graphic accounts of illness emerge as mechanisms inviting readers to take on an anorexic subject position. One such example (a surprising feature of a memoir) is Hornbacher’s prolific use of the second-person rather than first-person narrative. Her first use of “you” occurs just thirteen pages into her first chapter, and increases in frequency and duration as Marya’s eating disorder progresses.Wasted as textbook more than autobiography. Moreover, her upending of conventions of memoir constitutes a non-normative and disruptive approach to writing: as much as Hornbacher’s memoir lends itself to, invites, and participates in disordered reading, it is also itself an example of disordered writing. By this phrase I do not aim to haphazardly diagnose, much less disparage, literary or stylistic innovation per se. I invoke “disordered” in Eve Sedgwick’s sense of disarticulating or disrupting—as an invitation to see Hornbacher’s style as a strategic misalignment of expectations and conventions simultaneously illustrative of and participatory in the complex narrative performance of her anorexia.34Throughout the memoir, Hornbacher takes pains to characterize herself as a “better” anorectic than anybody else in a combination of ways: the duration of her illness; her apparently superhuman abilities to subsist—or supersist—higher and better than mere mortals—without food or sleep; her alarmingly low weight (fifty-two pounds) and, perhaps most pertinently, her assumption of an authoritative writing style. Hornbacher is a self-made expert on eating disorders. Her academic mode of writing is unusual for a layperson, but especially so in a memoir, where footnotes, citations, and bibliographies are practically 35 She directs the reader, in unfaltering imperatives, to “step onto the scale each day, ten times a day. . . . When you wake up, when you get home from school, after you binge, after you purge, when you eat dinner, after you throw up dinner . . . before you gulp handful of laxatives, after they take their hideous effect” (162). Hornbacher’s instructions become more and more explicit as her memoir and disorder progress. By the time she reaches her lowest weight of fifty-two pounds, her writing moves away from implied directions to overt instructions. To the non-disordered reader, a passage of this nature would induce shock and perhaps disgust; for those whose reading is disordered, however, Hornbacher’s words will be taken at face value:Hornbacher’s writing suggests that, if she is not deliberately styling the text as a how-to guide for eating disorders, she nonetheless has some consciousness of her role as teacher: the employment of “you” in most of her depictions of anorexic episodes does more than instruct the disordered reader to identify with her at her most ill moments; it instructs the reader to imitate them. Marya’s stay at Methodist is written with six pages of uninterrupted second-person narrative; her relapse in California covers five pages.I’d read the same sentence over and over, to prove that I could sit in front of food without snarfing it up, to prove it was no big deal. . . . Try this at home, kids, it’s great fun. You take the edge of your spoon and run it over the top of the yogurt, being careful (255)That is, the disordered reader really will (at least want to) “try this at home.” What this passage also illuminates, in addition to the author’s increasingly disordered mode of writing, is Marya’s own disordered mode of reading—reading food, reading eating behavior, (not) reading consequences.Hornbacher’s testimony reinforces the notion of “reading disorders” as a precursor to eating disorders and complicit in the establishment and perpetuation of anorexic discourse. Hornbacher’s presentation of her disordered eating behaviors in lengthy, excruciating  detail, with little mention and less emphasis on the negative physical or psychological effects thereof, is an exhibition of her own disordered reading of the world and herself. Moreover, her understanding of anorexia as superior to bulimia, as a choice she made—after reading a book she felt encouraged her—and her general approach to reading and textual consumption from childhood on arrestingly illustrate the idea of a genuine and meaningful relationship between dysfunctional reading and dysfunctional eating.deny. It is an act of disgust and of need,” Hornbacher explains, depicting it as a gluttonous, excessive condition (93). Instead of a bulimic, she writes, “I wanted to be an anoretic. I was on a mission to be another sort of person, a person whose passions were ascetic rather than hedonistic, who would Make It, whose drive and ambition were focused and pure, whose body came second” (107).36 Her interpretation of her eating disorders thus reinforces the overall presentation of anorexia as elite. Crucially, alongside this, she suggests that her anorexia was something she “chose” after reading psychologist The Best Little Girl in the World, whose anorexic protagonist is, to Marya, “perfectly pure” . She claims that she “decided that Hornbacher was bulimic for six years before developing anorexia, and alternated between the two for some years. She presents the disorders as startlingly different: to Hornbacher, anorexia and bulimia exist, it appears, in different people. “Bulimia acknowledges the body explicitly, violently. It attacks the body, but it does not as a disorder. She describes herself as being “perpetually grief-stricken” when, as a child, she finished books, which she read compulsively: “the book was dead. . . . What was the use? Why bother dragging the weight of my small body down to dinner? Why move? Why breathe? The book had left me, and there was no reason to go on” (28). At Interlochen, Marya accompanies her obsessive twenty-five-miles-a-day exercise habit with a book in hand, as though “reading” and “disorder” are inextricable entities, no longer discrete categories—each obsession complicit in the other (110). Indeed, as she attends college locally at the age of