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Eating Disorders and Social Media Prove Difficult to Untangle

Social media platforms like TikTok and Instagram try to monitor for content related to the problem, but it is not always clear what to do about it.

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By Kate Conger ,  Kellen Browning and Erin Woo

A 27-year-old YouTube star, prodded by her millions of followers with concerns about her health. A 19-year-old TikTok creator who features posts about being skinny. Teen communities throughout the internet, cleverly naming and culling their discussions to avoid detection.

They present a nearly intractable problem for social media companies under pressure to do something about material on their services that many people believe is causing harm, particularly to teenagers.

Those concerns came into sharp focus in recent weeks in a pair of Senate subcommittee hearings: the first featuring a Facebook executive defending her company , and the second featuring a former Facebook employee turned whistle-blower who bluntly argued that her former employer’s products drove some young people toward eating disorders .

The hearings were prompted in part by a Wall Street Journal article that detailed how internal Facebook research showed Instagram, which is owned by Facebook , can make body image issues worse for some young people.

On Tuesday, executives from YouTube, TikTok and Snapchat are scheduled to testify before a Senate subcommittee about the effects of their products on children. They are expected to face questions about how they moderate content that might encourage disordered eating, and how their algorithms might promote such content.

“Big Tech’s exploiting these powerful algorithms and design features is reckless and heedless, and needs to change,” Senator Richard Blumenthal, a Democrat of Connecticut and the chair of the subcommittee, said in a statement. “They seize on the insecurities of children, including eating disorders, simply to make more money.”

But what exactly can be done about that content — and why people create it in the first place — may defy easy answers. If creators say they don’t intend to glamorize eating disorders, should their claims be taken at face value? Or should the companies listen to users complaining about them?

“Social media in general does not cause an eating disorder. However, it can contribute to an eating disorder,” said Chelsea Kronengold, a spokeswoman for the National Eating Disorders Association . “There are certain posts and certain content that may trigger one person and not another person. From the social media platform’s perspective, how do you moderate that gray area content?”

The association advises social media companies to remove content that explicitly promotes eating disorders and to offer help to users who seek it out.

But young people have formed online communities where they discuss eating disorders and swap tips for the best ways to lose weight and look skinny. Using creative hashtags and abbreviations to get around filters, they share threads of emaciated models on Twitter as inspiration, create YouTube videos compiling low-calorie diets, and form group chats on Discord and Snapchat to share how much they weigh and encourage others to fast.

Influencers in fashion, beauty and fitness have all been accused of promoting eating disorders. Experts say that fitness influencers in particular can often serve as a funnel to draw young people into extreme online eating disorder communities.

YouTube, Snapchat, TikTok and Twitter have policies prohibiting content that encourages eating disorders. The companies should improve their algorithms that can surface such content, Ms. Kronengold said.

“It becomes an issue, especially when people are coming across this content who can be harmed by it or don’t want to see it,” she said.

Like many other popular YouTube creators, Eugenia Cooney, 27, makes videos that share her favorite fashion and makeup items with her more than two million followers. But for years, her viewers have not focused on the topics of Ms. Cooney’s videos. Instead, they flood her comments with concerns about her health.

Although she spoke in 2019 about her struggles with an eating disorder in interviews with other YouTubers, Ms. Cooney rarely addresses her audience’s concerns. While some viewers flock to her social media profiles on YouTube, Twitter, Instagram and the streaming service Twitch to beg her to seek treatment, others have accused her of using her platform to promote eating disorders to young people.

They say her videos are examples of “body checking,” a habitual behavior of reviewing the appearance of one’s body that is often associated with eating disorders. Over 53,000 people signed a petition in January asking social media companies to remove her content.

“I just kind of feel like everybody has the right to make videos and to post a photo of themselves,” Ms. Cooney said in an August video. “With me, people will always be trying to turn that into such a bad thing.” She did not respond to requests for comment from The New York Times. YouTube said Ms. Cooney’s content did not violate its rules.

“We work hard to strike a balance between removing harmful videos about eating disorders and allowing space for creators and viewers to talk about personal experiences, seek help, and raise awareness,” said Elena Hernandez, a YouTube spokeswoman. “We reduce the spread of borderline content about eating disorders that come close to violating our policies but don’t quite cross the line.”

YouTube does not prevent users from searching for eating disorder content, although it does include an eating disorder help line at the top of its search results for some common terms related to the topic.

The company surfaces one of Ms. Cooney’s fashion videos among its top search results for “thinspo,” a common phrase that refers to “thin inspiration,” along with compilations of videos that originally appeared on TikTok.

YouTube allows Ms. Cooney to make money from her videos. Ads from health food companies like Sweetgreen, Imperfect Foods and HelloFresh often appear on her content, even though Ms. Cooney mainly discusses makeup and fashion rather than diet or food.

Mishel Levina, a 19-year-old college student in Israel with 21,000 followers on TikTok, encourages her viewers to “block if you’re sensitive.” Her videos show off her waist and stomach, feature song snippets about being skinny, and include text about losing weight.

Ms. Levina acknowledged that some of her behavior was unhealthy, but said she was just sharing her life and was not urging other people to starve themselves.

“I’m being called out for promoting bad eating habits — I’m not promoting them,” she said in an interview. “I’m just making a joke out of them — it’s all a joke. It’s social media. I’m not pushing this on you. I’m sharing information. It’s your decision to take it and use it or to leave it aside and just skip it.”

Last year, TikTok began cracking down on content that explicitly encourages eating disorders and blocking some hashtags that promote disordered eating. But it has allowed creators to continue to share videos that discuss recovery or crack subtle jokes about eating disorders.

Despite efforts to hide harmful content, some content that promotes eating disorders is still available. Some hashtags related to the topic have over 70 million views. But searching for phrases like “anorexia” prompts the app to offer a phone number for the National Eating Disorders Association instead of any videos.

TikTok said that it, too, tried to differentiate videos of people sharing their personal experiences from more harmful content that promoted unhealthy behavior.

“We aim to foster a supportive environment for people who share their recovery journey on TikTok while also safeguarding our community by removing content that normalizes or glorifies eating disorders,” Tara Wadhwa, TikTok’s director of U.S. policy, said in a statement.

But many popular TikTok trends that do not explicitly promote eating disorders still highlight thin bodies, implicitly advocating thinness as the ideal.

“My first trend, ironically, is something that makes me feel awful,” said McKenzie Ellis, 26, whose music was featured in a recent “hip walking” trend where creators filmed close-ups of their waist while walking.

On Twitter, creators routinely share advice for crash diets and encourage disordered eating, and some amass tens of thousands of followers in the process. Twitter’s algorithms automatically suggest related accounts and topics for users to follow, based on the accounts they view. When a Twitter user views accounts that promote eating disorders, Twitter recommends topics like “fashion models,” “fitness apps & trackers,” “mindful eating” and “workout videos.”

Twitter said that its policies prohibit content that promotes eating disorders or provides instructions or strategies for maintaining them, and that the company primarily relies on users to report violative content. A spokeswoman for the company said that its topic recommendations differed by account.

“While we remove content that violates our policies on suicide and self harm, we also allow people to share their struggles or seek help,” the spokeswoman said.

On Snapchat, users often form group chats dedicated to privately encouraging one another to pursue eating disorders. Some of the chats are focused on providing negative feedback, essentially bullying the participants about not fulfilling their diet goals. Others provide positive feedback.

After an inquiry from The New York Times, Snapchat said it would ban terms related to the group chats from being used in users’ display names, group chat names and search. The company previously blocked a number of common terms associated with eating disorders and provides suggestions for resources, a spokeswoman said.

Ms. Levina, the TikTok creator, said she did not think she needed to moderate her content to avoid influencing young people to start unhealthy behaviors. Instead, Ms. Levina suggested, teenagers were old enough “to understand the information given and decide what to do.”

But Dr. Khadijah Booth Watkins, the associate director of the Clay Center for Young Healthy Minds at Massachusetts General Hospital, said that young people are especially impressionable, so content creators should consider that they could be swaying teenagers into making dangerous health choices.

“Having the awareness that you are being followed and that people are listening to you and seeking your guidance bears with it a certain level of responsibility,” Dr. Booth Watkins said. “Reliable and valid information about weight loss, particularly on social media, should only be done by qualified, licensed nutritionists.”

If you or a loved one is struggling with an eating disorder, contact the National Eating Disorders Association help line for support, resources, and treatment options at (800) 931-2237. You can find additional resources at NationalEatingDisorders.org .

Sheera Frenkel contributed reporting.

Kate Conger is a technology reporter in the San Francisco bureau, where she covers the gig economy and social media. More about Kate Conger

Kellen Browning is a technology reporter in the Bay Area covering the video game industry and general tech news. He graduated from Pomona College. More about Kellen Browning

Erin Woo is a reporting fellow on the technology desk. She graduated from Stanford University. More about Erin Woo

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Open Access

Peer-reviewed

Research Article

The social media diet: A scoping review to investigate the association between social media, body image and eating disorders amongst young people

Roles Conceptualization, Data curation, Formal analysis, Methodology, Visualization, Writing – original draft, Writing – review & editing

Affiliation Institute for Global Health, University College London, London, United Kingdom

Roles Conceptualization, Data curation, Methodology, Supervision, Validation, Writing – review & editing

* E-mail: [email protected]

• Alexandra Dane, 
• Komal Bhatia

• Published: March 22, 2023
• https://doi.org/10.1371/journal.pgph.0001091
• Peer Review
• Reader Comments

Eating disorders are a group of heterogenous, disabling and deadly psychiatric illnesses with a plethora of associated health consequences. Exploratory research suggests that social media usage may be triggering body image concerns and heightening eating disorder pathology amongst young people, but the topic is under-researched as a global public health issue.

To systematically map out and critically review the existing global literature on the relationship between social media usage, body image and eating disorders in young people aged 10–24 years.

A systematic search of MEDLINE, PyscINFO and Web of Science for research on social media use and body image concerns / disordered eating outcomes published between January 2016 and July 2021. Results on exposures (social media usage), outcomes (body image, eating disorders, disordered eating), mediators and moderators were synthesised using an integrated theoretical framework of the influence of internet use on body image concerns and eating pathology.

Evidence from 50 studies in 17 countries indicates that social media usage leads to body image concerns, eating disorders/disordered eating and poor mental health via the mediating pathways of social comparison, thin / fit ideal internalisation, and self-objectification. Specific exposures (social media trends, pro-eating disorder content, appearance focused platforms and investment in photos) and moderators (high BMI, female gender, and pre-existing body image concerns) strengthen the relationship, while other moderators (high social media literacy and body appreciation) are protective, hinting at a ‘self-perpetuating cycle of risk’.

Social media usage is a plausible risk factor for the development of eating disorders. Research from Asia suggests that the association is not unique to traditionally western cultures. Based on scale of social media usage amongst young people, this issue is worthy of attention as an emerging global public health issue.

Citation: Dane A, Bhatia K (2023) The social media diet: A scoping review to investigate the association between social media, body image and eating disorders amongst young people. PLOS Glob Public Health 3(3): e0001091. https://doi.org/10.1371/journal.pgph.0001091

Editor: Rakesh Singh, Transcultural Psychosocial Organization Nepal / KIST Medical College, NEPAL

Received: August 10, 2022; Accepted: January 23, 2023; Published: March 22, 2023

Copyright: © 2023 Dane, Bhatia. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Eating disorders in the 21st century, types and burden..

Eating disorders are a group of heterogenous, disabling and deadly psychiatric illnesses that severely impair daily psychological and social functioning [ 1 ]. Characterised by disturbed body image attitudes and extreme preoccupations with weight and shape, eating disorders manifest as persistent and worrisome disordered eating behaviours [ 2 ]. International ICD-11 and DSM-5 diagnostic classification tools recognise six principal clinical eating disorders [ Table 1 ] [ 3 ]. A supplementary Other Specified Feeding and Eating Disorder (OSFED) category captures approximately 60% of cases that do not meet criteria for clinical diagnosis [ 4 ].

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Eating disorders incur an estimated 6–10% increase in years lived with disability [ 7 ]. Outcomes range from cardiovascular disease, reduced bone density, to comorbid psychiatric conditions, namely depression, anxiety, obsessive compulsive disorder and specific phobias [ 8 , 9 ]. Amongst young females, eating disorders are one of the leading causes of disability, often preceding amenorrhea, reduced fertility, and adverse pregnancy and neonatal outcomes [ 10 , 11 ]. Anorexia has the highest mortality amongst all mental disorders: only 50% of individuals fully recover [ 7 , 8 , 12 ].

The cost of eating disorders at a health systems level is significant, fuelled by increased hospitalisations and the significant burden placed on primary and outpatient services. At a societal level, reduced workforce participation, family members as unpaid carers and young people out of education are noteworthy outcomes of eating disorders [ 11 ].

Epidemiology.

Despite perceptions of eating disorders as a culturally bound syndrome of the West, they affect individuals worldwide [ 7 ]. Estimating global prevalence, however, is challenging. Nationally representative data are scarce, the disorder tends to be omitted from national health surveys, and multiple changes to classification have confounded existing global data [ 13 – 15 ]. Despite this, the most recent Global Burden of Disease study calculated that in 2019, approximately 13.9 million people suffered from Anorexia or Bulimia. A subsequent review highlighted an additional 41.9 million overlooked cases of OSFED and binge eating disorder, indicating a total global prevalence of 0.7% [ 2 ]. However, since many cases never present at formal health services, actual prevalence may be much greater [ 16 ]. A review of 94 studies from Asia, Europe and North America revealed that the weighted mean of lifetime prevalence of any eating disorder was 8.4% for women and 2.2% for men [ 17 ].

Whilst females still represent the largest proportion of cases, the greatest increase is amongst males, athletes, those with obesity, and sexual and gender minorities [ 18 – 21 ]. Most eating disorders begin in adolescence but tend to persist throughout adulthood [ 22 ]. Therefore, young people constitute a subgroup of particular concern [ 13 , 17 ].

Aetiology and risk factors.

