social media and eating disorders dissertation

• Open access
• Published: 29 February 2024

Further evidence of the association between social media use, eating disorder pathology and appearance ideals and pressure: a cross-sectional study in Norwegian adolescents

• Camilla Lindvall Dahlgren   ORCID: orcid.org/0000-0002-6773-475X 1 , 2 ,
• Christine Sundgot-Borgen   ORCID: orcid.org/0000-0002-1149-0442 2 ,
• Ingela Lundin Kvalem   ORCID: orcid.org/0000-0003-2406-2102 3 ,
• Anne-Louise Wennersberg 2 &
• Line Wisting   ORCID: orcid.org/0000-0002-5424-7290 2  

Journal of Eating Disorders volume  12 , Article number:  34 ( 2024 ) Cite this article

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Few studies have investigated how the plethora of contemporary social media (SM) platforms relate to, and influence eating disorder (ED) pathology, appearance ideals and pressure to conform to these ideals in youth.

In this study, 1558 girls (53%) and boys (47%), predominantly within the 16–19 age range, completed an online questionnaire assessing SM use and perceived influence on appearance, ED pathology, internalization of appearance ideals and perceived appearance pressure.

Results showed that ED pathology was common, particularly in girls, and that internalization of body ideals was gender specific, a thin ideal being more prevalent in girls, and a muscular ideal being more common in boys. Results also showed a strong association between ED pathology and perceived pressure to conform to these appearance ideals. One fourth of the participants reported spending four hours or more on SM daily, and 80% of girls reported that SM, particularly Instagram and TikTok, had a negative influence on how they felt about their appearance. These girls had significantly higher levels of ED pathology and reported higher levels of appearance pressure from the media.

A clear pattern of associations between photo- and video specific SM platforms, ED pathology, internalization of body ideals and perceived pressure was found in this study. Adolescent girls appeared to be particularly at risk. The results illustrate an imperative need to keep addressing the potential risks of SM use in adolescents, and to continue monitoring the effect of SM on young people’s view of themselves, their appearance, and their eating habits. Future studies should attempt to identify aspects of SM use that may be particularly detrimental for girls and boys in their formative years, but also those that may enhance adolescents’ satisfaction and appreciation of their body and appearance.

Trial registration: The study is registered in the Open Science Framework (Identifier: 10.17605/OSF.IO/5RB6P https://doi.org/10.17605/OSF.IO/5RB6P ).

Plain English summary

Social Media (SM) has become an increasingly influential part of people’s everyday life, and has transformed the patterns of communication, especially in teenagers. In this study, we investigated the relationship between eleven commonly used SM platforms in adolescents, eating disorder (ED) pathology, appearance ideals, and pressure to conform to these ideals. A little over 1500 adolescent girls and boys, predominantly within the 16-19 age range, participated in the study. Most girls who participated reported that SM use, particularly Instagram and TikTok, had a negative influence on how they felt about their appearance. These girls had significantly higher levels of ED pathology and reported higher levels of appearance pressure from the media. Future studies should attempt to identify aspects of SM use that are particularly harmful for girls and boys in their formative years, but also those who have the potential of strengthening the sense of self-worth and contribute to positive identity formation.

Social Media (SM) has become an increasingly influential part of people’s everyday life, and has transformed the patterns of communication, especially in teens [ 1 , 2 ]. Recent studies show that as many as 95% of adolescents use SM [ 3 ], with Facebook, Snapchat and Instagram being some of the most popular platforms [ 2 ]. Although some studies report positive associations between SM use, psychological well-being and social support [ 4 , 5 ], the majority show negative associations, especially in girls [ 6 , 7 ]. Its negative influence on body image, with eating disorders (EDs) as an ultimate adverse consequence, is especially critical in teens as adolescence is a peak onset period for EDs [ 8 ].

Eating disorder pathology is characterized by negative body image, weight and shape concerns, disruptive eating patterns and low self-esteem [ 9 ]. It is common in adolescents [ 10 ] and can, if left untreated, lead to the development of clinical EDs [ 11 ]. The process through which SM negatively affects body image and ED pathology in adolescents is often described using the tripartite influence model [ 12 ]. Here, SM, in conjunct with parents and peers, constitutes one of the most important avenue for reinforcement of appearance ideals, and the pressure to comply to these standards [ 13 ]. What makes SM use especially perilous is the endless focus on appearance, the persistent feedback to one’s presentation of the physical self, and the vast opportunities for comparison, which may lead to the internalization of unattainable and unhealthy appearance ideals. Internalization of ideals is often followed by an unceasing need for self-evaluation and improvement [ 14 , 15 ], sometimes leading to harmful eating behaviours and cognitions. In line with the tripartite influence model, several studies support the adverse association between SM use [ 16 , 17 , 18 ], the experience of appearance pressure from media [ 19 ], and the internalization of appearance ideals. The internalization of appearance ideals decrease body satisfaction [ 20 ] and increases body image concern in adolescent boys and girls [ 20 , 21 ]. Also, in line with the tripartite influence model, studies report that SM use associate with [ 18 , 22 , 23 ] and predict [ 21 , 24 ] ED pathology in adolescents.