seventeen, Marya fuels her body and her disorder with books and seemingly little else. Recalling the “stack of books” feeding her in her nocturnal starvation behavior, her reading “Bertrand Russell and John Stuart Mill and Marx” to occupy herself in place of eating, Hornbacher’s attitude here and elsewhere suggests a cyclical relationship between her (disordered) reading habits and disordered eating habits: one makes the other worse and so on, ad nauseam (218).37Girding this idea further is the prominence that books and reading have in Hornbacher’s memoir. These function as an obsession and emotional crutch just as much as her eating disorder does, a fact which betrays her reading 38 Many prominent intellectual women were subjected to this treatment, including Virginia Woolf in England and Charlotte Perkins Gilman in the United States.39 Gilman, 40 This prohibition, she explains, is singularly painful to her: “to lose books out of one’s life, certainly more than ninety per cent of one’s normal reading capacity, is no light misfortune.”41 Indeed, for Hornbacher, too, it is at just this point—bereft of her ability to starve and her ability to read—that she states she “lost it altogether” (198). It is of interest to note that Hornbacher’s disorder is very much connected to the act of reading, as opposed to the content per se, or the physical object. Reading is disordered; being read to is not: she writes of being read to at Lowe House in wholly therapeutic terms; how, despite her resistance, “the reading set off tiny explosions of longing in [her] chest” (201).Whilst an inpatient at Lowe House, Hornbacher recalls being “fed” with books as well as food, using reading—which she does “voraciously”—to alleviate her anxieties (196). Indeed, no longer able to indulge her obsessional starvation, Hornbacher describes her disorder in relation to books in place of food: “We talked about books. They brought me books. I sat at the table, behind my battalion of books, peering over the top, half-reading, half-talking to them, telling them about my books. Then Staff took away my books” (198). These actions recall the once-popular and later widely maligned “rest cure” pioneered by late nineteenth-century American physician Silas Weir Mitchell. This treatment, aimed primarily at women, not only required total bed rest and the imposition of a rich, heavy, and large diet (indeed reminiscent of many anorexia refeeding programs), but also prohibited forms of mental exertion like reading and writing.This final section seeks to examine how disordered reading and writing practices relate to the advent and growth of pro-anorexia culture and to illuminate the processes of anorexic discourse through looking at some of the rhetoric of pro-eating disorder websites.The Best Little Girl in the World. This event not only suggests that because she chose anorexia after reading the story of a “perfectly pure” anorectic (43), so too can (and should) the reader choose to be anorexic after reading Hornbacher’s story, it also offers the most compelling evidence for the notion of disordered reading and its role in anorexic discourse. Marya, as a disordered reader, is triggered to develop anorexia after reading an account of it she interprets as attractive; other (disordered) readers have read Hornbacher’s book and authored websites that encourage others (deliberately or not) to develop eating disorders. That is to say, not only are there disordered readers, those readers may also become disordered writers—like Hornbacher, and like the authors of pro-anorexia websites. It is my hypothesis that these websites are, in general, authored by those who read maladaptively in the fashion described above and who, consequently, showcase their personally disordered interpretations of text—from Wasted to images of the Holocaust—and, in so doing reinforce the validity of reading in this way.42Here I return, momentarily, to the beginning of Hornbacher’s illness and her decision to become anorexic after reading 43 One prominent tenet of the “faith” is the “Thin Commandments,” a list of doctrines that state overtly the claims Hornbacher only implies. For instance, “3. You must buy clothes, cut your hair, take laxatives, starve yourself, do anything to make yourself look thinner”; “10. Being thin and not eating are signs of true will power and success.”44 The near universal presence of this list across pro-ana websites is of particular interest when considering pro-anorexia as a symptom of disordered reading. The Thin Commandments were not written as an instructive basis for the pro-ana cult. Rather, they were conceived of by eating disorder therapist Carolyn Costin as a tool to use in the treatment of anorexia.45 The repurposing of this initially therapeutic text into an instructive model for inspiring anorexia that has become cornerstone of the pro-anorexia movement demonstrates both the disordered reading and the discursive process it encourages. The act of appropriating and reproducing texts across sites perpetuates an anorexic discourse by effacing the therapeutic intent and cementing the disordered reading as the dominant narrative.As touched on previously, pro-anorexia pages tend to reconsider the disorder as a lifestyle, usually a pious, ascetic way of life, consumed by devotion to their goddess, Ana.46 In a similar vein, other sites offer detailed, aspirational descriptions of the goddess figure, Ana, depicting her as a small, fairy-like creature with blue eyes and blond hair. To Ana devotees, she is a reminder of their perceived shortcomings: “She’s someone who’s perfect. It’s different for everyone—but for me, she’s someone who looks totally opposite to the way I do.”47 Ana, this superlative idol, thus emerges as an ideological doppelgänger of Hornbacher, who exists as a god in her memoir, simultaneous author and lead character of the anorexia bible.These websites also commonly feature themes of rebirth, transformation or resurrection, adopting images like dragonflies or butterflies  and 