The aetiology of eating disorders is complex; no single risk factor accounts for their manifestation [ 23 ]. Rather, prevalence is hypothesised to be the result of numerous biological, psychological, psychosocial, and behavioural factors [ Table 2 ].

https://doi.org/10.1371/journal.pgph.0001091.t002

Body image, a multidimensional psychological construct encompassing how we think, feel and act towards our bodies—has been recognised as the most salient and consistent predictor of eating disorder symptomatology [ 9 , 25 , 26 ]. Although grounded in physical appearance, body image is rarely synonymous with it—individuals often view themselves through a lens of dysmorphia, seeing fatness, ugliness, or an endless list of flaws. The need to ‘fix’ what is ‘faulty’ is thought to precede compensatory disordered eating and appearance altering behaviours [ 27 ]. Owing to pubertal weight gain, wavering self-esteem, and a strong desire to fit in, body image concerns often begin in adolescence [ 28 ].

The rise of social media

With increasing eating disorder prevalence, attention has turned to the growth of social media. In 2020, social media reached 49% of the global population [ 29 ]. Platforms including Facebook (FB), YouTube (YT), Snapchat (SC), Instagram (IG), WeChat and TikTok have created a new online world for today’s youth. Recent reports reveal that 91% of UK and US adolescents use social media, with over 50% checking these at least once per hour [ 30 ]. Users can choose who to follow or message, what content to engage with or upload, what to highlight or conceal. Using filters and editing tools, individuals can alter their identities and dictate how they and their lives are perceived by others [ 20 ].

What is posted and well-received is not coincidental–it is dynamic, shaped by broader social and cultural ideals related to beauty [ 31 ]. Online, young people are exposed to the ever-changing societal ideals of the ‘desired body’, with perfection as the often-unattainable end goal [ 9 ].

Rationale for review

Body image dissatisfaction and eating disorder pathology amongst young people is rising. According to a recent UK Government report, 95% of under 18’s report that they would change their appearance, and body image was one of the top three anxieties amongst Australian youths [ 32 , 33 ]. An estimated 13% of young people experience an eating disorder by the age of 20, and 15–47% endorse disordered eating cognitions and behaviours [ 23 ]. Exploratory evidence indicates that social media usage may be partly to blame [ 34 , 35 ].

Research has highlighted factors such as the ease of accessing harmful eating disorder-promoting content, the pervasiveness of personalised ‘for you page’ algorithms and the explosion of weight loss trends that inspire extreme fitness or thinness [ 20 , 36 , 37 ].

In parallel, recent publications have drawn attention to rising concerns of modern social media platforms and public health, and the need to understand app engagement amongst younger demographics [ 38 ].

Despite this, the association between social media, body image and eating disorders remains relatively unexplored. However, with 41.9 million neglected cases of eating disorders in 2019, combined with unprecedented social media exposure amongst young people, this issue warrants further review from a global health perspective. Is social media a plausible risk factor for the development of body image concerns and recent rise in eating disorders? If so, is it a global or western phenomenon?

Research aim and objectives

Our review aims to systematically map out and critically review the existing global literature on the relationship between social media, body image and eating disorders amongst young people. We provide a glossary of key terms to aid global health audiences unfamiliar with terminology related to social media, body image and eating disorders [ Table 3 ] .

https://doi.org/10.1371/journal.pgph.0001091.t003

In this review, we assess whether social media use could be a plausible and significant risk factor for the development of subclinical and clinical eating disorders on a global scale. We identify populations of young people affected, primary outcomes and any moderating or risk enhancing factors. We also explore pathways that may mediate the relationship between body image concerns and eating disorders/disordered eating behaviours within distinct social media platforms. Finally, we highlight gaps in the literature and recommend areas of focus for future research and for global health.

Methodology

We used Arksey and O’Malley’s framework and the updated PRISMA checklist for scoping reviews [ 39 , 40 ] to guide our approach.

Search strategy and study selection

We searched MEDLINE, PyscINFO and Web of Science databases in May 2021 and updated our search on 20 th July 2021. We identified appropriate search terms through preliminary reading and listing relevant Medical Subject Headings. Keywords were related to four principal concepts: social media, body image, eating disorders and young people [ Table 4 ]. We entered keywords manually and used the “*” symbol to capture all potential word-endings. A full search strategy for PsycINFO is in S1 Fig .

https://doi.org/10.1371/journal.pgph.0001091.t004

We exported search results from each database to the reference manager Zotero. First, we removed duplicates. Next, we screened titles and abstracts and eliminated irrelevant papers. Subsequently, we assessed full-text articles against predetermined eligibility criteria, and recorded reasons for exclusion [ Table 5 ]. We identified additional studies through hand searching reference lists. Both authors independently screened titles and abstracts and reviewed full-text articles for inclusion. One reviewer carried out data extraction from all included studies, and the other reviewer independently verified that all entered information was correct. Any discrepancies were resolved by enlisting the help of additional reviewers who were not part of the study but had the relevant background in global health and nutrition.

https://doi.org/10.1371/journal.pgph.0001091.t005

To allow for sufficient depth of analysis and documentation of individual differences, we included studies involving young people (defined by the WHO as individuals aged 10–24 years), irrespective of gender, sexuality, ethnicity, or existing eating disorder status. If papers did not indicate the age range of participants, we included them if the reported mean age was ≤ 24. Our review was not restricted by geographic location or country income grouping, as a deliberate measure to develop a global understanding of social media use and body image or eating disorder, without making assumptions about the existence or nature of the phenomenon in countries categorised as low- or middle-income. We included studies on any social media platform (singular, multiple, or general), but not those focusing on mass media and / or internet use. We excluded studies exploring social media interventions and body image / disordered eating outcomes because they were beyond the scope of our review. Papers published between January 2016 and July 2021 were eligible.

Data extraction, charting and critical appraisal

Data charting process..

We used a data extraction table to synthesise relevant information from each study, starting with study type, country, and World Bank Income classification [ 41 ]. We also recorded number of participants, gender (percentage female), age range (mean and standard deviation), sexual orientation and ethnicity. After testing the extraction framework on a small number of included articles, BMI and eating disorder prevalence were added as additional participant characteristics.

We extracted information on study objectives, social media platform(s), underlying theoretical framework (stated or indicated) and definitions of exposure (social media usage), outcome (body image or eating disorder / disordered eating), mediator or moderator variables.

Critical appraisal.

Formal critical appraisal is not a requirement of scoping reviews [ 42 ]. However, we aimed to analyse the relationship between social media, body image and eating disorder pathology and the plausibility of social media as a risk factor for clinical / subclinical eating disorders to guide future global health research and policy, and thus felt that a rigorous understanding of the quality of evidence was necessary.

We used three validated critical appraisal tools to account for study design, including: (i) the Joanna Briggs Institute (JBI) checklist for analytical cross-sectional studies for cross-sectional, ecological momentary assessment, mixed methods, and longitudinal observational studies; (ii) an adapted version of the JBI tool for quasi-experimental studies for experimental and mixed methods experimental studies; and (iii) the Critical Appraisal Skills Checklist (CASP) for qualitative studies.

We gave studies one point for every checklist item fully met, and half a point when the item was partially met, and then calculated the proportion of checklist items met by each study. We categorised study quality as High (≥ 75% checklist covered), Moderate (50%-74% checklist covered), and Low (<50% checklist covered).

Theoretical framework

Our review and appraisal of the evidence was informed by Rodgers’ 2016 integrated theoretical framework [ 43 ] on the influence of internet use on body image concerns and disordered eating pathology. Interactions with others as well as individual online behaviours are important pathways linking internet use to body image and eating pathology, and a hypothesised feedback loop between the two reinforces the addictive nature of social media and sustained motivations for use despite potentially adverse outcomes. Whilst previous frameworks have focused on singular theoretical perspectives that explain this relationship, Rodgers incorporates five theories to provide mechanistic insight, including (i) sociocultural theory, (ii) self-objectification and feminist theory, (iii) impression management involving self-discrepancy and true-self theories, (iv) social identity theory, and (v) gratification theory.

• Sociocultural Theory postulates that social agents (media, peers, and family) convey a strong need to conform to societal body ideals [ 44 ]. Comparisons to similar others online and the internalisation of the thin ideal may lead to binge eating disorder and compensatory disordered eating behaviours [ 45 ].
• Self-objectification and Feminist Theory hypothesises that in an appearance obsessed society, women are acculturated to internalise a third person perspective of themselves, leading to habitual body monitoring, dissatisfaction, and subsequent disordered eating behaviours [ 46 ]. Social media offers opportunity for posting self-images, which are then subject to scrutiny and feedback.
• Impression Management (self-discrepancy and true self theories) emphasises that individuals seek to control their identity in line with societal ideals [ 47 ]. On social media, individuals can curate a perfect online persona—their ‘ideal self’. The discrepancy between the ideal self and less perfect offline self is thought to induce body image concerns. Compensatory disordered eating behaviours may be employed to move closer to the online ideal.
• Social Identity Theory posits that individual identity is drawn from group membership with like-minded individuals. On social media, opportunities to be part of ‘in groups’ are endless, irrespective of physical proximity. Examples include weight loss groups, healthy eating and fitness communities, pro-eating disorder pages, and eating disorder recovery groups. Shared values of online communities may influence body image and eating behaviour via perceived consensus and ‘in group’ norms.
• Gratification’s Theory restores the agency of individuals in seeking out certain social media content in accordance with inherent personality traits, needs, and interests. Individual characteristics, heterogenous motivations for social media use and specific online behaviours may heighten vulnerability to subsequent body image concerns and disordered eating behaviours.

We used Rogers’ framework in our scoping review in two ways. First, we assessed whether each included article addressed any of the framework’s specific pathways and noted any underlying theoretical assumptions that were outside of Rogers’ model but could potentially extend it. Second, we evaluated included studies to understand how well the current scope of literature matches Rogers’ proposed view, and how we could extend and update the integrated model in light of emerging evidence on social media use, body image and disordered eating published since 2016.

The review was based on previously published studies and therefore no ethical approval or participant consent was required.

This section details the findings of our review, beginning with an overview of search results and study characteristics. We then summarise the main exposures, outcomes, mediators and moderators identified in the literature. We present our synthesis of the literature in a framework describing a self-perpetuating cycle of risk.

Study selection

We identified 273 articles from database searches, and after de-duplication, screening abstracts, reading full-texts, and hand-searching reference lists, we included 50 studies (45 quantitative and 5 qualitative) in our review ( Fig 1 ) (See S1 Table for individual summaries of the 50 studies).

https://doi.org/10.1371/journal.pgph.0001091.g001

Study characteristics

Study design..

We reviewed 45 quantitative (30 cross-sectional, 6 experimental, 5 mixed methods, 2 ecological momentary assessment, and 2 longitudinal observational studies) and 5 qualitative studies. Qualitative studies collected data through focus group discussions (n = 4) and interviews (n = 1).

Study location.

Ninety percent of studies (n = 45) were conducted in high-income countries. The largest number of studies were conducted in Australia (n = 12) and the United States (n = 11). Canada, Italy, Singapore, and United Kingdom were included in three studies each, Spain and Ireland in two each, and Belgium, France, Germany and Sweden in one each. Studies conducted in Sri Lanka (n = 1), China (n = 2), Malaysia (n = 1) and Thailand (n = 1) comprised the evidence base on upper-middle-income and lower middle-income countries, and none included populations in low-income countries.

Participants.

48% of studies (n = 24) included only female participants, 2% of studies (n = 1) included male participants, and 50% (n = 25) included both genders. One study reported transgender participants, although this subcategory constituted only 9.3% of the study’s total sample [ 48 ].

Where ethnicity was reported, >75% of studies (n = 18) reported majority White participants, 17.4% (n = 4) reported majority Chinese participants, and <5% reported majority Hispanic participants.

Only 17 studies described participants’ BMI. Most participants (82%) were of a healthy BMI (18.5 to 25), with smaller proportions who met criteria for overweight (12%) and underweight (6%) BMI categories. Four studies (8%) identified participants with an existing eating disorder.

Most studies recruited participants from university (n = 20) and secondary schools (n = 19), with fewer studies using online (n = 6), community (n = 4) and clinical (n = 1) settings to recruit young people.

Underlying theoretical frameworks.

Most studies borrowed ideas from multiple theories. 78% of papers referred to Sociocultural Theory, with an emphasis on social comparison. 26% referred to Gratification’s Theory, 24% reported Self-objectification and Feminist Theory, 24% highlighted Impression Management Theory, and 12% of studies mentioned Social Identity Theory. We identified seven theories outside of Rodgers’ framework [ S2 Table ].

Social media platforms assessed.

Twelve studies assessed general social media usage, 18 indicated multiple platforms, and nine focused on appearance orientated sites only (Facebook, Instagram, Snapchat, YouTube). Where specified, most studies investigated Instagram (n = 15), followed by Facebook (n = 5) and WeChat (n = 1).

Motivation for social media usage.

Across studies, reasons for social media usage included: identity management, fitting in with friends, posting content for peer feedback, and seeking out weight loss, fitness, or pro-eating disorder material.

Quality appraisal.

Many quantitative studies (n = 28) were of moderate quality. Generally, unfulfilled criteria included failure to address confounding variables, and lack of control group in experimental conditions. Most qualitative studies (n = 4) comprised high-quality evidence (>75% checklist met), although they did not always consider ethical issues or the positionality of the researcher [ S3 – S5 Tables].

Relationships between social media, body image and eating disorders

The overarching relationship between social media use, body image and eating disorders operates through a range of mechanisms. Typically, social media usage led to body image concerns, eating disorder or disordered eating outcomes, and poor mental health via the mediating pathways of social comparison, thin / fit ideal internalisation, and self-objectification.

Specific social media usage.

Approximately 58% of studies (n = 29) investigated specific types of social media exposure, including time, frequency, use of appearance-focused platforms, and investment in appearance related activity [Table A in S1 Data ].

Seven studies investigated the relationship between time spent on social media and body image or eating disorder-related outcomes. Time was significantly associated with these variables in two studies, although both papers failed to acknowledge other social media activities and possible mediators [ 49 , 50 ]. Three cross-sectional studies discovered that time spent on social media was associated with body image dissatisfaction via the mediating pathways of social comparison and thin ideal internalisation [ 51 – 53 ], indicating that the relationship between exposure and outcome is more nuanced than the mere number of hours spent online.