It is the engagement with appearance-based content and activities in SM that seems to especially associate with ED pathology. The extent to which adolescents engage in these activities varies based on the SM platform they use [ 25 , 26 ]. Existing evidence suggest that appearance-focused and picture sharing focused platforms (e.g. Instagram, Snapchat) compared to more text-based platforms (e.g. Twitter and Facebook) more clearly associate with elevated ED pathology [ 27 ]. Among studies on more recent platforms such as e.g. TikTok and Tinder, similar trends have been documented in young adults [ 28 , 29 ]. Because the majority of studies include young adults, studies exploring if association with appearance pressure, the internalization of appearance ideals, and the severity of ED pathology differs by platform, in adolescents have been requested [ 30 ].

It is well established that adolescent boys report lower levels of body dissatisfaction and disordered eating, and higher levels of positive embodiment compared to adolescent girls [ 31 , 32 , 33 , 34 ]. However, findings investigating gender differences in how the use of various SM platforms are linked to appearance pressure, the internalization of body ideals, and ED symptoms, are inconclusive [ 18 ]. One study found that exposure to SM appeared to affect level and type of internalization of body ideals differently among boys and girls. In this study, the authors suggest that the distinct platform preferences among girls and boys, based on potential gender differences, might account for some of the findings [ 18 ]. Among the few studies in male samples, findings indicate that adolescent girls, more frequently than boys, use SM platforms that are visually oriented [ 35 ], which, in theory, makes them more susceptible to negative experiences on SM [ 17 , 24 , 36 , 37 ]. Further, emerging literature suggest that adolescent boys exhibit more positive agency over their SM use, and that they use more body positive coping styles compared to girls [ 38 ]. Hypothetically, this could protect boys from negative experiences of SM use. Other studies challenge these observations by reporting that platform choices and activity participation may vary, but that disordered eating cognition and behaviour still are prevalent in both boys and girls [ 39 , 40 ]. Given that few comparable studies have addressed these gender differences in adolescents, further research is essential to gain a clearer understanding and to tailor future media literacy interventions more precisely for both boys and girls [ 25 ]. Furthermore, despite a growing body of literature supporting the link between SM, ED pathology and appearance ideals and pressure, replications are essential to advance scientific understanding, particularly in exploring how these relationships manifest across different cultures and geographic regions. The primary objectives of this study were (1) to examine the utilization of various SM platforms and assess their perceived influence on appearance among adolescent girls and boys, (2) to investigate gender differences in ED pathology, appearance internalization and pressure, and time spent on SM and (3) to investigate associations and potential gender differences in time spent on SM, ED pathology, internalization of appearance ideals and pressure to conform to these ideals. The following hypothesis were formulated:

Girls are more likely to perceive a negative influence from SM compared to boys

Participants who report experiencing a negative influence from SM will exhibit significantly higher levels of ED pathology, internalization of appearance ideals and media pressure compared to participants who do not.

There are positive associations between ED psychopathology, internalization of the thin/low body fat appearance ideal , media pressure and time spent on SM in girls.

There are positive associations between ED psychopathology, internalization of the muscular appearance ideal , media pressure and time spent on SM in boys.

Associations between ED psychopathology, internalization of appearance ideals, media pressure and time spent on SM are significantly stronger in girls than in boys.