94 lbs (43kg) after her stomach ripped after eating 5.6 liters . . . of food.”50 Although this caption purports to be a warning against the dangers of anorexia, it actually serves the disordered reader as a warning against the dangers of eating. It was not, after all, starvation that killed the woman but, rather, consumption: her perceived gluttony. The written message overwrites the visual, subverting the stated intention and proffering to the reader an alternative narrative more concordant with a pro-anorexia stance. Moreover, positing photographs such as these as apparent warnings against eating disordered behavior is entirely duplicitous—not only is the impact of the photo very different from its alleged intentions, hence its application as a warning spurious, it is also an entirely impotent tool in the treatment of eating disorders, and the astute reader may recognize this tacit assumption as the product of a culture persistently beholden to the myth of anorexia as having a fundamental visual basis. Again, visual culture is given too much credit: no photo can cure anorexia—not even, in perhaps the most shocking use of images on pro-eating disorder websites, where Holocaust imagery is juxtaposed with photographs of anorexia sufferers.51The multimedia aspect of the Internet redoubles these websites’ influential potential. Whereas a simple text can only go so far, websites can couple text and image, and use video, even music, to promote anorexia to readers, sometimes outside of the bounds of the community: Video-sharing website YouTube currently hosts over 37,000 “thinspiration” videos. “Thinspiration” is usually found in images of their transformation of texts into promotional materials. The websites, consequently, saturated with maladaptively interpreted documents, serve to endorse reading disorders, as Hornbacher’s text also does, thereby perpetuating an anorexic discourse and the exploitation of previously value-neutral texts as encouragement.These websites promote eating disorders, intentionally or not, solely on account of the authors’ maladaptive interpretation of image and text: disordered representation and reading. The publishing of images of corpses; the memorials; the equation of anorexia and the Holocaust; “religious” doctrine—all betray the authors’ own disordered approach to reading and 52 Offering a literary-analytic perspective on the idea of anorexia as communicable through texts, I have presented a possible underlying mechanism for the phenomenon. Proponents of “Ana” prescribe, among other things, reading “triggering” material, the ultimate of which is widely considered Marya Hornbacher’s memoir Wasted, which has been accused of glamorizing the illness and encouraging readers to “try it.” Coupled with knowledge of research that shows starvation in healthy men induces eating-disordered behavior, and that such behavior often focuses on obsessive acts of reading, this paper outlines a hypothesis that states a relationship between disordered modes of reading and disordered eating attitudes and behaviors.53 Exploring the rhetoric Hornbacher exploits in her memoir illuminates how those predisposed to anorexia might interpret the text. These readers, for whom anorexia memoirs and other eating disorder literature hold special meaning, consume texts in unexpected ways—one example being those passages that, though they would alienate and appall the majority of readers, act as instructions for those who have non-normative reading attitudes—and regurgitate these interpretations across networks of similar readers online. Close reading of pro-anorexia web content allows me to speculate about how disordered reading works on the other “end” of text—not only as an illustration of individual reading and eating pathology, but as a mode of reception. Excavating Hornbacher’s text clarifies some of the specific ways in which Wasted may encourage disordered eating; further, episodes in her memoir emphasize her own fixation with analysis in general and book-reading in particular. Those textual moments suggest that she herself reads in this distinctive disordered way and that authors of pro-anorexia websites also have these disordered reading attitudes, suggesting, further, that the maladaptive analytical process of a reading disorder necessarily involves the proliferation of such processes—forming an overarching rhetoric of disease; a pernicious cycle in which self-destruction is, accidentally-on-purpose, encouraged: an anorexic discourse.Noting the current fashionable status of anorexia nervosa and the advent and proliferation of websites promoting the anorexic lifestyle, this essay has sought to elucidate the phenomenon. The presence, prominence, and popularity of this emergent discourse, which frustrates a variety of dominant medical, psychiatric and cultural narratives, is greater than ever. Further, a growing body of research orbits around the concern that anorexia nervosa might be transmissible through secretive online networks—and highly contagious.This brief analysis of narrative and anorexia has revealed that reading, writing, consuming, constructing, or deconstructing texts each holds a significant role in anorexia nervosa: there is an intriguing interplay between these ways of engaging with narrative and the instigation, development, maintenance, and transmission of disordered eating behavior. Further investigation ought to be initiated to better understand how anorexia nervosa is narratively constituted, transmitted, shaped, and performed and how narrative engagement and anorexia interact. The close reading of life-writing in relation to anorexia acquisition and the illness experience would begin to address questions such as: What makes anorexia so narratively compelling? What can be learnt about treating and preventing anorexia from how people who become anorexic retrace and explain that becoming? What might reading across anorexia memoirs reveal about anorexia as a “reading disorder”? Are there ways of reading and approaching texts indicated in these narratives that are indicative of future illness and illness trajectories? And how, for example, do shifts and differences in anorexia illness experience within and between narratives, especially life-writing, provide a means to understanding anorexia treatment and recovery?