High frequency of social media usage and body image dissatisfaction was supported by two studies [ 54 , 55 ].

Appearance focused social media platforms.

Three cross sectional studies indicated that appearance focused platforms, namely Instagram and Snapchat, are significantly associated with body image concerns, eating disorder pathology, anxiety and depressive symptoms [ 51 , 56 , 57 ].

Investment in appearance related activities.

17 studies identified that investment in appearance related activities (‘selfie’ avoidance, manipulation and posting edited photos, and significantly investing in ‘likes’ and ‘comments’) may be noteworthy exposures. These activities were consistently associated with body image dissatisfaction and risk of eating disorder pathology across a range of cross-sectional, experimental, and qualitative study designs (n = 14).

There were anomalies to this trend (n = 3). First, two studies found that posting ‘selfies’ on Instagram led to higher body esteem, rather than body image dissatisfaction [ 58 , 59 ]. However, included participants may have had significantly higher pre-existing body esteem, rather than this emerging as a consequence of posting.

Social media trends.

Two prominent hashtags featured in the literature, drawing on the idea of social media as a source of inspiration or aspiration towards greater fitness (#Fitspiration) and thinness (#Thinspiration) ([Table B in S1 Data ]).

#Fitspiration . Eight studies investigated the impact of the fitspiration trend on body image dissatisfaction and eating disorder pathology with mixed results: 50% supported the relationship, 25% partly supported it, and 25% refuted it. Three moderate- to high- quality experimental studies demonstrated that exposure to fitspiration imagery relative to control images resulted in body image dissatisfaction and negative mood for participants, pointing towards a causal relationship [ 60 – 62 ]. Qualitative insight highlighted that for some, fitspiration inspired healthy eating and exercise. Others felt extreme pressure to ‘eat clean’ or exercise to excess, with subsequent bingeing and disordered eating outcomes [ 63 , 64 ]. A mixed methods study of fitspiration followers on Instagram found that 17.7% were at risk of developing an eating disorder, 17.4% demonstrated high levels of psychological distress, and 10.3% displayed addictive levels of physical exercise [ 65 ].

#Thinspiration and pro-eating disorder content . Three studies explored the relationship of the #thinspiration trend with body image and eating disorders. A mixed methods study concluded that the hashtag glorified “emaciated people” and “bone-thin girls”, promoting starvation as a lifestyle choice instead of a symptom of mental illness. Posts provided individuals with tips on how to lose weight and hide an eating disorder [ 48 ]. A cross-sectional study found that 96% of included participants followed the thin-ideal on social media, of whom 86% met the criteria for a clinical/subclinical eating disorder, and 71% and 65% reported symptoms of depression and anxiety, respectively [ 66 ]. Whilst these statistics are alarming, the study relied on self-reported symptoms and used novel eating disorder diagnostic tools that had not been extensively validated.

Eating disorder pathology.

20 studies explored eating pathology as an outcome of social media usage [Table C in S1 Data ] .

Clinical/subclinical eating disorders.

Five cross-sectional studies yielded statistically significant associations between social media usage and various clinical eating disorders. These ranged from night eating syndrome [ 67 ], to binge eating disorder [ 68 ] and bulimia nervosa [ 69 ].

One cross-sectional and one qualitative study indicated orthorexia nervosa symptomatology amongst participants, ranging from obsessions with ‘clean eating’ to avoidance of ‘demonised’ foods and compulsive exercise behaviours [ 64 , 70 ]. A study of 713 participants confirmed orthorexia nervosa prevalence of 49% [ 70 ], far greater than the estimated <1% in the general UK population. However, participants were recruited from ‘fitness’ Instagram pages, and thus unlikely to be representative of all social media users or the general population.

Disordered eating behaviours.

More commonly, 11 studies found statistically significant associations between social media usage and disordered eating behaviours, including bingeing, purging, use of laxatives and extreme dieting. One cross-sectional study found that 51.7% of adolescent girls and 45% of boys engaged in meal skipping and excessive exercise [ 57 ]. Although the sample size was large (n = 993), behaviours were self-reported and study quality was low.

Eating disorder maintenance or recovery.

Two studies explored the effect of social media on eating disorder maintenance or recovery. A mixed-methods study found that only 3% of 499 participants with clinical/subclinical eating disorders used social media to aid recovery or as a form of treatment. The remaining 97% indicated that it hampered recovery, one stating that “when I get really hungry, I go into these sites to get motivation to not eat for a bit longer” [ 48 ].

Body image concerns.

33 studies demonstrated significant associations between social media usage and body image dissatisfaction, including body shame, low self-esteem and body related anxiety [Table D in S1 Data ] . Of these, five hypothesised that body image dissatisfaction preceded subsequent eating disorder pathology [ 50 , 71 ].

Mental health.

Although not the primary focus of the research, nine studies revealed significant associations between social media usage, body image concerns or disordered eating pathology, and poor mental health [Table E in S1 Data ] . Outcomes included low mood (n = 4), anxiety and depressive symptoms (n = 5).

We identified three key mediators [Table F in S1 Data ] .

Thin / fit ideal internalisation.

12 studies investigated thin / fit internalisation as a mediator between social media usage and body image or disordered eating outcomes. Eleven (92%) indicated that it is a plausible mediator, across cross sectional (n = 7), experimental (n = 1) and qualitative (n = 3) study designs. In a qualitative study, female participants (n = 27) in focus group discussions reported feeling pressure to adhere to an ever-changing ideal [ 72 ]. In qualitative interviews, a sample of Swedish adolescents reported feelings of alienation following failure to adhere to the ‘toned but not too muscular’ ideal, whilst focus groups with Irish adolescents revealed participants’ feelings of self-blame and disgust [ 64 , 73 ].

Appearance comparisons.

21 studies explored the mediator of appearance comparisons on social media, with 19 (90%) reporting a significant relationship. Comparisons tended to be ‘upward’ and yielded feelings of inadequacy and self-loathing [ 53 , 63 , 68 ]. In contrast, an observational longitudinal study revealed that comparisons on Facebook did not predict body image dissatisfaction six months later [ 74 ]. However, Facebook use was marked as ‘outdated’ amongst younger participants (mean age in this study was 14.7 years) which could account for the non-significant finding.

Self-objectification.

Six studies recognised self-objectification as a significant mediator. Generally, participants reported self-criticism, picking out flaws in photos and purposively posting photos accentuating certain body parts [ 48 , 51 , 73 ].

The relationship between social media and body image / disordered eating was inflected by several moderating factors, broadly categorised as biological [Table G in S1 Data ] , cognitive [Table H in S1 Data ] and socio-environmental [Table I in S1 Data ] characteristics.

18 studies investigated gender as a moderator, 14 of which found significant differences between males and females. Generally, girls invested heavily in photos of themselves, endorsed the thin / fit ideal, made more comparisons with others, and engaged in higher levels of disordered eating pathology, specifically dieting and emotional eating [ 50 , 57 , 75 ]. In contrast, boys endorsed a more muscular ideal, with goals of functionality and fitness, rather than weight loss [ 76 , 77 ].

Qualitative focus groups implied that social media and body image is perceived as a gendered subject, with boys feeling reluctant to admit adverse effects due to stigma or fear of emasculation [ 63 ]. As most studies implemented self-report tools, and over half comprised mixed gender participants, this may have distorted findings. Remaining studies (n = 4) found no difference between males and females. Discrepancy may be due to variance in the assessment tools utilised for body image or disordered eating outcomes and differential sex ratios and mean age of participants.

Five studies investigated BMI as a moderator. Three indicated high BMI as strengthening the relationship between social media, body image dissatisfaction and eating disorder pathology. The two anomalies to this trend both included participants with abnormally low average BMIs [ 71 , 78 ]. All studies relied upon self-reported BMI, thus increasing risk of measurement error and bias.

Pre-existing body image concerns.

Four studies indicated that inherent body image concerns (shame and low self-esteem) predicted certain social media behaviours and heightened susceptibility of eating disorder pathology. In contrast, body appreciation appeared to buffer against this effect [ 71 ], however, self-compassion was not a moderator [ 79 ].

Risk of eating disorder.

Five studies highlighted that high-risk individuals with elevated eating disorder scores or a pre-existing eating disorder are more inclined to seek out damaging content on social media (such as thinspiration or weight loss). They may be more susceptible to mediating factors (internalisation and comparison) and are thus at heightened risk of further clinical / subclinical eating disorders [ 78 , 80 , 81 ].

Socio-environmental factors

Social media literacy..

Three studies indicated low social media literacy amongst participants, including difficulty switching off from damaging posts and an inability to recognise edited versus unedited posts [ 63 , 73 , 82 ]. In contrast, focus groups with adolescent girls in the US showed that having studied social media in school, girls were critical of its artificiality, reported that they could appreciate others’ beauty without jealousy, were self-accepting and did not feel the need to seek compliments online. Some engaged in comparisons, although this did not appear to lead to body image dissatisfaction and eating disorder pathology [ 83 ].

A self-perpetuating cycle of risk?

Our synthesis indicates that certain social media exposures and individual risk factors can strengthen this relationship, whilst numerous moderators may weaken, or even disrupt it. This led us to extend Rodgers’ framework [ 43 ] in light of new research, referred to here as a ‘self-perpetuating cycle of risk’ [ Fig 2 ].

https://doi.org/10.1371/journal.pgph.0001091.g002

Our findings indicate that specific features of social media usage (appearance focused platforms, investment in photos, and engagement with fitspiration and thinspiration trends) lead to body image concerns, disordered eating pathology and mental health outcomes. This relationship is shaped by the mediating pathways of thin / fit ideal internalisation, appearance comparisons, and self-objectification, which have been supported by additional meta-analyses [ 3 , 84 , 85 ].

However, due to the cross-sectional nature of most studies, it is impossible to identify the direction of causality: for example, do body image dissatisfaction and disordered eating occur because of social media usage, or do these pre-exist, encourage engagement in certain online activities, and result in unfavourable clinically significant outcomes?

Our revised framework recognises both possibilities. It is plausible that specific individual risk factors (particularly high BMI, poor body image and existing eating disorders) combined with differential motivations for social media use (identity formation, gratifications from peer feedback) encourage certain behaviours when users engage with social media (photo manipulation, searching for thinspiration and fitspiration content), strengthen the effects of mediators, and increase risk of poor body image, disordered eating, and mental health outcomes. This shifts away from the fatalistic notion that social media causes poor body image and eating disorders in all users. Instead, it suggests that certain individuals are simply more vulnerable to its deleterious effect.

This relationship is not linear. Results highlight that social media is highly addictive, and individuals use it despite negative outcomes [ 59 ]. In fact, to ‘fix’ their poor body image, users may be even more inclined to do so (e.g., manipulate photos to obtain more likes)—indicated by a hypothesised feedback loop. It is this which may trigger the self-perpetuating cycle of risk. However, this cycle can be broken. Several moderators, or buffers, that have the potential to disrupt it. Many studies showed that whilst individuals still internalised the ideal or compared themselves to others, high social media literacy and body appreciation prevented this from resulting in body image dissatisfaction, disordered pathology and poor mental health [ 71 , 83 ].

Our scoping review of 50 studies conducted in 17 countries found that social media usage is a plausible risk factor for the development of clinical / subclinical eating disorders across a range of country income groupings. We extended current thinking to describe how social media provides a platform of perfectionism, often embeds unhealthy ideals of disordered eating and fitness and can hamper recovery from eating disorders. We also identified mediators, moderators and important risk factors that shape this relationship and offer opportunities to intervene.

Taken as a whole, the literature underlines a complex, yet meaningful relationship between social media usage, body image concerns, and disordered eating pathology. While our review points to potentially large scale implications among the approximately 3.9 billion social media users worldwide, it is important to note that not every user has poor body image or an eating disorder [ 29 ]. This begs the question, what makes certain individuals more susceptible?

Significance for global health

Disturbingly high prevalence of body image dissatisfaction, disordered eating pathology and comorbid mental health outcomes were reported amongst young social media users in this review [ 57 , 66 , 70 ]. Given the sheer scale of social media reach (approximately 60% of the world’s young people), a large proportion of young people could be exposed to the self-perpetuating cycle of risk [ 29 ]. Significantly, findings were reflected amongst Asian samples, mirroring concerns regarding the explosion of eating disorders in Asia [ 86 , 87 ] which has a population of 4.6 billion. Social media use as a risk factor for eating disorder pathology clearly warrants attention outside of high-income western countries [ 17 ].

Currently, up to 80% of eating disorder sufferers remain out of formal healthcare systems, with many presenting at late stages [ 66 ]. Denial, stigma, and fears that one’s disorder isn’t serious enough already hampers treatment seeking [ 14 ]. Today, young people are often immersed in a digital world where desires to change one’s body, excessive exercise and preoccupation with food appears normal [ 88 ]. How can young people identify that they have a problem, when their behaviours seem to be nothing out of the ordinary?

Eating disorders, clinical or subclinical, are serious psychiatric disorders with a range of comorbid health outcomes [ 28 , 89 ]. Unfortunately, they are often misunderstood, omitted from nationally representative health surveys, and viewed as less important than other mental health disorders [ 12 ]. Reports of 41.9 million neglected eating disorder cases in 2019, combined with a surge in cases recorded by health systems and charities alike calls for a serious reconceptualisation of the disorder [ 36 , 90 ].

This issue also sits within the wider arena of adolescent mental health. The WHO Global Strategy for Women’s, Children and Adolescent Health coupled with The Mental Health Action Plan 2013–2020 demonstrate that investment in young people and their mental health yields invaluable gains for society [ 91 , 92 ]. Although eating disorders were recognised by The National Institute of Mental Health as a priority area for adolescents in 2007 with prevalence equalling that of bipolar and substance use disorders, they remain absent from these seminal reports and constitute a fraction of global mental health research [ 12 , 93 , 94 ].