Procedure and sample

Data for this this study was gathered within the context of a broader prevalence study investigating EDs in Norwegian adolescents [ 34 ]. Over twenty upper secondary schools from five of Norway’s eleven counties were invited to participate, with a significant concentration in Oslo and Viken, both notable as the largest and among the most densely populated regions in the country. Participants in this study, predominantly within the 16–19 age range, were students from six of these schools spanning the administrative regions of Oslo, Viken, Vestfold and Telemark, and Rogaland, who accepted the invitation to take part in the research. Data collected was conducted between November 2020 and May 2021. A link to an online survey was distributed to students via their school e-mail accounts or via the schools' digital platforms. Students aged 16 years or above who provided electronic consent were eligible to participate. Students were informed that participation was voluntary, and entailed responding to questions regarding eating patterns, body and weight, loneliness, appearance attitudes and pressure, quality of life and non-suicidal self-injury (see [ 35 , 41 ]). Students completed the survey either in class or at home using individual electronic devices. Prior to initiating data collection, information was made available to students, parents, and teachers via short informational videos, digital pamphlets, and communication through the schools’ digital platforms. The study was approved by the Norwegian Regional Committee for Medical and Health Research Ethics (Reference ID 116178) and the Norwegian Data Protection Authority at Oslo University Hospital. The study is registered in the Open Science Framework (Identifier: https://doi.org/10.17605/OSF.IO/5RB6P ).

Sociodemographic information. The online survey included items on self-reported weight and height (used to calculate Body Mass Index; BMI kg/m 2 ), age, gender, immigrant background, school, grade, and study programme.

Social Media Use and Influence. The selection of SM platforms was based on market research (iPSOS) tracking SM use in Norway in 2020. All participants were asked (Yes/No) if they were currently using one or more of the following platforms: Instagram, Snapchat, TikTok, YouTube, Pinterest, Twitter, Facebook, Reddit, Twitch, Jodel and Tinder. If participants answered “Yes,” they were also prompted to register which of the above-mentioned platform(s) they were currently using, and how much time they spent on SM daily (< 30 min, 30–60 min, 1–2 h, 2–3 h, 3–4 h, or > 4 h). Categorical responses were transformed to numbers (1–6) and scored on a Likert scale with the anchors 1 (< 30 min) and 6 (> 4 h). Participants were also asked to report (Yes/No) whether any of the SM platforms they used had a positive and/or negative influence on how they felt about their appearance (« Do any of the social media platforms you use have a positive influence on how you think about your appearance?» and « Do any of the social media platforms you use have a negative influence on how you think about your appearance? »). If the response was “Yes”, participants were prompted to choose which platform(s) they felt had a positive or negative influence.

The eating disorder examination questionnaire short (EDE-QS)  [ 42 ] is a derivative of the Eating Disorder Examination Questionnaire (EDE-Q) [ 43 ]. Comprising twelve items on a 4-point scale spanning from 0 to 3 (0 = 0 days, 1 = 1–2 days, 2 = 3–5 days, 3 = 6–7 days), the EDE-QS assesses ED cognitions and behaviors over the preceding 7 days. A sum score is calculated (Minimum = 0, Maximum = 36) where higher scores indicate higher levels of ED symptomatology. The EDE-QS has demonstrated good internal consistency, test–retest reliability, and convergent validity in individuals with probable and non-probable EDs [ 42 , 44 ]. Its brevity and psychometric properties underpin the instrument’s potential as an effective screening instrument for EDs in in non-clinical samples [ 42 ]. A cut-off score of 15 is reported to represent the best trade-off between sensitivity and specificity [ 44 ]. As suggested in Prnjak et al. [ 44 ] however, a slightly lower cut-off can be applied to ensure the inclusion of participants experiencing, or likely to experience clinically significant ED symptoms. In the context of this research, a cut-off score of 13 was applied [ 34 ]. For the study’s purpose, the English version of the EDE-QS was translated to Norwegian, ensuring alignment with the Norwegian translation of the EDE-Q [ 45 ]. Cronbach’s alpha obtained in the current sample was 0.90 indicating excellent internal consistency.

The Sociocultural Attitudes Toward Appearance Questionnaire-4 (SATAQ-4R) [ 46 ] assesses the internalization of appearance ideals and the pressure to achieve these ideals from parents, friends, significant others, and the media. The SATAQ-4R provides separate versions for males and females, with 31 statements for females, and 28 statements for males. Responses are given on a 5-point Likert scale with the anchors Strongly Disagree and Strongly Agree. Both versions have seven subscales: (1) internalization: thin/low body fat; (2) internalization: muscular; (3) internalization: general attractiveness; (4) pressures: family; (5) pressures: media; (6) pressures: peers; and (7) pressures: significant others. A mean score is calculated for each subscale, where higher scores indicate higher internalization and perceived pressure. The Norwegian version of the SATAQ-4R has shown good psychometric properties [ 47 ]. For female adolescents, Cronbach’s alpha was 0.93, while for male adolescents it was 0.92, both indicating excellent internal consistency.