Adolescent relationships with parents are of the highest importance. The relationships likely reflect the nature of internal working models in youth sport that may well function as a psychological template during the construction of youth prosocial behavior. However, researchers’ focus to date has concerned specific aspects of parental practices in child-based sporting activities. There is a lack of research covering parent-athlete interpersonal relationships concerned with how the relationships affect adolescent prosocial behavior. The purpose of this mixed methods explanatory sequential study was to examine teenage athletes’ prosocial behavior and their relationships with parents. To achieve our purpose, we obtained quantitative data from 1348 athletes and non-athletes (ages 12–16), and qualitative data from 12 adolescent athletes and 12 youth sports parents. In the quantitative phase, we assessed adolescent prosocial behavior regarding the following six forms of prosocial behavior: public, anonymous, dire, compliant, altruistic and emotional. In the qualitative follow-up, three themes emerged from the adolescent athlete’s perspective: (1) sport as an escape; (2) parent-child relationships in youth sports; (3) adolescents’ desired behavior. Three themes emerged from the parental perspective: (1) sport as protection and as a school of life; (2) painful decisions to release a child; (3) understanding adolescent behavior. We found protection from delinquent behavior and increased prosocial behavior with securely attached young athletes who are actively involved in sports. Recent decades have seen a growing concern for the prospects of today’s youth. The significant problems with young people relate to pervasive, destructive and inappropriate behavior: delinquency, aggression, bullying, drug abuse, etc. ,2. TheseRegarding leisure activities, investigations of adolescent involvement in sports activities are worth conducting. An analysis of children’s and especially adolescents’ behavior draws attention to the role of sports in the development of prosocial behavior . SocietyResearchers define prosocial behavior as a voluntary behavior intended to help or benefit another ,10. ThusMany researchers have emphasized that the sporting environment promotes the prosocial development of youth ,14,15 whHowever, both positive and negative associations exist with sports participation, mainly due to its competitive nature and the excessive pressure to win. Researchers and most likely most countries consider aggression a significant observable problem in sporting events from the level of youth sports to games played at the highest levels of competition . FurtherAs reviewed, past research explored the differences in prosocial behavior between genders, the influence of genetic inheritance, and the relationship between personal characteristics and psychological factors. However, research on environmental factors, such as the influence of parents on adolescent prosocial behavior, the sporting environment and the effects of the interactions of these factors, is limited. We intended to explain the link between teenage athletes’ prosocial behavior and their relationships with parents. This study used a sports context to analyze the importance of the relations and communications in the family during adolescence and their significance in the promotion of prosocial behavior in adolescents. Understanding adolescent-parent relationships, adolescent prosocial behavior, and sports participation as a means to promote positive educational interactions between parents and children and to promote prosocial actions, are essential.The researchers used mixed methods research ,20, whicThis study used an explanatory sequential mixed methods design that consisted of two distinct phases . In thisn = 529) of all participants were involved in a competitive sport and had been playing sports for an average of 3.97 years (SD = 2.43).Adolescents (716 girls and 632 boys) aged between 12 and 16 years  participated in the quantitative study. We recruited from seven general education schools in Kaunas, Lithuania, using multi-stage sampling. In phase one we selected schools from all lists of schools. In the second step, we chose participants using a simple random sampling of classes from the selected schools. In the third phase, we invited all schoolchildren to participate in the survey from the selected classes. In total, 39.2%  . We tranReliability of the subscales ranged from 0.63 to 0.86. The PTM-R assesses six types of prosocial behaviors: public, anonymous, dire, emotional, compliant, and altruistic. Public prosocial behaviors are defined as behaviors intended to benefit others and enacted in the presence of others . Anonymous prosocial behaviors are defined as helping behaviors performed without the knowledge of who helped . Dire prosocial behaviors are defined as helping in crisis or emergency situations . Emotional prosocial behaviors are defined as an orientation toward helping others under emotionally evocative circumstances . Compliant prosocial behaviors are defined by helping others in response to a verbal or non-verbal request . Altruistic behaviors are defined as voluntary helping behaviors motivated primarily by concern for the needs and welfare of another . The subjects rated each statement using a 5-point Likert-type scale . Higher scores on each of the subscales reflected a stronger tendency to engage in prosocial behavior.We assessed students’ sports participation using the question “Do you participate in competitive sports?” with two alternative answers: “Yes, I’m actively involved in sports, I go to sport classes at least two hours a week, participate in competitions