Since 2007, the rise of social media has brought new challenges. Despite its dominance in the lives of Generation Z, we are only just beginning to learn about its impact [ 95 , 96 ]. Of significance, The UK Royal Society for Public Health (RSPH) published a damning report on social media and mental health, whilst social media, body image and eating disorders have been recognised as emerging policy areas for the UK, Australian and US government alike [ 97 – 100 ]. In 2020, The UK launched their Online Harms White Paper to promote a regulatory framework of online safety and stimulate innovative social media intervention to protect young users. Eating disorder risk, however, remains absent from many of these youth centred goals in the UK [ 101 ].

Despite this rising concern, regulation of social media remains weak, with significant gaps between ‘safety policies’ and the real-life experiences of users [ 80 ]. Age, anonymity, and the pervasiveness of algorithms play a key role in this. Although required that users must be at least 13 years of age, most popular social media platforms have no robust means of age authentication. Recent figures reveal that up to 42% of children under the minimum age have a social media profile [ 102 ]. Users of all ages can join under any email address and disguise their identity through use of aliases. Once online, access to content is generally unrestricted, whilst algorithms suggest personalised content based on prior user engagement. In April 2021 Instagram sparked headlines after ‘appetite suppressants’, ‘fasting’ and ‘weight loss’ was recommended to certain users based on their previous searches [ 103 ]. Although rectified, content that glorifies eating disorders remains highly accessible, with little promise of intervention. More critically, internal research by Facebook conducted in 2019 leaked to the media in September 2021 showed not only that 40% of Instagram users who reported that they felt unattractive said that dissatisfaction began while using the platform [ 104 ], but also suggests that Facebook knew about the app’s potential to harm teenage girls’ mental health [ 105 ].

Further to this, evidence suggests that social media literacy amongst the young is low, and clinical recognition of eating disorder symptomatology and online risk factors poor [ 106 ]. In parallel, social media has been described as more addictive than alcohol and cigarettes, body image dissatisfaction and eating disorder pathology are on the rise, and the mental health of today’s youth is declining [ 98 ]. In light of COVID-19 lockdowns and further shifts towards an online world, this issue demands greater global attention [ 55 ].

Recommendations and future research

As the topic is in its infancy, our recommendations for intervention and future research are generally exploratory.

Community level

Primarily, opportunity lies in raising awareness of social media and its possible connection to body image dissatisfaction and eating disorder symptomatology. In the UK, only 23% of young people learn about body image at school, although 78% believe that this would be useful [ 32 ]. Through investments in social media literacy [ 83 ], young people could learn to appreciate body diversity, navigate social media through a critical lens, and challenge the artificiality of the societal ideal of beauty. Open discussions between students, teachers, and parents could reduce the stigma associated with eating disorders and help young people to identify body image concerns and eating problems before they manifest as serious disorders. Preliminary research investigating social media literacy has shown promising outcomes [ 107 ].

Societal and health systems level

At a societal level, recognition of the issue within government and health systems is paramount. To optimise positive social media use, communication between these players and social media companies should be enabled. From this, policies to enhance age verification, minimise access to pro-eating disorder content and increase the health and safety of users could be developed [ 106 ]. Recently, the UK Government Equalities Office approached social media influencers and advertising companies to devise strategies to enhance body diversity online [ 97 ]. Results are yet to materialise, although there is evidence of an emerging online ‘body positivity’ movement [ 95 , 108 ].

Within a clinical setting, appreciating eating disorders as serious mental health problems, screening patients presenting relevant symptomatology regardless of body size, and integrating social media as an additional factor within treatment plans could be advantageous [ 109 ]. At the global level, we recommend building health system capacity in low and middle-income countries in preparation for the potential future burden of eating disorders as a progressive strategy. However, based on funding, budget cuts, and the priority that other health issues currently take, the likelihood of this being implemented is unclear [ 110 ].

Study design

As discussed, the scope of evidence in this review is limited by the cross-sectional design adopted by most studies, the homogeneity of included participants, and limited geographic scope. Moving forward, researchers should consider conducting longitudinal studies with representative samples and cross-cultural comparisons covering all regions. This would provide greater clarity regarding the true directionality of the relationship, and grant insight into the impact of social media on young people across the life course. Likewise, ongoing qualitative studies with young people would aid understanding and provide rich data on a topic that is unique to this age group.

While our review describes certain risk factors, mediators and moderators in the extended framework, the nature of their role was not conclusive (including gender and personality traits). Future research would benefit from focusing on these to see whether they are as meaningful as current evidence suggests. The increase in eating disorder incidence among males and gender differences described by a small number of studies suggest that this particular moderator requires further investigation [ 111 ].

Next, previous research has highlighted that certain subcategories, including those with high BMI, athletes, and young people who identify as lesbian, gay, bisexual and transgender (LGBT) are more susceptible to body image dissatisfaction and eating disorders [ 112 ]. Study populations in this review tended to be White school or university students and did not reflect the intersectionality nor diversity of national populations. Thus, it would be beneficial to assess the relative impact of social media on eating disorders across these high-risk groups.

Finally, prior evidence suggests that media penetration and adoption of ‘western ideals’ increases the risk of eating disorder pathology [ 113 ]. Despite global scope, this review did not retrieve any studies from low-income countries. Therefore, this assumption requires further testing in these contexts. Future research should explore the relationship in low income, non-western cultures, which may be important as social media use rises globally.

Limitations of this review

First, due the cross-sectional nature of most included studies and generally ‘moderate’ quality, causation between social media usage and outcomes cannot be presumed. Likewise, with variance in tools used to assess mediators and outcomes, most of which were self-reported, measurement error and bias are possible.

Secondly, despite the reviews’ inclusive geographic scope, studies were concentrated within middle-high income countries in Europe, Asia, and Australasia. Although few cross-cultural differences emerged, scarcity of evidence from low-income countries means that generalisability is indicative rather than conclusive. Likewise, included samples were relatively homogenous. Most participants were of White ethnicity, average BMI, and female. Paucity of diverse evidence limits meaningful insight into any subcategories of particular risk.

Next, although the social media platforms covered in the literature were extensive, the digital landscape evolves rapidly. For example, TikTok (the most downloaded mobile application in 2020) is the focus of significant media concerns regarding body image yet is only mentioned by one study [ 55 ]. It may be that findings still fail to capture the most recent trends.

In the 21 st century, social media use amongst a developmentally susceptible age category is unprecedented and largely unregulated. ‘Likes’ and comments can validate identity, the societal ideal of beauty appears ubiquitous, and most people (albeit enhanced and filtered) appear to be perfect. In pursuit of acceptance, popularity and validation, the common option is to follow suit–to manage one’s own online identity to meet the ideal marked by others, to manipulate and scrutinise ‘selfies’, and once posted, angst over the numbers of likes or comments received. However, despite one’s best efforts, this online change is rarely good enough. Through the lens of social media, someone else can always look better, skinnier, or prettier [ 73 ]. Likewise, pro-eating disorder content is rife, and the ‘healthy’ #fitspiration trend may be fuelling new waves of disturbed eating and exercise pathology. The outcome is a population of young people at risk of corroded body image, gaping discrepancies between their actual and ‘polished’ online selves, and an increased likelihood of engaging in compensatory disordered eating behaviours, as our review has shown.

In parallel, cases of eating disorders are escalating, with prevalence far exceeding what was previously thought. Although it is not possible to isolate one single cause, the plausible link between social media, body image dissatisfaction and eating disorders is alarming. Based on the scale of social media usage, this could impact the wellbeing of a significant proportion of the world’s young- particularly those who are already vulnerable. Where the body of evidence is so recent, and social media ever evolving, the ramifications of this are not yet fully clear.

However, with significant strides being made in the realm of global adolescent mental health, intervention is clearly possible. Through recognition, funding, research, and prioritisation, there is hope that this issue will receive more attention, and concern will translate into tangible action. Our goal should be to have a generation of young people who are body positive, who use social media in a progressive way, who eat food because it is a basic human need, and who do not measure self-worth by the circumference of their thighs. We must also aim for widespread education and early identification of at-risk individuals, so that eating disorder symptomatology can be challenged long before it presents at formal healthcare settings.

The burden of body image dissatisfaction and eating disorders as a global health issue has been ignored for too long. The rise of social media has reinforced the need to turn attention to the ‘Cinderella disease’ of mental health, which this scoping review has demonstrated as worthy of a place on the global public health agenda.

Supporting information

S1 fig. full search strategy carried out in pyschinfo..

https://doi.org/10.1371/journal.pgph.0001091.s001

S1 Table. Summaries of individual studies.

https://doi.org/10.1371/journal.pgph.0001091.s002

S2 Table. Additional theories outside of Rodgers’ framework.

https://doi.org/10.1371/journal.pgph.0001091.s003

S3 Table. The Joanna Briggs Institute (JBI) checklist for analytical cross-sectional studies.

https://doi.org/10.1371/journal.pgph.0001091.s004

S4 Table. Adapted version of the Joanna Briggs Institute tool for quasi-experimental studies.

https://doi.org/10.1371/journal.pgph.0001091.s005

S5 Table. The Critical Appraisal Skills Checklist (CASP) utilised for qualitative studies.

https://doi.org/10.1371/journal.pgph.0001091.s006

S1 Data. Tables A to I.

Data categorisation tables for the synthesis of results.

https://doi.org/10.1371/journal.pgph.0001091.s007

Acknowledgments

We are grateful to Delan Devakumar for comments on an earlier draft of the manuscript.

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How do we solve social media’s eating disorder problem?

Subscribe to the center for technology innovation newsletter, samantha lai samantha lai research analyst, center for technology innovation - the brookings institution @_samanthalai_.

February 24, 2022

Eating disorders have been on the rise over the course of the pandemic. In the last two years, the number of adolescents admitted into hospitals for eating disorders has skyrocketed , with medical experts citing increased time on social media as a contributing factor. As internal research leaked by Meta whistleblower Francis Haugen claims, “the tendency to share only the best moments [and] a pressure to look perfect” could leave many with a desire to look or act different. That, coupled with a plethora of online content on dieting and what it means to have the perfect body, have further exacerbated users’ insecurities and misled them down dangerous paths. Taken to the extreme, many social media users have also been guided to dangerous pro-eating disorder communities, corners of the internet where users actively encourage and shame each other into unhealthy or even life-threatening weight loss.

Lawmakers have become increasingly aware of these dangers. In a hearing last September, Sen. Richard Blumenthal (D-CT) had his office create a fake Instagram account to understand the prevalence of pro-eating disorder content on the platform. As lawmakers work to hold tech companies to a higher standard in protecting users, this is an important aspect of user safety that cannot be overlooked.

Pro-eating disorder communities aren’t new

Pro-eating disorder communities have had a long history on the internet. As early as 2001 , Yahoo removed 113 pro-anorexia websites from its servers. After a Huffington Post exposé on “thinspiration” blogs on Tumblr, the platform took action against a cluster of pro-eating disorder blogs. And decades after the problem first surfaced, social media continues to struggle with the same problem. Over the last few years, YouTube , Instagram , TikTok and more faced criticism for failing to address pro-eating disorder content and search terms on their platforms. Communities of eating disorder enthusiasts have been found on Twitter , Discord , Snapchat and more.

All major social media networks explicitly state in their terms and conditions that users should not promote behaviors of self-harm, including the glorification of eating disorders. Ad policies on Pinterest , Instagram , Snapchat , TikTok and other online platforms have either banned or imposed restrictions on weight loss ads. Across most platforms, search terms and hashtags such as “anorexia”, “bulimia”, and “thinspiration” have been rendered unsearchable. When users look up related terms, they are instead directed to a “need help” page, with resources such as the National Eating Disorder Association (NEDA) volunteer hotline.

Yet social media platforms’ eating disorder problem continues to remain unresolved because, at the end of the day, it is only part of a larger, much more complex problem. While the leaked Facebook papers claimed 1 in 3 teenage girls said their body image issues had been made worse by Meta’s Instagram platform, other researchers have questioned this conclusion, flagging that “disentangling cause and effect in correlational research that links experience and mental health is an enormous challenge”. It is important to also consider how users’ life experiences shape their social media experiences, as harmful messages on food and dieting do not exist solely in the vacuum of social media. Diet culture is everywhere in the modern world, rooted in the belief that being thin equates to healthiness and attractiveness, manifesting in “guilt-free recipes” and New Year resolutions to lose weight. In turn, disordered eating habits are often normalized, with a 2008 survey sponsored by the University of North Carolina at Chapel Hill reporting that 75% of women report disordered eating behaviors across age groups, racial and ethnic lines. But women are not the only victims of disordered eating, and the condition affects people across genders and sexual identities. Eating disorders are a serious problem, and have the highest morbidity rate of all mental illnesses.

But while social media platforms are not solely responsible for causing eating disorders, they are responsible for amplifying them among wider audiences. Increasingly, more young people are using the internet as a tool to find answers, following misguided or even dangerous advice from influencers and peers. Platforms rely upon machine learning algorithms to filter content based on user preferences and seek out new audiences for various information, especially so they could market more ads. For users with preexisting body image issues, seeking out one or two fitness or healthy recipe videos could fill their feeds with similar videos, and those who continue watching similar content could easily be led to content explicitly promoting eating disorders. Such regular exposure has the potential to trigger or worsen disordered eating behaviors for users. For closed-network social media platforms such as Snapchat or Discord, the same functionalities that allow people to connect with those they’ve never met before have also facilitated the formation of closed group chats, where users share how much they weigh and encourage others to fast.

Existing measures are inadequate

Existing takedown policies fall short on various counts. As it is with most other content moderation challenges, people and companies posting and promoting such content have outsmarted AI systems with misspelled alternatives to banned search terms and hashtags for users to find each other. Many users also post untagged content, which can slip through existing systems unchecked.

Among platforms and other stakeholders, there is also the bigger problem of what should and should not be taken down. When talking about user welfare, it is also important to recognize that users contributing to these platforms, even those that are actively glorifying eating disorders, are also struggling with debilitating mental illnesses, and that taking down accounts could cut them off from much-needed communities of support.

What can be done?