Statistical analyses

Data was analysed using IBM SPSS Statistics 27. After testing for normality using Histograms, Normal Q-Q Plots and Kolmogorov–Smirnov statistics, between group difference were analysed using Mann–Whitney U-tests for non-parametric data, and Chi-square tests for categorical variables (Cramer’s V effect sizes were used). To test hypothesis (1) and (2), independent samples t-tests were conducted. Phi ( \(\mathrm{\varphi }\) ) (for dichotomous variables) or Pearson’s r (Z/ \(\sqrt{N}\) ) were used to report effect sizes, and are interpreted as 0.10 (small), 0.30 (medium) and 0.50 (large). To test hypotheses (3) and (4) correlational analyses were performed. These were reported using Spearman’s rho ( \(\uprho\) ). Spearman’s rho ( \(\rho\) ) is interpreted as 00–0.19 (very weak), 0.20–0.39 (weak), 0.40–0.59 (moderate), 0.60–0.79 (strong) and 0.80–1.0 (very strong). To test hypothesis 5), independent t-tests were performed after transforming Spearman’s rho ( \(\rho\) ) correlations into Fisher z correlations. An alpha of 0.05 was used to determine statistical significance in all analyses. In Table 5 , results are reported based on data from Instagram, Snapchat, TikTok, and Pinterest, as these were the four visual platforms with the highest reports of negative influence among both boys (1.4–24.7%) and girls (23.9–76.4%). The other platforms were rated considerably lower in terms of negative influence, ranging from 0.5 to 5.7% in both boys and girls, and were not included in these analyses.

Participant characteristics

A total of 1558 (53% girls, 47% boys) responded to the questionnaire. Ages ranged from 16 to 23 ( SD  = 0.95), with 99.2% (N = 1546) of the participants falling within the age range 16–19. The mean age of the total sample was 17.0 ( SD  = 0.95) years. The mean BMI score for the total sample was 21.8 ( SD  = 3.4), 21.7 ( SD  = 7.7) for girls, and 21.8 ( SD  = 3.3) for boys.

SM platform use and perceived influence

Daily time spent on SM is reported in Table  1 . A total of 99.6% of the participants reported using one or more of the listed SM platforms. Self-reported individual and cumulative SM platform use for the total sample and stratified by gender is presented in Table  2 . Compared to boys, girls reported a significantly greater daily duration on SM, X 2 (5, n = 1552) = 67.7 , p  =  < 0.001, Cramer’s V  = 0.21. Overall, 56.7% of participants reported that one or more of the SM platforms they were currently using had a negative influence on how they felt about their appearance. A significantly larger proportion of these were girls (80.0%) compared to boys (29.7%), Chi-Square = 395.1, df = 1, p  < 0.001. Perceived negative influence was reported as follows; Instagram (girls = 76.4%, boys = 24.7%), TikTok (girls = 55.1%, boys = 12.6%), Snapchat (girls = 23.9%, boys = 10.8%), Pinterest (girls = 29.8%, boys = 1.4%), YouTube (girls = 24.3%, boys = 8.2%), Tinder (girls = 5.7%, boys = 2.6%), Jodel (girls = 4.6%, boys = 1.0%), Facebook (girls = 3.9%, boys = 2.5%), Twitter (girls = 1.4%, boys = 1.1%), Reddit (girls = 0.5%, boys = 1.1%) and Twitch (girls = 0.5%, boys = 0.5%). Results also showed that there was a notable response overlap with regards to the number of SM platforms that elicited negative thoughts about one's own appearance. For instance, among the girls who reported perceiving a negative influence on their appearance from Instagram, 23.1% also reported experiencing a negative influence from Snapchat. Furthermore, the proportion of girls reporting negative appearance influences from Instagram, Snapchat, and TikTok collectively was 18.7%, which decreased to 8.7% when Pinterest was included in the analysis. The corresponding rates for boys were 8.5%, 4.9% and 0.7%. A total of 55.8% reported that SM had a positive influence on how they felt about their appearance. A significantly larger proportion of these were girls (61.7%) compared to boys (49.7%), Chi-Square = 22.6, df = 1, p  < 0.001. Perceived positive influence was reported as follows; TikTok (girls = 39.6%, boys = 22.3%), Instagram (girls = 32.2%, boys = 29.9%), Snapchat (girls = 17.6%, boys = 24.1%), YouTube (girls = 16.4%, boys = 22.3%), Pinterest (girls = 8.5%, boys = 1.0% Tinder (girls = 3.7%, boys = 2.3%), Jodel (girls = 1.0%, boys = 2.1%), Facebook (girls = 1.6%, boys = 4.4%), Twitter (girls = 1.2%, boys = 1.6%), Reddit (girls = 0.4%, boys = 4.5%) and Twitch (girls = 0.8%, boys = 3.0%). Among the girls who reported perceiving a positive influence on their appearance from Instagram, 12.7% also reported experiencing a positive influence from Snapchat. Furthermore, the proportion of girls reporting positive appearance influences from Instagram, Snapchat, and TikTok collectively was 7.1%, which decreased to 1.9% when Pinterest was included in the analysis. The corresponding rates for boys were 17.0%, 9.6% and 0.5%.