and these activities have been lasting for at least two years”, “I exercise only in PE classes, I’m not physically active in my free time”.2) and used Cohen’s  (G4). “You go into competition, and you hate your opponent because it’s easier to fight this way and to win” (G4).How young athletes can consciously leave stress and anger behind, control their emotions and behavior and follow the human values of athletic etiquette in such a short time after competitions is difficult to comprehend. “Respect for the opponent is always there; you shake hands and bow truly because that means respect” (G4). “Every athlete in one way or another is very sensitive towards his teammates, even the opponent: respect, help, and trust are always there” (A12).Consequently, the emotions experienced in sports and behavior modeling transfer to everyday communication in life: “I learned a lot from sports, how to behave, how to communicate with people, family, and peers and how to make decisions and how to accept the right one” (R2). Therefore, not surprisingly, parent-child relationships reflect the strengthening of character in adolescent athletes. Sports influence the development of a purposeful, goal-seeking and robust personality. The understanding of common goals and objectives by both parents and children helps build the desired parent-child relationships in the family.In the qualitative follow-up, three major themes emerged from parents’ point of view see : (1) spoAll participants in the study, in one way or another, mentioned their child’s noticeable changes after involvement in sporting activities. Parents admit that sports encourage personality and adolescent behavior development in their growing child: “The importance lies not in physical abilities, but in thinking, in confidence; children who play sports are taught to see and understand the world differently, to behave in a different manner” (A1).The parents see that the sporting environment helps foster their child’s individuality. Children develop a sense of duty, and their character becomes stronger with independence. Empathy, altruism, and prosocial behaviors develop during adolescence: “Children who are involved in sports are friendly, they share the last piece of a sandwich, the last coins” (D6) “It means that your child is emphatic. Other human values are very important. Her sense of duty has become stronger, and she is not afraid of work, she is ready to work hard and long, with patience to achieve the desired result [says slowly but surely]. She (daughter) achieved what she wanted through hard work” (M10).It is a painful decision for parents to let their child act independently. The participants shared their regretful feelings that the participation of their developing children in sports had become a means of escaping the influence of parents. They understand that adolescence and detachment are inseparable. In this period of a child’s growth, parents must address new experiences: adolescents start rejecting the active participation of their parents in sports. Parents have to learn to equalize, to watch their child’s emotions, and adjust to an adolescent’s changing mood: “I haven’t seen her for a month again. I want to hug my child and so on, but I don’t have her. I became aware that I have no child, I am like some kind of supporting, invisible means used only for the financing of everything” (L12).The youth expressed reticence and avoidance of parents tactfully and diplomatically: “He used to say: mom, you don’t need to come here [competitions], don’t worry. I asked him to call me, but he would answer: mom, I’m busy, I don’t have time” (C2).Parents model their behavior and try to find the best ways of approaching their children. From the interviews with the parents, we observed that they all consider their input as significant and supportive, regardless of the form (positive and supporting or negative and destructive) and the level of their participation in their children’s sporting activities from their perspective. Every parent described different participation experiences, sometimes entirely unexpected. An agitated mother calls her situation desperate and her involvement in youth sports as “fake support” (D6). Another parent indicated careful parent involvement: “very carefully, everything must be very natural” (M10). Other types of parental involvement emerged: “over-involved parents” (A1), “critical parents” (S5), and “parents as coaches’ assistants” (Ch3). This topic emerged with the goal to describe parents’ understanding of support: what kind of support and behavior would be appropriate and what kind of support exists within their families.Looking back at the beginning of a child’s participation in sports, parents have interesting insights. The insights concern the fundamentals of a child’s education in a family that qualifies the understanding of support when the child starts playing sports: “Parents must be an example to be followed and communication with them must be pleasant; only then will children take on what you are trying to instill” (M10). Another research participant shares the same opinion: “first of all, there has to be an example in the family, especially for a small child, while he grows and becomes acquainted with the environment” (R2). Life changes a lot when children are born. Parents must satisfy their children’s needs and ignore some of their own needs. Chloe said that “life changed when they were born” (Ch3). Parents have new responsibilities and duties, and less spontaneity and enthusiasm remain, “you have to assume responsibility at once, you have to take care of things, you have to dedicate a big part of your time to something” (S5). The same is true for sporting activities. Children have different needs and expectations in new environments. New parental commitments must be established harmoniously with the child’s intentions in sports. New learning must occur, and everyone must adapt. For parents, this is similar to working with oneself. In sporting