The good news is that these challenges are not insurmountable, and there are methods for social media companies to improve their responses to content promoting disordered eating. Regarding how algorithms work in the status quo, the problem is that they work too well in catering to user preferences, bombarding users with the content they need to facilitate their self-harm. Recognizing these fallacies following the fallout over the Facebook papers, Meta announced the rollout of a “nudge” function for teens on Instagram, which can be activated when a user spends an extensive amount of time watching workout videos or diet content. In response, the algorithm would instead redirect them to unrelated content such as animal videos or travel pictures. Similar functions could be enabled across other platforms and for all users, as eating disorders could affect a wide range of people other than teenage girls. To encourage algorithmic accountability, researchers should also be granted access to platform data. This would allow those specializing in eating disorders and teen wellbeing to analyze how platform algorithms handle and remove this content. The involvement of third-party standards heightens the pressure on platforms to be accountable for their users’ wellbeing. While it is unlikely for platforms to start doing this voluntarily, the EU’s Digital Services Act is likely to open up such avenues going forward. A similar framework for the US would be useful in encouraging further research and promoting accountability.

Users should also be granted more agency in filtering through content that could be harmful to their wellbeing. A useful example of this would be Twitter’s “ mute ” function, which allows users to avoid seeing tweets on specified keywords. Expanding this across platforms could grant users the tools they need to avoid dangerous content on their own terms. However, a “mute” function will still be inadequate for image- or video-heavy platforms such as Instagram, TikTok, or Pinterest. For such platforms in particular, users should be allowed expanded control over the categories of content they are shown. Facebook’s ad preferences page has shown that platforms already collect and categorize users’ content preferences. There should be an option for users to eliminate categories of content, going beyond eating disorders and self-harm to gambling content for recovering addicts and pregnancy content for mothers who have miscarried. This could remove even untagged content, as those would often be categorized with other dieting or exercise posts.

With existing technologies, categorical removals will likely be imprecise and overly broad. Removing unhealthy food content would mean removing most food content as artificial intelligence software would not be able to make the distinction. Regardless, this could still be useful, in particular for users in recovery whose only other alternatives would be to risk exposure to such content or get off social media completely. In the long run, platforms could also explore alternatives to letting users choose what specific categories of content they would want to reincorporate or avoid completely. Approaches to this would differ based on how platform algorithms prioritize and recommend content.

Instead of simply linking to the NEDA webpage, social media companies should take a more proactive and involved approach. Theories on inoculation have shown that people become more resilient to political misinformation when they have been told to prepare for it. Similarly, social media companies could ensure that their users are better primed for harmful narratives surrounding diet culture and eating disorders by preemptively challenging harmful narratives. This could involve working with NEDA and other healthcare experts to create informational graphics, short videos, or easy-to-read Q&A resources. These resources could then be incorporated into social media feeds of high-risk users as standalone posts. Platforms could also create an eating disorder resource center for users, similar to the Voting Information Center on Facebook feeds during the time of the 2020 elections. Instead of simply referring them to a phone number where they could seek further information, platforms could compile useful resources that users could click through to educate themselves.

Comprehensive changes in algorithmic design, data control mechanisms and user control can make social media a safer space for all users. But at the end of the day, it is important to recognize that this ties back to a very human problem: a cultural norm of fat-shaming and diet culture, the scientifically unsound idea that skinnier is superior. All this will have to be accompanied by a larger movement for body positivity, in education, media, and beyond, with the understanding that all bodies are good and worthy of love.

Alphabet and Meta are general, unrestricted donors to the Brookings Institution. The findings, interpretations, and conclusions posted in this piece are solely those of the author and not influenced by any donation.

“Social Media Surveillance”  by Khahn Tran is licensed under  CC BY 4.0

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PERSPECTIVE article

Social media use among adolescents with eating disorders: a double-edged sword.

• 1 Al Amal Psychiatric Hospital, Emirates Health Services, Dubai, United Arab Emirates
• 2 Global Remote Research Scholars Program, St. Paul, MN, United States
• 3 Punjab Medical College, Faisalabad, Pakistan
• 4 Bangladesh Medical College, Dhaka, Bangladesh
• 5 Shifa International Hospital, Islamabad, Pakistan
• 6 Mental Health Center of Excellence, Al Jalila Children’s Specialty Hospital, Dubai Health, Dubai, United Arab Emirates
• 7 College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai Health, Dubai, United Arab Emirates

Eating disorders are on the rise with a significant impact on mental health. Misuse of social media platforms is likely a significant contributing factor. This trend is especially pronounced among adolescents, who are increasingly using social media platforms for communications, building relationships, learning and entertainment. The unsupervised sharing of social media content can have drastic consequences on the physical and psychological wellbeing of youth, which often takes the form of “thinspiration” or “fitspiration”. This probably serves as a trigger for those already struggling with eating disorders. In addition, there is a lack of awareness among youth and adults on ideal knowledge-sharing practices related to an eating disorder. By addressing the unique challenges that social media presents for youth with eating disorders, communities can work towards creating a safer and more supportive online environment on a global scale. At this junction, this article aims to share the current challenges of social media use among adolescents with eating disorders and put forth recommendations for how social media could be used as a tool for positive impact in this population.

1 Introduction

Eating disorders (ED) are a group of mental illnesses that can have significant impacts on an individual’s physical and mental health. Adolescents are highly susceptible to developing eating disorders ( 1 ). Eating disorders are the third most prevalent chronic illness among adolescents, with only obesity and asthma ranking higher ( 1 ). The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) categorizes eating disorders into five groups: Anorexia Nervosa (AN), Bulimia Nervosa (BN), Binge-Eating Disorder (BED), Other Specified Feeding or Eating Disorders (OSFED), and Unspecified Feeding or Eating Disorders ( 2 ).

Globally, the prevalence of eating disorders has more than doubled in the past decade, from estimates of 3.5% to 7.8% ( 3 ). Forty percent of cases occur among adolescents aged between 15 and 19 ( 1 ). The prevalence of disordered eating behavior has been found to be substantial, ranging from 14% to 22% in epidemiological studies ( 4 ). AN, BN, and BED have been found to affect 0.3%, 0.9%, and 1.6% of the population, respectively ( 4 ). Community samples have also indicated that eating disorders are more prevalent among adolescent females, with 5.7% affected, compared to 1.2% of adolescent males ( 5 ).

The onset age of AN, BN, and BED have now shifted to early adolescence, with a median age of 12 years, whereas previous trends indicated mid to late adolescence ( 1 ). Furthermore, the biopsychosocial model acknowledges that the increased exposure to social media content that emphasizes on appearance may be linked to greater levels of internalization of beauty standards, thereby leading to increased adoption of such ideals as personal goals for the individual ( 6 ). This trend is especially pronounced among adolescents, who are increasingly using social media platforms for communications, building relationships, learning and entertainment.

An estimate of over 90% of adolescents have at least one social media account, and their presence on social media continues to grow ( 7 ). In the USA alone, a 2018 study shows that 93% of youth aged 14-22 use social media including platforms like Snapchat, Instagram, Facebook, and Twitter ( 8 ). Eighty-one percent of these use it on a daily basis ( 8 ). The consensus among most reports is that social media use among adolescents is on the rise ( 9 – 11 ). The growth has been higher since the COVID pandemic that pushed all activities online ( 9 – 11 ). One possible explanation for this potential rise in eating disorders among adolescents could be the influence of celebrity influencers on the body image perception of this age group. This was highlighted in a study where adolescents who had a tendency to develop eating disorders and influenced by popular personalities were found to be significantly associated with body image disturbances ( 12 ).

A scoping review from 2021 concludes 4 major factors of influence that eventually lead to disordered eating behaviors ( 13 ). These include visual appeal, content dissemination, socialized digital connections and adolescent marketer influencers ( 13 ).Visual appeal refers to use of social media by large scale food companies to share images and videos of their food products that promotes eating disordered behaviors. Social media as a platform for content dissemination can also allow for sharing of food recipes and experiences that can promote such behaviors among adolescents with eating disorders.

The impact of socialized digital connections can be a powerful influencer due to the presence of online communities that shape the views and behaviors of individuals through peer pressure and social norms. Adolescent market influencers can further impact on eating behaviors among social media users through their content sharing methods, which can create the perception of influencers being “role models” of food consumption by their viewers. Wilksch, at. el in their study display how increased use of Instagram and Snapchat was associated with significantly higher global Eating Disorder Examination Questionnaire (EDE-Q) scores and disordered eating among girls ( 14 ).

Our research question revolves around the relationship between social media use and eating disorders among adolescents. Specifically, we aim to explore how social media platforms contribute to the development and exacerbation of eating disorders in this demographic, as well as the potential for using social media as a positive tool for support and intervention.

Our objectives are threefold. Firstly, we seek to elucidate the challenges posed by social media, such as the promotion of unrealistic beauty standards and the prevalence of content that can trigger or encourage disordered eating behaviors among adolescents. Secondly, we aim to raise awareness about these challenges among both youth and adults, emphasizing the need for informed knowledge-sharing practices related to eating disorders. Lastly, we propose recommendations for change, including the implementation of policies on social media platforms, awareness campaigns, and research efforts to better understand the impact of social media on adolescent mental health.

Our methodology involves a comprehensive review of existing literature, including studies on the prevalence of eating disorders, the impact of social media on body image and disordered eating behaviors, and the potential benefits of awareness campaigns and online communities. Additionally, our recommendations for change are based on a synthesis of findings from the literature and our analysis of current trends in social media use among adolescents.

By addressing these questions, we aim to provide a clear understanding of the scope and methodology of our perspective article, highlighting its significance in addressing the critical issue of eating disorders among adolescents in the digital age.

2 Current challenges

Social media platforms often promote unrealistic beauty standards, for instance idealizing lean bodies. These likely push adolescents to engage in unhealthy dieting and excessive exercising ( 13 ). Additionally, these contribute to developing self-esteem issues and self-hatred ( 13 ).

According to a study based on the use of TikTok (a social media platform) among children and adolescents diagnosed with eating disorders, it was seen that the participants reported participants found anorexia nervosa, termed Pro-Ana and Bulimia nervosa, termed Pro-mia, content frequently without actively searching ( 15 , 16 ). This may lead the users to imitate behaviors related to ED and non-suicidal self-inflicting injuries ( 15 , 16 ). This type of content, which often takes the form of “thinspiration” or “fitspiration”, can serve as a trigger for those already struggling with eating disorders. “Thinspiration” and “fitspiration” are terms that refer to content, often disseminated through social media, intended to inspire individuals toward achieving thinness or fitness, respectively. In the context of eating disorders, these concepts can contribute to unhealthy body image ideals. Thinspiration typically focuses on promoting extreme thinness as an aesthetic goal, while fitspiration emphasizes achieving a fit and muscular physique ( 17 ). It can even encourage the development of these tendencies in vulnerable children. Furthermore, in a study done on adolescents in a school, it was seen that children with disordered eating were more likely to get bullied by their peers ( 18 ). This in turn may have a drastic effect on their mental health ( 18 ).

In addition to this, there is a lack of awareness among youth and adults on ideal knowledge-sharing practices related to an eating disorder. In a cross-sectional study done among families with children with eating disorders, it was seen that more than half of the parents did not have any knowledge regarding the eating disorder recovery websites ( 19 ). A significant percentage of teenagers frequently visited the pro-eating disorders website and 96% of them reported learning new weight loss or purging technique ( 19 ).

In the past few years a trend of appreciating all body types has been started on social media platforms ( 20 ). This is referred to as body-positive content and it encourages showing unedited, unenhanced, and unfiltered photos. Although this trend has a positive intention, some studies have shown that such exposures may be linked to a higher level of self-objectification ( 21 ). For instance, body-positive content emphasized on accepting various body appearances and shapes that are unique to each individual. However, as the focus is still on the body, self-objectification is expected to increase especially in women. In addition, cultural pressures as seen in many Western societies have contributed to women viewing themselves as “objects”. This eventually has a negative impact on physical and emotional wellbeing ( 22 ). Furthermore, social media has been observed as a communication medium for negative self-harm behaviors, which in turn creates a cycle of amplifying or encouraging such behaviors through shared videos ( 23 ).

3 Discussion

3.1 recommendations for change, 3.1.1 regulations on social media-use among adolescents.

It is imperative that social media platforms implement policies that acknowledge the negative impact of social media on body image and resultant disordered eating behaviors among adolescents. Such policies should include measures to protect users’ personal data and encourage safe reporting of negative content online. A dedicated mental health taskforce, including mental health professionals, should be put in place to oversee the implementation of these policies and monitor their effectiveness in creating a positive online environment. Such a task force would ensure that the policies are adequately enforced and would provide insights into how social media platforms can improve their policies to better protect the mental health of adolescents with eating disorders.

An example of such initiative is seen by the announcement of an action plan by the United States Government, which is focused on protecting youth mental health, safety, and privacy online by collaborating with departments of health and human services, commerce, education, and justice. This enables an integrated approach to monitoring potentially harmful social media activities as well as creating tailored education initiatives to promote healthy social media usage among adolescents ( 24 ). By implementing such measures, social media platforms can play a vital role in promoting positive mental health among adolescents with eating disorders and creating a safe online environment for all users. At a personal level, the role of parents or caregivers in regulation of social media use in this population should not be underestimated. There is a need for increased discussion and engagement between parents and adolescents with eating disorders to prevent and manage the potential risks of social media use for their wellbeing.

3.1.2 Awareness campaigns and online communities

It is important for experts in the mental health field and official health organizations to spearhead awareness campaigns. These should aim at educating adolescents about eating disorders and promoting healthy conversations about these topics online. Studies have shown the impact of use of social media on eating disorders and body image issues ( 25 ). These campaigns can help reduce the stigma surrounding eating disorders and promote early detection and treatment. A review of eating disorders related hashtag campaigns during the Eating Disorders Awareness Week on the X platform (formerly known as Twitter) concluded that awareness campaigns effectively promoted posting about eating disorders ( 26 ). To further promote awareness, education about eating disorders should be integrated into social media platforms as well as school curricula, providing students with a solid foundation of knowledge and resources to help identify and address these issues ( 26 ). Anti-bullying efforts should also be incentivized among youth online to ensure that social media platforms remain a safe and supportive space for all users. This can be done by adding virtual badges for online profiles that are actively engaged in promoting anti-bullying content on social media.

Additionally, workshops and training exercises can be arranged to train mental health influencers on social media advocacy for eating disorders. These exercises can aid influencers understand the importance of promoting positive body image and self-love. Additionally, online educational forums can also create a space for youth to discuss eating disorders and their impact on mental health, thereby promoting a supportive online community that values mental health and wellness. By working together, experts, educators, influencers, and adolescents can help create a safer, more supportive online environment for all.

3.1.3 Research and funding

Literature shows the need for research and funding aimed towards understanding the impact of social media on overall mental health and eating disorders among youth. This can help in developing effective interventions and guidelines for social media use. Such research can help identify the specific features of social media that contribute to disordered eating behaviors, including the role of algorithms, body shaming, and the prevalence of idealized body images.

Furthermore, studying the impact of social media algorithms on disordered eating behaviors is crucial. Algorithms can influence what content users are exposed to, which can further reinforce harmful beauty standards and promote disordered eating behaviors. By understanding the role of algorithms, researchers can develop interventions that aim to address the negative impact of these algorithms and promote healthy social media use among youth.

4 Conclusion

Eating disorders are on the rise with a significant impact on mental health. Misuse of social media platforms is likely a significant contributing factor. There is also a great potential in utilizing these platforms as positive tools for youth struggling with eating disorders. Taking this double-edged sword into consideration, investing in research and funding for understanding the impact of social media on eating disorders can help develop early interventions and guidelines that promote healthy social media use among youth. By addressing the unique challenges that social media presents for youth with eating disorders, communities can work towards creating a safer and more supportive online environment on a global scale.

Data availability statement

The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.

Author contributions

FN: Writing – original draft, Writing – review & editing. MR: Writing – original draft. NB: Writing – original draft. AS: Writing – original draft, Writing – review & editing. ZA: Writing – review & editing. HD: Writing – review & editing. MS: Writing – original draft, Writing – review & editing.

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: eating disorders, adolescents, social media, children, youth, mental health

Citation: Nawaz FA, Riaz MMA, Banday N, Singh A, Arshad Z, Derby H and Sultan MA (2024) Social media use among adolescents with eating disorders: a double-edged sword. Front. Psychiatry 15:1300182. doi: 10.3389/fpsyt.2024.1300182

Received: 07 November 2023; Accepted: 24 January 2024; Published: 09 February 2024.

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Copyright © 2024 Nawaz, Riaz, Banday, Singh, Arshad, Derby and Sultan. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Meshal A. Sultan, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Social media and eating disorder psychopathology: A systematic review

Vol.15, no.3 (2021).

Paula Frieiro Padín Rubén González-Rodríguez Carmen Verde-Diego Raquel Vázquez-Pérez

https://doi.org/10.5817/CP2021-3-6

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• Author biographies
• Additional information

The relationship between socialization through social media (SM) and eating disorders (EDs) is a serious problem for public health, largely affecting the mental health of younger people. This work aimed to identify scientific works addressing ED psychopathologies, studying their relationship with SM usage. In this systematic review, we analyze the available scientific evidence, thereby providing tools for intervention, prevention, and treatment. A systematic review and PRISMA analysis of narrative syntheses was carried out. Works were selected from the databases of Web of Science, Scopus, PubMed, and PsycINFO. Out of a total of 257 references, 19 articles were identified and selected; among them, correlational studies predominated. A growing interest in the subject matter was identified, as it is undergoing constant changes. The investigations found that EDs and SM usage are influenced by the time spent on SM, the type of interactions, and shared photographs, as well as gender and sociocultural context.

Paula Frieiro Padín

Department of psycho-socio-educational analysis and intervention, university de vigo, ourense.

Frieiro Padín, M.Sc., is a Ph.D. student and pre-doctoral fellow in the Department of Psycho-socio-educational Analysis and Intervention, at the University of Vigo.

Rubén González-Rodríguez

Rubén González-Rodríguez, Ph.D. University of Santiago de Compostela and University of A Coruña, is a lecturer and researcher in the Department of Psychosocial and Educational Analysis and Intervention at the University of Vigo.

Carmen Verde-Diego

Carmen Verde-Diego, Ph.D. University of Santiago de Compostela, is a full professor and researcher in the Department of Psychosocial and Educational Analysis and Intervention at the University of Vigo.

Raquel Vázquez-Pérez

Raquel Vázquez-Pérez, Ph.D. University of Vigo, is a lecturer and researcher in the Department of Psychosocial and Educational Analysis and Intervention at the University of Vigo.

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Editorial Record

First submission received: December 3, 2020

Revision received: April 19, 2021 May 19, 2021

Accepted for publication: May 21, 2021

Editor in charge: David Smahel

Introduction

Research on the psychological implications of the use of and exposure to social media (SM) is an area that is gaining momentum and reveals an unmet need due to the rapid increase in mental illnesses linked to SM usage, which poses a threat to public health (Ljungberg et al., 2020). The use of SM at the beginning of the advent of the Internet provoked suspicions among experts who predicted risks to users’ well-being. This consideration was subsequently nuanced, as mixed evidence has emerged; that is, the use of SM is beneficial when employed to create meaningful social connections, but harmful in situations such as isolation and social comparison (Clark et al., 2018). Although SM are designed to promote social connection and interaction, many SM users engage in passive utilization, rarely interacting with others’ content (Quiroz & Mickelson, 2021). Thus, among passive SM users —though not limited to them­— no interpersonal connections are generated, fostering conditions of isolation and social comparison, which influence personal well-being (Clark et al., 2018). These situations can lead to dissatisfaction in people's self-perception, which can result in efforts to “improve,” for example, through restrictive diets and excessive exercise, typical symptoms of some eating disorders (Rodgers, 2016).

The literature that studies the connection between SM and ED psychopathologies is their initial development. Hence, this work aims to carry out a systematic review addressing the currently available research in the area, thus contributing to the development of a solid knowledge base on the subject. By comprehending this topic, mental health professionals can identify unhealthy behaviors, such as high-usage SM time or the kind of shared images that promote disordered eating attitudes and behaviors (Šmahelová et al., 2019).

Eating Disorder Psychopathology and Concern for Body Image

EDs have been recognized for centuries, with the first clinical description of anorexia nervosa in 1689 by Richard Morton, and the coining of the term by William Gull at the end of the nineteenth century (Black & Grant, 2014). In these disorders, unlike almost any other mental health pathology, sociocultural factors contribute notably to their etiology (Black & Grant, 2014; Schaumberg et al., 2017) although it has been shown that genes also play an important role. Body dissatisfaction among young women has been shown to precede the development of EDs, and it is a consistent and robust predictor (Stice et al., 2011).

The present study focuses on the approach to anorexia nervosa and bulimia nervosa. Following the criteria determined by the American Psychiatric Association (APA, 2013), anorexia and bulimia are the EDs in which occurs a fear of weight gain, as well as an alteration in the self-assessment of the body itself. In this sense, this work includes subclinical EDs, which have a higher prevalence rate than diagnosed EDs (Loth et al., 2014). In ED psychopathologies, body dissatisfaction, negative or altered body image, and eating disorders represent a broad spectrum of food concerns, which are precursors to the development of anorexia and bulimia (Hilbert et al., 2014).

Anorexia nervosa and bulimia nervosa are serious psychiatric diseases with substantial morbidity, and much of the mortality rate is attributable to medical complications inherent to their evolution (Westmoreland et al., 2016). In the review of Chesney et al. (2014), the authors identified a high mortality rate for people with anorexia nervosa, which decreases their life expectancy by 10 to 20 years. Suicide is the second leading cause of death among people with anorexia and also poses a risk among those diagnosed with bulimia nervosa (Goldstein & Gvion, 2019). Besides, anorexia, bulimia nervosa, and binge eating are difficult to treat and constitute a clear public health problem (Napolitano et al., 2019).

The concept of body image has been studied in different disciplines, including psychology, psychiatry, medicine, and sociology, making the different perspectives essential to explain the alterations of body image and EDs (Blood, 2005). Body image has been defined as a person's perceptions, thoughts, and feelings about their body (Grogan, 2016). In this line, Schilder (1950) argued that it is not only a perceptual construction of one's body but also a reflection of attitudes and interactions with others. Perceptual body image, that is, the accuracy of body-size estimation relative to actual size, is distinguished from attitudinal body image , which is evaluated by four measurements: global subjective satisfaction, affect and feelings, cognitions, and behaviors (Thompson et al., 2012).

Concerning the sociocultural influence of EDs, diagnostic problems in anorexia and bulimia have been shown to be related to culture because, although they occur in diverse populations, the evidence currently suggests a transcultural variation in their development and presentation. Anorexia is most prevalent in high-income post-industrialized countries, such as the United States, many European countries, Australia, New Zealand, and Japan. Its prevalence is comparatively lower among the Latino, African-American, and Asian populations in the United States, which may be biased because of the lower use of mental health services by this population. In terms of bulimia, diagnosis is also prevalent in industrialized countries (United States, Canada, many European countries, Australia, Japan, New Zealand, and South Africa). In clinical studies of bulimia nervosa in the United States, people with bulimia are mainly white women (APA, 2013).

Sociocultural influences have identified that black women may have greater acceptance of a variety of body types and a broader understanding of “beauty” comprising different body sizes (Howard et al., 2017). However, as different Asian countries have become industrialized and globalized, the gap in the amount of EDs between Asia and the West has declined (Soh & Walter, 2013). Even in Asian countries where EDs were believed to be less prevalent than in the West, comparative studies have emerged documenting food attitudes and levels of body dissatisfaction that are similar or worse than those reported in Western countries (Pike & Dunne, 2015).

Use of the Social Media

Concerning SM usage, for many people, it is a daily activity (Gruzd et al., 2018) and constitutes a new virtual scenario that potentially influences the psychological and social development of younger people (American Academy of Pediatrics, 2016). Studying the performance of this activity is a complex reality that goes beyond evaluating the time spent on SM by young people (Pertegal-Vega et al., 2019). Furthermore, it is not currently possible to establish a relationship between the number of hours spent on SM and problematic use of the Internet. However, there is evidence that problematic use of SM leads to a decrease in real-life, social community participation, and academic achievement, as well as to relationship problems, all of which may be indicative of potential addiction (American Academy of Pediatrics, 2016).

There is a wide range of content generated and disseminated via SM, including entertainment, communication, and knowledge pertaining to various subjects (Gündüz, 2017). Some of the essential features inherent in different SM are that they are interactive and that the user generates content using text, images, or videos. SM also create specific profiles that make it easier to connect with other people or organizations and in which one's content is grouped (Tao et al., 2016). This systematic review focuses on the most widespread SM platforms, such as Facebook, Instagram, and Twitter, where sharing photos about one's physique and personal appearance is habitual. These SM may contain different comparison objectives or different characteristics that influence physical comparisons (Fardouly et al., 2017). The use of SM involves interaction with people who are well-known in real life, rather than with fictional images, and it can influence the peer competition generated by such exposures (Ferguson et al., 2014). In addition to competing with peers, people may also aspire to be like celebrities and influencers without realizing that they, too, use beauty filters and edited pictures on SM to present an ideal aesthetic (Hendrickse et al., 2017).

In 2021, the global SM penetration rate reached 53.6% (Statista, 2021). In Western Europe, its usage rate was at 79%, followed by North America at 74%, and Central America with a usage percentage of 71%. In Southeast Asia, the percentage was 69% and in Oceania, 64% (Statista, 2021). The lowest figures were on the African continent but there were notable differences: in the north, 45% of the population uses SM whereas, in Central Africa, only 8% of the people use SM, the lowest regional proportion in the world (Statista, 2021). Among the youngest, 16 to 24 years old, nearly 9 out of 10 people in the EU participate in SM (88%). In Europe, taking into account the population between 16 and 74 years old, SM usage went from 36% in 2011 to 54% in 2019 (Eurostat, 2020). Globally, the SM platform with the highest number of users, among whom interaction through photographs predominates, are Facebook (2.449 million), WhatsApp (2 billion), Youtube (2 billion), Instagram (1 billion), and TikTok (800 million) (Statista, 2020).

Involvement of Social Media in Body Dissatisfaction and Eating Disorder Psychopathology

The negative image of one's body, in particular body dissatisfaction, is highly prevalent among young women (Fallon et al., 2014). Various studies have shown that the use of and exposure to SM generate body image concerns as well the development of EDs (Holland & Tiggemann, 2016). In this sense, eating disorders are etiologically related to the internalization of social pressure resulting from the standards of feminine beauty of modern industrial society or the Western culture (Stice et al., 2011). The dissemination of these extended aesthetic models on SM creates a risk for the development and maintenance of health problems, as in the case of EDs (Grabe et al., 2008). To this is added that the social comparison on SM generates body dissatisfaction in users when they realize that they cannot achieve the generalized thin ideal (Frederick et al., 2017).

It has been shown that the visualization and exposure to attractive peers through SM contributes to the development of a negative body image (Hogue & Mills, 2019; Kim, 2020), together with the photographic self-retouching performed by SM users (Mills et al., 2018). SM images are powerful tools not only for communicating but also for perpetuating ideals that influence adolescents' sense of identity. Even when not maliciously intended, images displayed on SM can increase the risk of significant negative consequences in all areas of emotional, mental, and physical health, including an increased risk of EDs and mood disorders (Kwon, 2020). The use of SM combines two influences, on the one hand, the media and, on the other hand, group pressure, promoting a negative body image and requiring social-health intervention and prevention programs for possible EDs (Mabe et al., 2014).

To the social media exposure itself are added the dynamics of interaction through “likes” and comments received on the shared photographs, issues that must be present for our comprehension of ED psychopathologies (Tiggemann et al., 2018). Also, visual images of the SM tend to show carefully selected and retouched photographs. Therefore, it is common for users of SM like Facebook to believe that other people are happier and more successful than they are (Hou et al., 2019). Being critical of SM content, having high self-esteem, and a lower tendency to engage in social comparisons buffers the effect of SM on body satisfaction (Brichacek et al., 2018).