activities, parents learn to behave with children and learn to admit to their mistakes.An instance that illustrates the changes in parents’ lives is at the time they follow their children’s example and start playing sports themselves. This example is a very positive behavior that shows that children’s involvement in sports brings positive changes to parents’ lives. Children help parents start playing sports: “When I took her to a sport class, I would sit on a bench and wait; then, I started exercising to make the waiting less boring” (M10). “It’s nice when children start playing sports, and then their parents get involved. They spend time together not only at home, but in the gym too. In competitions, parents start playing sports as well” (M10).New skills are required, perhaps different from those used at home, to show empathy when a child loses a competition: “sometimes, I have to express consolation. To me, this means improving my personality, learning what to say, when to speak, to not say too much nor too little; learning how to behave” (L12). The research participants believe that being in sports similarly to their child allows for the development of their personalities: “At the same time, I see the advantages for myself too because I am still learning to find balance in life [holds back tears], to choose priorities” (A1). “It teaches tolerance, patience, and believing in your child when no one else believes; I think that is the most important thing” [tries to hold back tears] (A1).The objective of this mixed method explanatory sequential study was to reveal the effects of participation in youth sports and relationships with parents on adolescents’ prosocial behavior. We identified six factors in the quantitative research (study I), including public, emotional, altruistic, dire, compliant, and anonymous behaviors, which predicted the prosocial behavior of adolescent athletes and non-athletes. During the quantitative study, we further analyzed whether a difference exists between adolescent athletes and non-athletes in their prosocial behaviors. The expression of prosocial behavior among adolescent athletes resulted in two scales (public and dire) compared to adolescents who do not play sports.Next, we conducted a qualitative analysis (Study II) to understand the experience of athletes, to look at the study results from multiple forms of data and to gain a complete understanding of the research. In the quantitative research, the adolescent athletes most extensively expressed confidence in public prosocial behavior. Since public prosocial tendencies are behaviors that benefit others in front of an audience , the spoAlso, we see parents’ experiences allow for the assertion that adolescents’ public prosocial behavior through theme “sport as protection and as a school of life” and the subtheme “a place to show themselves”. Parents described their children’s feelings of being proud to show their medals, trophies and other achieved victories and explained how much it means to them. The parents indicated that making these achievements visible to everyone was very important to the adolescent athletes.The quantitative results show that emotional prosocial behavior is not inherent to athletes. In the sports environment, emotional, altruistic, compliant prosocial actions may not be inherent in result-oriented athletes. Teenage athletes who are actively engaged in sports learn to set goals, plan their activities and seek desired results . AthleteThe study revealed statistically significantly higher results for adolescent athletes’ dire prosocial behavior compared to non-athletes. Carlo and colleagues defined helping in emergencies as a dire prosocial tendency . SportinQuantitative research revealed that compliant behavior was not statistically significant in adolescent athletes. The qualitative theme “parent-child relationships in youth sport” from an adolescent point of view explains the results and demonstrates how compliant adolescent behavior develops and how parent-child relationships in youth sport appear. Adolescent athletes express themselves and illustrate how sport brings families closer together. Different communication between the parent and the child appears, with increased trust feeling and positive emotions that are very important to adolescent athletes. Compliant behavior is highly visible in parent-adolescent athletes. However, adolescents reflected their opinion about the need for mutual communication as well.Altruistic behavior in adolescent athletes as shown in the quantitative results is not statistically significant. However, the qualitative phenomenological study explained and expanded upon the quantitative results. Parent interviews revealed that empathy, altruism, and prosocial behavior develop during adolescence, especially in sports environments. Parent interviews also highlighted that parenting style and family culture has a direct impact on adolescent altruistic behavior. This finding may be bi-directional. For instance, the study by  also exaThe results of the quantitative study show that adolescent athletes scored higher on public, dire and anonymous prosocial behavior. The qualitative phenomenological analysis showed how prosocial tendencies such as anonymous are inherent to athletes, especially relative to family involvement in youth sports. The responses provided by the adolescents indicate anonymous prosocial behaviors in the theme “desired behavior by adolescents”, which illustrates the different types of prosocial behaviors. Adolescent athletes’ anonymous prosocial behavior is reflected through the subtheme namely “prosocial behavior” . AthleteAdolescents’ relationships with parents are a critical factor and likely reflect the nature of the internal working models in youth sports that may function as a psychological template in the development of prosocial behavior during adolescence. Adolescents’ involvement in sports and their relationships with parents are significant predictors of prosocial behaviors. Public, anonymous and dire prosocial behaviors are evident in adolescent athletes. Maximizing emotional, compliant, altruistic prosocial behavior through fostering interpersonal relationships between a parent and a child is possible. This study expands upon the understanding of how the quality of parent-adolescent interpersonal relationships increases the development of adolescent prosocial behavior.