Due to all of the above, research has been carried out addressing the relationship between the general use of SM and eating behaviors and even with the development of EDs. To our knowledge, the present study offers the first systematic review of the investigations that correlate both objects of study, SM and ED psychopathologies. Although we are aware of the existence of a systematic review that relates the use of SM to body image, it does not establish as a requirement the inclusion of at least one measure of EDs (Holland & Tiggemann, 2016).

Research Question

To support this systematic review, the PECO method was used, which promotes the selection of firm search criteria that facilitate the research question (R. L. Morgan et al., 2018). The acronym for this method corresponds to Population, Exposure, Comparator, and Outcome (R. L. Morgan et al., 2018). Thus, the PECO outline of this study was formulated as follows; P: Among the population using SM, what is the effect of; E: exposure to SM image content versus; C: make more limited use of SM; O: preventing ED psychopathologies. From the PECO and the theoretical aspects set out in the introduction, the research question could be developed: Can the population using SM be affected by its content, influencing the development of ED psychopathologies?

Search Strategy

In this study, the analysis of the literature was carried out through a systematic review following the PRISMA standards related to methodological design: protocol, search process, selection, and synthesis of results (Moher et al., 2009). This methodology was used to identify the largest possible number of studies on SM that include measurement and evaluation or diagnosis of EDs. The methodological decisions made were reflected in an ad hoc designed protocol.

The search was conducted between December 2019 and January 2020, identifying empirical research of an essentially quantitative nature from the following databases: Web of Science, Scopus, PubMed, and PsycINFO. The search strategy used the following combinations of the English terms and their Spanish equivalents: “Social media,” “Social networking sites,” “Bodyimage,” “Self-esteem,” “Eating disorders,” “Anorexia,” “Bulimia,” “Thinspo,” “Self-objectification,” “Instagram,” “Twitter,” and “Facebook”. The terms were selected and combined to obtain the most results in each search.

Inclusion and Exclusion Criteria

To be included in the analysis, the studies had to meet the following criteria: 1) examine the use of an existing and widely used SM platform. To identify them, we used the results of the Pew Research Center's Internet and Technology Survey, which determines the most popular platforms (Pew Research Center, 2019); 2) include a measurement assessing and/or measuring EDs: the SCOFF questionnaire (J. F. Morgan et al., 1999), the Body Attitudes Test (Probst et al., 1995), the Bulimia Test-Revised (Thelen et al., 1991), the Eating Attitudes Test (EAT, EAT-26; Garner et al., 1982), the Body Attitudes Questionnaire (Ben-Tovim, & Walker, 1991), the Eating Disorder Inventory (EDI, EDI-2, EDI-3; Garner, 2004), or the Eating Disorders Examination Questionnaire (EDE-Q; Fairburn et al., 1993). Validated scales and questionnaires in countries and languages other than the original were taken into account; 3) the article had to be written in English or Spanish, due to their prevalence in our search results, as they reported a large number of results, as well as the European languages comprising the largest number of speakers globally. At the same time, most often for pragmatic reasons, only publications in English and the native language are included (Ferreira et al., 2011); 4) be published from 2004 onward (the year in which Facebook emerged as the first SM platform showing photographs).

The following exclusion criteria were established: 1) presentations, dissertations, theses, books, book chapters, communications at conferences, and other technical documents; 2) mainly qualitative studies; 3) studies about contact and dating websites, chats, and forums, online game pages, and virtual reality apps; 4) articles aimed at evaluating and examining SM groups that promote anorexia and bulimia; 5) articles on specific populations ( e.g., athletes, dancers, models, and others), which could lead to bias in the data analyses; 6) validations of standardized tests and instruments.

Selection of Studies

In compliance with the PRISMA guidelines, a flowchart was used to provide a general overview of the selection process for the articles (Moher et al., 2009). After the search, the articles were selected, first, based on their titles, then, on their abstracts, and finally, considering the entire journal article. At the initial stage of title selection, all articles were included whose title indicated some aspect of the use of SM, body image, and ED psychopathologies. This process was similarly followed at the abstract selection stage; qualitative studies were removed at this stage. Lastly, once the abstracts were selected, the full text was read to determine the final eligibility of the studies. Articles were only rejected at this stage if they did not include an independent measure of the use of SM and an independent measure of EDs or a component of EDs, or if they did not provide the information required to calculate the effect size.

Figure 1. Flowchart of the Articles Included in the Study .

The initial selection identified a total of 257 studies, from which 44 duplicate studies were removed. After deleting 6 articles that did not meet the language criteria and 18 publications in other formats, the titles and abstracts of 189 articles were read. Of these, 123 were removed because their content did not correspond to the purpose of the study, the general use of social media and ED psychopathologies. In the final phase, 47 studies were removed for not incorporating specific ED measures, eventually resulting in a total of 19 articles that met all the previously defined criteria (Figure 1).

Data Extraction

This step was performed by two reviewers, who independently read each article and compiled the data in a template. The extraction information was made by reading the article (Moher et al., 2009) and providing the following data: author, publication year, title, editorial data, country, type of publication, category/methodology, topic, abstract, keywords, and database source. After the final selection of studies, the authorship, year, country, sample size, female percentage, design, SM measurement instruments, and key findings were also entered in the template. When questions arose about the suitability of an article in the final selection, additional information about the study was sought, and disagreements were resolved through discussion. The results of the articles analyzed were dominated by frequencies, percentages, and means.

In the results phase, the 19 articles that met all the previously determined inclusion criteria were analyzed. Regarding the methodology of the studies, 17 were correlational studies (of which 3 included a longitudinal component), 1 article was descriptive, and 1 used an experimental design. Almost half of the studies included participants from the United States ( n = 8). The remaining studies were carried out in Australia ( n = 3), Canada ( n  = 2), Korea ( n = 1), Thailand ( n = 1), England ( n = 1), Singapore ( n = 1), The Netherlands ( n = 1), and Fiji ( n = 1).

Of the articles analyzed, 68.4% used only female samples ( n = 13). Although 6 studies included male samples, in all of them, males were the minority gender. The number of participants in the selected studies increased from 55 participants in the smallest sample to 1,087 people in the largest sample. The age range of participants across the studies was between 10 and 64 years of age. The identified studies were published between 2011 and 2019. The largest number of publications took place in 2017 ( n = 6), followed by 2015 ( n = 3). For more information see Table 1.

Table 1. Overview of the Articles Included in the Review.

From the organization and analysis of the main findings of each of the articles, 5 categories were identified that synthesize the results on the use of SM and ED psychopathologies. The 5 categories identified correspond to: Time spent on SM; Use of and interaction through SM; Sociocultural influence; Gender influence; Self-esteem and satisfaction with body image.

Time Spent on SM

The time spent on SM and the development of ED psychopathologies were strongly related in studies that considered both variables. Authors like Kaewpradub and colleagues (2017) found that the time spent on image-related SM was associated with problematic eating behaviors. Reinforcing this idea, Santarossa and Woodruff (2017) reported that over-use of SM is related to body image concerns, self-esteem, and ED psychopathologies. Tiggemann and Slater (2014) agreed on the relationship between usage time and the internalization of the thin ideal, body monitoring, and drive for thinness. The study by Murray et al. (2016) revealed that lower weight and appearance esteem mediated the relationship between excessive time on SM and restrained eating for males and females. One study indicated that the increased use of Facebook was associated with more body dissatisfaction but not directly with EDs (Howard et al., 2017).

Regarding the daily connection time, Santarossa and Woodruff (2017) found that female participants connected to SM between 3.9 to 4.1 hours daily, and their male counterparts between 2.8 and 2.9 hours. Yellowlees et al. (2019) reported that 98% of the participants used SM accounts, with an average daily usage of 2.52 hours ( SD  = 2.34), highlighting the time spent on Facebook, followed by Instagram. The result with a lower daily average on SM (MySpace and Facebook) was 81.31 minutes ( SD  = 99.20) (Slater & Tiggemann, 2015).

Tiggemann’s and Slater’s (2017) study included a longitudinal component and found that the number of Facebook profiles increased over a two-year period from 71.7 to 91.3%, as did the connection time, the average number of contacts, and concern for body image. Concerning the drive for thinness, these authors observed that, after its initial measurement ( M = 17.65, SD = 9.32), it increased at the second measurement ( M = 20.51, SD = 9.73). The time spent on SM had stronger correlations with concern for body image than did the general exposure to the Internet, representing a powerful socio-cultural influence among preadolescent girls (Tiggemann & Slater, 2014).

Use of and Interaction Through SM

Interaction through comments, photo sharing, and selfies was very relevant for the dissatisfaction with and control of body image. In early papers that addressed the subject, such as that of Tiggemann and Slater (2014), it was observed that 14% of the girls had a MySpace profile and 43% had a Facebook profile. In subsequent studies, three out of four participants (75.1%) reported having a Facebook profile, and 46.3% had a MySpace profile (Slater & Tiggemann, 2015). Authors like Saunders and Eaton (2018) identified new patterns, incorporating SM into their study of Instagram and Snapchat, observing the following results: 15.1% of the participants were Facebook users, 33.6% were Snapchat users, and 51.3% were users of Instagram, which represented the most frequently used platform.

Together with the percentage of SM usage, the type of interaction that occurred on the networks was very relevant in the works analyzed. The total number of friends and specific activities, such as looking at other people's profiles or leaving comments, were directly related to concern for body image, self-esteem, and EDs among adolescents (Santarossa & Woodruff, 2017). The longitudinal study by Tiggemann and Slater (2017) found that body internalization and monitoring predicted an increase in the number of friends. As for presenting images of friends' bodies versus those of famous people, Hendrickse et al. (2017) emphasized the need to differentiate the effects produced, with a greater influence of known peers over celebrities. In this line of argument, Ferguson et al. (2014) found that the comparison between known peers is more relevant for body self-esteem and eating problems among adolescent girls.

Concerning self-objectification indices, in the sense of judging one's body compared to social standards, it was noted that Facebook users have higher self-objectification ( M  = 2.17, SD = 12.85) than non-users of this SM ( M = -5.59, SD = 14.62). The authors also reported that people who devoted much of their time on SM to photo sharing were more likely to develop body dissatisfaction and drive for thinness (Meier & Gray, 2014).

The control of body mass index (BMI) associated with following health and physical exercise accounts correlated positively with the internalization of the thin ideal and drive for thinness (Cohen et al., 2017). The study conducted by Butkowski et al. (2019) found that the drive for thinness also correlated with feedback received from selfies and body monitoring. Yellowlees et al. (2019) noted that the relationship between the total number of selfies and EDs was nonsignificant, such that those who posted the most selfies did not report more body dissatisfaction. However, these authors did find that unposted selfies were linked to body dissatisfaction and monitoring.

Concerning the comments received, Hummel and Smith (2015) noted that the search for feedback through comments predicted food restriction when a large number of comments was received. Those who received many comments and those who received negative feedback through SM were more likely to report food restriction at the second period of their longitudinal study. For Slater and Tiggemann (2015), comments on the SM about physique, both positive and negative, were positively related to self-objectification and self-monitoring. Positive comments on appearance ( M = 3.04, SD = 1.35) were received more than negative ones ( M = 1.08, SD = 1.28). In sum, the corpus of scholarly literature reviewed above highlights the importance of including SM-dynamics in research studies on body concern and EDs (Slater & Tiggemann, 2015).

The only study that focused on patients with an ED diagnosis highlighted that significant use of apps and smartphones prolonged or worsened the behavior in the most severe cases of the disease, finding that 41.8% of the diagnosed people felt that the apps helped perpetuate the disease (Tan et al., 2016).

Sociocultural Influence

Sociocultural influence has been reaffirmed through the results as one of the determinants of the possible development of ED psychopathologies. The variation and sociocultural representativeness of the different samples varied depending on the article analyzed. However, a predominance of Caucasian samples was observed, as in Walker et al. (2015), a study in which Caucasians accounted for 81.3%; in Cohen et al. (2017) with 77.5%; and in Butkowski et al. (2019), with 60%. The following works were noteworthy for collecting different samples: Ferguson et al. (2014), in which most participants were Hispanic (94.1%), a reflection of the community surrounding the university; the study examining a Western and ethnic sample in Fiji (Becker et al., 2011); and the work that used a racial perspective, where Black women accounted for 48.26% of the sample (Howard et al., 2017).

In the work with the Fijian sample (Becker et al., 2011), not only ethnic issues were considered, but also Western exposure through trips abroad. As for the research that explored the differences between Black and White women, the result suggested less body dissatisfaction and a lower likelihood of EDs in Black women, as well as more frequent use of Facebook among White women seeking greater validation (Howard et al., 2017). Focusing on the Fiji study, ethnic cultural orientation was associated with a lower incidence of EDs, whereas trips abroad were associated with a higher likelihood of EDs (Becker et al., 2011). Concerning Black women, they were observed to experience lower levels of body dissatisfaction and marginally lower levels of EDs than White women (Howard et al., 2017).

Gender Influence

Of all the studies reviewed, 68.4% examined exclusively female samples, addressing the impact of SM use on body image and EDs mostly from a female perspective. Although some investigations had male samples, not all of them developed and analyzed gender differences (Hummel & Smith, 2015; Tiggemann & Slater, 2014).

Authors such as Santarossa and Woodruff (2017) argued that the few existing gender differences could be attributed to the use of gender-specific tools when available, for example, the SATAQ-3 female version and the SATAQ-M male version.

On average, male participants used general media for more time but females used the Internet and SM more, as a means of body image-related content, and 61.3% of them sought body-image-related products on SM (Kaewpradub et al., 2017). In the gender analysis, female high school participants reported significant differences in purging behaviors, laxative use, weight loss pills, and excessive exercise (Kaewpradub et al., 2017). However, male high school participants scored significantly higher in behaviors that imply a risk of obesity (Kaewpradub et al., 2017).

Murray et al. (2016) revealed that females had a significantly more contained and emotional diet, poorer self-esteem about their appearance, and a worse perception of their weight, which mediated their overuse of SM. It was also revealed that on the SM, women engage in more social comparison activities, and men tend to use SM to make friends and expand their social network. However, research results show that men's body image and dietary behaviors are also influenced by SM (Murray et al., 2016).