Low-protein diets (LPD) are an important means of delaying the need for dialysis and attaining a stable metabolic balance in chronic kidney disease (CKD). Many authors consider a low educational level and illiteracy to be adverse features for a good dietary compliance.We report the case of a 77-year old woman, illiterate, affected by advanced CKD (stage 4 according to KDIGO guidelines). She was initially ashamed of her problem and did not declare it, leading to an overzealous reduction in protein intake. However, with her daughter’s help, who translated the dietary prescription into images, she overcame the barrier represented by illiteracy and was able to correctly follow the prescriptions, attaining good kidney function stability and preserving an adequate nutritional status.The case underlines the importance of a personalized approach to dietary prescriptions and suggests that it is possible to achieve a good compliance to the dietary treatment of CKD also in patients with relevant cultural barriers. Low protein diets are considered effective tools in reducing proteinuria, correcting and preventing signs, symptoms, and complications of chronic kidney disease (CKD), delaying the start of dialysis, preventing malnutrition and providing cardiovascular protection .The use of low-protein diets is still open for debate. Besides the risk of malnutrition, the main reason why many authors feel diets are not worth prescribing is that it is often met with poor compliance, especially when the diet is combined with the complex therapies that are usually needed in our patients with advanced CKD –6.Adherence to the prescriptions is also linked to the educational level; however, recent studies have underlined that the educational level may not be an absolute barrier in motivating patients and attaining compliance , 8. WhilNew England Journal of Medicine, showing how low compliance to anti-diabetic drugs was resolved by the “diagnosis” of illiteracy [Illiteracy, justly considered a “silent epidemic”, is not negligible in several areas, including developed countries, especially in elderly patients. The importance of illiteracy was underlined in a recent case report published in literacy .Our case report describes an illiterate patient with severe CKD, who created with her daughter a clear and simple visual aid allowing good compliance; her story calls once more for attention to this neglected social and clinical problem, and conversely suggests that illiterate patients may provide important lessons on compliance and empowerment. While warning against discrimination of patients with a low educational level, this case underlines the importance of taking time in the clinical practice to consider cultural barriers which could potentially impair the success of the care in CKD patients.A 77 years old woman was referred in 2014 to our outpatient unit dedicated to advanced CKD in the Brotzu Hospital in Cagliari, Sardini, from a different nephrology unit where she had been followed since 2005. In 2006, a kidney biopsy led to the diagnosis of focal and segmental glomerulonephritis with advanced tubular interstitial damage.Her clinical history was characterised by long-lasting hypertension (for at least 30 years). In 2011, she underwent total thyroidectomy, due to a multi-nodular colloid-cystic goitre. In 2013, she underwent a radical left mastectomy for a ductal infiltrating carcinoma (G2 pT2 pN3) and was treated afterwards with radiotherapy and aromatase inhibitor. Furthermore, in the past few years, she had lost a considerable number of teeth and suffered from chewing difficulties.The patient had been referred to our unit because of a rapid worsening of her kidney function, with an estimated Glomerular Filtration Rate (eGFR), calculated with the Chronic Kidney Disease – Epidemiology Collaboration (CKD-EPI) formula that decreased from 25 to 16 ml/min in five months. An in-depth history and a basic workout had ruled out the most common causes of rapid worsening of the renal function, including dehydration caused by infectious illness or by climatic conditions, ingestion of NSAIDs or any other drug out of those prescribed, cardiac, and vascular disease. At referral, her therapy included levothyroxine 100 mcg, furosemide 50 mg, losartan 50 mg, lercarnidipine 10 mg, ramipril 10 mg, allopurinol 150 mg, ezetimibe 10 mg/simvastatin 20 mg, calcium carbonate 1.25 g twice a day and cholecalciferol 25,000 UI every other week.The patient lived with her husband and had had four children; a son and a daughter lived close by. One son had been on hemodialysis and had died at the age of 48 years from sepsis.The patient, living in the countryside, was illiterate, a rare but not exceptional situation in her age group in our region .2) and the blood pressure control was suboptimal (PA 150/90 mmHg without difference in orthostatism).At the first physical evaluation, the patient was overweight  divided into three main meals and a midmorning snack, with a high consumption of pasta and bread. Since the importance of reduction in protein intake had been discussed in a previous clinical visit, at referral she had tried to self-manage her diet, resulting in an unbalanced low-protein diet, completely avoiding animal proteins and reducing the caloric intake. This overzealous attitude is a common and often underestimated problem in particular in elderly patients “scared” of dialysis. Almost paradoxically, in such cases, starting a “low protein diet” may lead to an increase in animal-derived proteins, to attain a stable balance, protective not only for the nutritional status but also for the renal