In the study that analyzed a clinical sample (Tan et al., 2016), the participants were mostly women (94.5%). In this sense, the authors state that the small male sample could limit the generalization of this study to male individuals with EDs. Consequently, they established the need for future studies to include more male participants with EDs.

Self-Esteem and Satisfaction With Body Image

This systematic review shows that, in some studies, problematic use of SM was associated with decreased self-esteem and satisfaction, alteration of body image, and a possible increase of depressive behaviors.

Excessive time on SM was associated with lower self-esteem about physique, which, in turn, was related to increased dietary restriction (Kaewpradub et al., 2017). The results of the study by Santarossa and Woodruff (2017) suggested that symptoms derived from the problematic use of SM are worrisome, as they were associated with lower self-esteem and more symptoms of EDs. Comparisons related to appearance provided through Instagram were positively associated with concern for body image, suggesting that the greater the body dissatisfaction, the higher the drive for thinness (Hendrickse et al., 2017).

Walker et al. (2015) reported that BMI and depression explained variations in the development of EDs, as well as the comparison of physical appearance on SM. Ferguson et al. (2014) observed a small correlation between the use of SM and a reduction in life satisfaction.

The study of Kaewpradub et al. (2017) found that one-third of the participants had abnormal attitudes towards eating and body image. Internet and SM usage were negatively associated with body image satisfaction but positively associated with inappropriate eating behaviors, binges, purges, laxative use, diuretics, and drive for muscularity. Similarly, Walker et al. (2015) observed that the presentation of one's image on Facebook was positively correlated with the internalization of the thin ideal, self-objectification, and drive for thinness.

The results of this study show that the use and dynamics generated in SM can determine the appearance and/or permanence of behaviors linked to ED psychopathologies. The time spent on SM, the interactions and dynamics, the sociocultural influence, gender, and self-esteem have all been shown to influence the type of exposure, utilization of SM, and also the possible development of ED psychopathologies. Usage patterns varied depending on the year in which the study was conducted, largely due to the rapid changes that occur in the functionalities of SM (Pantic, 2014), and the age of the SM users.

The time spent on SM linked to the development of EDs is a determining factor, as it increases the exposure and visualization of beauty references with which to compare oneself. Thus, as proposed by the Social Comparison Theory (Festinger, 1954), through SM, one arrives at a self-assessment of one's abilities and skills by comparing oneself with others. At the same time, the greater the exposure to SM, the greater the possibility of internalizing the thin ideal of beauty (Tiggemann & Slater, 2014). It is noteworthy that the most recent studies that considered the time spent on SM (Santarossa & Woodruff, 2017; Yellowlees et al., 2019) observed more minutes of daily consumption, compared to less recent research (Slater & Tiggemann, 2015), confirming the increasing tendency of SM consumption. This was also seen in the longitudinal study by Tiggemann and Slater (2017). In general, the increase in time spent on SM produces stronger correlations with concern for image (Tiggemann & Slater, 2014).

Interactions that occur in SM play a decisive role in the content that is presented and perceived, which is a predictor of concern for one's image (arising from the desire to receive feedback in comments and “likes” for published photos). Although SM has the potential to strengthen social relationships, negative reviews and comments can also occur (Hummel & Smith, 2015). As posited in the Parasocial Interaction Theory (Horton & Wohl, 1956), the illusion of reciprocal interaction that the audience experiences toward media figures can influence the comparison with their own body. As for the self-assessments of one's body that can be produced through SM, we highlight selfies seeking social validation oriented to physical appearance, which is reinforced through “likes” and comments by third parties (Butkowski et al., 2019). However, unposted selfies revealed greater bodily control behavior, associated with possible more severe EDs (Yellowlees et al., 2019). It is also essential to consider and attend to the type of accounts that are followed, such as health, beauty, and physical exercise accounts that correlate with the drive for thinness (Cohen et al., 2017). Another dynamic determinant of the use of SM is that it can serve as a means to anonymously seek support and recommendations through online communities that encourage thinness (“thinspo”), anorexia (“proana”), or bulimia (“promia”) (Brotsky & Giles, 2007; McCormack & Coulson, 2009), all of which can encourage EDs to be kept off the radar of family and friends (Gavin et al., 2008). However, Tiggemann et al. (2013) note that, if body image is perceived as an unrealistic objective, adolescent girls will be less likely to compare themselves socially with such images.

Sociocultural influence is relevant to the etiology of EDs (Black & Grant, 2014) and has been considered in a large part of the reviewed articles. Sociocultural perspectives suggest that societies have different body ideals that change over time, highlighting the tripartite influence model (van den Berg et al., 2002), which proposes that the media, peers, and family are key sociocultural channels for the transmission of these ideals. In this sense, the great growth in SM usage that is occurring should be borne in mind (Statista, 2021). Currently, Caucasians have constituted the predominant population in studies that examined the use of SM and its influence on EDs, with the exception of the following studies: Ferguson et al. (2014), an investigation in which Hispanic participants predominated; the study that used ethnic samples from Fiji (Becker et al., 2011); and the work that analyzed Black and White populations (Howard et al., 2017). The study that used the Fijian sample also considered an external sociocultural influence, expressly considering personal trips abroad, which was associated with more EDs (Becker et al., 2011). These results might be explained through the trend toward the globalization of body image, and the thin ideal of Western beauty that is fostered through the media (Yan & Bissell, 2014). The study with a Hispanic sample is of particular interest, given the lack of scholarly works on Hispanic populations (Ferguson et al., 2014). The diverse results obtained across these studies highlight the need for future studies to delve into sociodemographic issues, focusing on more diverse samples and also addressing socioeconomic differences.

The data in this systematic review showed the predominance of articles that have only studied female samples. In the six articles that did include males and females, analyses were limited to the female population and showed girls' increased likelihood of weight dissatisfaction, dieting to control weight, and purging (Anderson & Bulik, 2004; Lewinsohn et al., 2002). This trend is consistent with reports by the American Academy of Pediatrics (2003), which state that males constitute only 10% of all ED cases. Although the multifactorial perspective of the etiopathogenesis of body image suggests that gender creates a disadvantage and increases the women´s risk of EDs (Worell & Todd, 1996), further research comparing the two genders is needed. Related to gender, we have also seen issues such as intrasexual competitiveness, proposed by Hendrickse et al. (2017), which has a positive relationship with comparisons that occur on Instagram. Of the works that also studied males, 26.3% observed significant differences such as girls’ increased dissatisfaction with weight and weight management behaviors, which is reinforced by the increased prevalence of EDs among women (Keski-Rahkonen & Mustelin, 2016). The World Health Organization (WHO, 2019) indicates that these alterations usually occur during adolescence and early adulthood and are more common among women, which is compounded by girls' increased use of the Internet and SM with body-image-related content (Kaewpradub et al., 2017). However, more research is needed to build on the initial findings of Murray et al. (2016), which indicated that men's body image is also influenced by SM, and thereby clarify how the use of SM impacts body image and EDs among boys. There is some research in this area, such as that of Griffiths et al. (2018), who looked into adaptive and maladaptive SM usage in the context of body dissatisfaction, EDs, and anabolic steroid use. More work is needed, however, to further address the socio-cultural influence in the male population (Griffiths et al., 2018).

Most young people want to be accepted by their peers, so they attach more importance to their physical appearance as a way to gain approval by others, comparing themselves to others on SM, which, in turn, relates to lower self-esteem the more time they spend on SM (Kaewpradub et al., 2017). In addition to a concern for image and self-esteem, the study of Santarossa and Woodruff (2017) also reported a higher probability of ED and associated ED symptoms. Black women tended to have significantly higher levels of self-esteem and were less likely to compare their body to that of others (Quick & Byrd-Bredbenner, 2014). These behavior patterns can be better understood from the Objectification Theory (Frederickson & Roberts, 1997), which posits that women's bodies have been constructed socially as objects to be observed. As a consequence, women may practice self-monitoring, judging, and self-observing according to social standards, as if they were an external viewer.

Health workers and relatives of people with ED psychopathologies are largely unaware of the relationship between SM and this group of pathologies. It is hoped that this systematic review will help draw attention to the effects that continued use of SM can have on EDs. Sowles et al. (2018) reported that more than half of the parents of ED patients in their sample did not know the dynamics and interaction processes that occur in SM. The patterns of the drive for thinness (Tiggemann & Slater, 2017), internalization of the thin ideal through SM (Meier & Gray, 2014), and inappropriate eating behavior (Walker et al., 2015) can encourage, worsen, and normalize illness behaviors through continued use of SM (Tan et al., 2016). Specialists should also be attentive to body monitoring and validation behaviors through selfies among people with EDs, as these issues should be considered possible indicators of the development of pathology (Yellowlees et al., 2019).

A study on general Internet use and body image has concluded that public health efforts are needed to support girls and young women to achieve and maintain a positive body image in the current digital age (Carter et al., 2017). It is necessary to provide guidelines for healthy Internet use, as well as to reinforce girls’ and women’s authentic identity (not what is projected on SM) (Carter et al., 2017). To our knowledge, to date, there is only one other published review article linking SM usage and body image (Fallon et al., 2014) although that study did not include in its evaluation criteria that the studies reviewed must have ED measures. In this sense, the present review fills an important gap in the literature on ED psychopathologies.

The interactive nature of SM requires concrete and up-to-date research. SM are also a predominant media during the age of onset of the development of ED psychopathologies—puberty and adolescence. This systematic review may serve to gather key findings on the subject, helping to identify potential limitations and continue to address this topic through organized knowledge on the subject. Thus, the results can also be integrated into future research and discussions on the development of ED psychopathologies and the influence of SM. Moreover, this systematic review aims to respond to professional demands for comprehension of the use of SM and the development of ED psychopathologies, as well as to serve as the basis for generating preventive interventions when necessary (Šmahelová et al., 2019).

The PECO method (R. L. Morgan et al., 2018) was utilized to obtain greater accuracy in the selection of studies for inclusion in this systematic review as well as for establishing internal validity. The authors carried out an evaluation and examination of the quality and relevance of individual articles, using validated templates (Briggs, 2020). The discussion of the articles to achieve consensus strengthened the reliability. Each reviewer individually synthesized the results, followed by a joint discussion and assessment of each study, and finishing with the assignment of the studies to the categories presented in this systematic review. The number of articles in this synthesis of the existing literature further adds to the contribution to the field.

As a limitation of this study, it should be noted that there is only one clinical sample; a greater number of clinical samples could help to further define coping strategies. The databases (Web of Science, Scopus, PubMed, and PsycINFO) were chosen for their predominance in multiple fields although, certainly, a larger number of databases might have yielded additional results. Another limitation lies in the impossibility of computing the average age of the participants in each of the studies (due to variability in how the findings were reported). Had this comparison been possible, we would have been able to compare the studies with even more granularity. Although the inclusion of video-predominant media went beyond the scope of the present study, future studies could also benefit from comparing video versus picture exposure. Future reviews that include studies published in additional languages would also positively contribute to research in this area.

This systematic review provides a synthesis of the current state of knowledge on the relationship between the use of SM and ED psychopathologies and notes that the use of SM is significantly linked to body image concerns and the possible development and/or perpetuation of EDs.

After analyzing the studies, a predominance of studies published in international journals mainly from the United States ( n = 8) was identified. Thus, given the corroborated sociocultural influence, we underscore the need to increase research in territories such as southern Europe, where no research was found in this area despite the high use of SM. Thus, is necessary to expand the sociocultural diversity of the samples, as well as to work with a larger male sample. A greater number of longitudinal studies would help to determine and clarify how SM influences the development or permanence of EDs over time. Similarly, it would be relevant to have a greater number of experimental and quasi-experimental studies to better establish cause-and-effect relationships between variables and more robust conclusions on the impact of the use of SM on body image and ED psychopathologies. As this review has shown, interest and concern about the effect of SM usage on body image and ED psychopathologies are growing. However, studies that directly address socialization on the SM and EDs must also attend to the rapid changes and dynamics occurring in SM platforms as elements of communication and relationship in contemporary society. Prevention related to these media also needs to be promoted, to generate skills and information to resist media messages issued concerning the Western ideal of bodily perfection.

1 “Foodporn” refers to the eye-catching exposure of food through SM.

Acknowledgement

This research was funded by the Ourense Provincial Council and the University of Vigo (DIXITOU1-X002).

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This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License .

Copyright © 2021 Padín, González-Rodríguez, Verde-Diego, Vázquez-Pérez

Exploring the perceived influence of social media use on disordered eating in nutrition and dietetics students

Affiliation.

• 1 Department of Clinical Sciences and Nutrition, University of Chester, Chester, UK.
• PMID: 37475206
• DOI: 10.1111/jhn.13212

Background: Social media use (SMU) is increasingly widespread. More recently, SMU has been associated with increases in disordered eating; however, few qualitative studies have explored this issue in nutrition and dietetics students specifically, where susceptibility to disordered eating may be particularly high. The present study therefore aimed to investigate the perceived impact of SMU on disordered eating in nutrition and dietetics students.

Methods: One-to-one, in-depth, semi-structured interviews were conducted with nutrition and dietetics students from universities across the UK. Interviews explored students' views on the potential influence of SMU on their eating-related thoughts, feelings and behaviours. Data were thematically analysed to identify key themes.

Results: The findings suggested that SMU may provide students with a useful tool for the exploration of new recipes, ingredients and health-related information, thus enabling them to improve their eating behaviour and diet quality. However, students also showed high levels of objective awareness regarding the problems associated with SMU, including the presence of misinformation, body image dissatisfaction, social pressures and disordered eating. Interestingly, despite enabling them to detect sources of misinformation, students also discussed the negative impact that their course had on their eating habits, suggesting course content may be an additional risk factor for the development of disordered eating for this particular group.

Conclusions: Future research should investigate ways to mitigate the negative impact of SMU and course content on disordered eating in nutrition and dietetics students.

Keywords: dietetics; disordered eating; nutrition; social media; students.

© 2023 The Authors. Journal of Human Nutrition and Dietetics published by John Wiley & Sons Ltd on behalf of British Dietetic Association.

• Dietetics* / education
• Feeding and Eating Disorders*
• Nutritional Status
• Social Media*
• Universities