function –18.This was the case also in our patient. On account of the calculated previous protein intake, we attempted to re-equilibrate the diet by substituting the normal carbohydrates, on which the Italian diet is based, with protein-free food , with a target intake of 0.6 g/kg/day , increasing at the same time the animal-derived proteins. The diet included a daily intake of 1.3 g of sodium, 2 g of potassium and 800 mg of phosphorus.At the first clinical visit after the diet prescription, kidney function was further reduced Table , and theNotwithstanding her difficulties, the patient appeared motivated in following any advice that could postpone dialysis , the family was involved in the counselling process and underwent extensive counselling during the following clinical visits.At the following visit, overall compliance  was remarkably improved Table . When asOne and half years later, she was following the diet with good compliance, stable GFR and satisfactory nutritional status Table . Indeed,This clinical case shows how a low protein diet could also be followed where the premise does not look promising. Illiteracy is indeed an important obstacle as the impossibility to rely on written aids makes the daily management more difficult.When prescribing a diet, the evaluation of the education level is not a point to be underrated, as even the best possible diet would never be successful if not understood by the patient. Our patient presented with this huge barrier: she was illiterate, and she was consequently unable to follow a written diet; moreover, being ashamed of her lack of education, she did not declare it in the beginning. This is not an exceptional problem in our setting: in Sardinia, in the 1940s, the rate of illiteracy was quite high, especially in the countryside and among women. Within a farmer’s family, children would generally start working from the earliest age possible and would not even attend primary school, which was the case for our patient .When we realised this challenging problem, we decided not to give up because the patient, who had lost a son on haemodialysis, strongly refused the future option of renal replacement therapy.A number of studies demonstrate an association between low educational level and low dietary compliance. Hadžiabdić analysed the factors that influence the adherence to low-calorie diets in overweight and obese patients and underlined how poor educational level is one of the negative predicting factors for a successful program . Khan inThe literature also shows suggests that, beyond education, the socio-economic level is related to the choice of “good quality” food . RecentlSeveral diseases are influenced by the socio-economic status: this is the also case of type 2 diabetes, which shares some features with chronic kidney disease, accounting for diet and need for self-management. Walker has recently analysed the association between socio-economic factors, psychological status and disease, highlighting a significant correlation between glycated haemoglobin, education, income, and self-efficacy .Shah compared the treatment burden in celiac patients and in other chronic diseases, including CKD on dialysis. Celiac disease shares with CKD the importance of dietary compliance, which is made more complicated by the need to pay attention to gluten contamination; an issue not shared by CKD patients, who may, on the contrary, profit of occasional unrestricted meals. Also, poor diet compliance in patients with celiac disease has been associated with income (cost of food), lifestyle, educational level and time available to prepare meals .Illiteracy and low socio-economic background have many further correlates, including poor oral status; indeed, our patient presented with chewing difficulties, a significant issue as for malnutrition, especially in the elderly, that should also be taken into account when prescribing a diet , 29.Despite the initial difficulties, the daughter’s idea to convert the dietary advice into visual form allowed the patient to follow the diet in an optimal way. This also helped to avoid the risk of undernutrition, or of an unbalanced and over restricted protein intake, which could potentially be more deleterious than a high protein intake, both with respect to general health and to residual kidney function Table .As shown in the figures, using the symbols of a clock, the sun and the moon with the stars, the woman could understand what meal the pictures referred to. The patient knew that pasta, rice and bread had to be replaced by protein-free food in order to reduce total protein intake and to reach the target, calculated by her residual kidney function.This self-made method achieved the goal of adequate compliance, reducing the patient’s “performance stress” and allowing her to follow the diet without depending on her family, who, due to work commitments and personal needs could not provide continuous assistance. In this process, we believe that the use of visual aids also played a fundamental role in reassuring the patient, who was scared with the prospect of starting dialysis primarily because of her family loss. We assume this psychological aspect was important since the patient continued to rely on her support, having learned how to follow her diet correctly.This strategy permitted the stabilization of the residual kidney function, thereby fulfilling the patient’s wish to delay dialysis as much as possible.Our report warns against the discrimination of patients who are illiterate with regard to the prescription of low protein diets and the belief that they have limited understanding and poor compliance. The case described here may highlight how breaking cultural barriers can be empowering and enhance compliance and motivation, which may conversely be strengthened by the clinical success obtained. It also suggests the importance of the family support unit and underlines how CKD involves the whole family, and how family involvement may also be a resource for attaining compliance.