ED pathology

The mean EDE-QS score in the total sample was 6.7 ( SD  = 7.0), 9.5 ( SD  = 7.7) in girls, and 3.6 ( SD  = 4.3) in boys. In total, 19.9% (33.2% girls, 4.8% boys) scored at or above the EDE-QS clinical cut-off. Girls accounted for a significantly greater proportion of clinical EDE-QS scores compared to boys, X 2 (1, n = 1557) = 194.5, p  =  < 0.001, φ = 0.36. EDE-QS scores were also significantly higher in girls ( Mdn  = 7.0) compared to boys ( Mdn  = 2.0), U(N females  = 828, N males  = 729) = 148,372.5, Z  = − 17.4, p  =  < 0.001.

Associations between ED pathology, internalization of appearance ideals and pressure, and time spent on SM

Assessment outcomes and gender comparisons for age, EDE-QS and SATAQ-4R scores are reported in Table  3 . Girls scored significantly higher than boys on most SATAQ-4R subscales. The exception was the Internalization: Muscular subscale where boys scored significantly higher than girls. As for perceived pressure, girls scored significantly higher than boys on the two subscales family and media. Associations between ED pathology, internalization of appearance ideals and appearance pressure is reported in Table  4 . Results showed significant positive correlations between ED pathology and internalization of appearance ideals with effect sizes ranging from 0.24 (weak; Muscular) to 0.73 (strong; Thin/Low Body Fat) in girls. In boys, corresponding effect sizes were weak, ranging from 0.34 (Muscular) to 0.39 (Thin/Low Body Fat). The association between appearance pressure and ED pathology ranged from 0.44 (moderate; Family to 0.61 (strong; Media) in girls, and from 0.31 (weak; Family) to 0.42 (moderate; Media) in boys. Time spent on SM was significantly, albeit very weakly correlated with ED pathology in both girls (Spearman’s rho = 0.12) and boys (Spearman’s rho = 0.15). There were no significant gender differences in the association between time spent on SM and EDE-QS scores, or time spent on SM and media pressure. However, the association between time spent on SM and internalization of the Thin/Low Body Fat ideal was significantly stronger in girls than in boys ( p  < 0.01). The opposite was true for the association between time spent on SM and internalization of the Muscular ideal, which was significantly stronger in boys than compared to girls ( p  < 0.05). Also, the association between EDE-Q scores and media pressure was significantly higher in girls than in boys ( p  < 0.01).

Associations between perceived positive and negative influence of SM use, internalization of appearance ideals, pressure, and ED pathology

Participants who reported “Yes” to the question “Do any of the specific SM platforms you use have a negative influence on how you feel about your appearance” scored significantly higher (M = 9.1, SD  = 7.5) on the EDE-QS compared to participants who did not responded “Yes” (M = 3.7, SD  = 4.8), t (1466) = 18.5, p  =  < 0.001. The effect size was large ( d  = 0.9). There were no significant differences in EDE-QS scores between those who did, or did not responded “Yes” to the question “Do any of the specific SM platforms you use have a positive influence on how you feel about your appearance”.

In Table  5 , EDE-QS scores, SATAQ-4R scores and time spent on SM are compared based on whether the participants did, or did not respond “Yes” to the question “ Do any of the social media platforms you use have a negative influence on how you feel about your appearance ”. A “No” response in Table 5 indicates the lack of affirmation that the SM platform has a negative influence on the participants perception of her/his appearance. The four visual platforms that were ranked highest in terms of perceived negative influence were chosen for these analyses. Overall, participants who responded “Yes” had significantly higher EDE-QS and SATAQ-4R scores compared to those who did not responded “Yes”. An inconclusive pattern regarding the relationship between time spent on SM and reports of negative influence emerged across the four visual SM platforms.

In line with existing literature on gender differences in ED pathology [ 48 ], our results showed significantly higher levels of ED pathology in girls compared to boys. Our results also concur with previous studies [ 49 , 50 ] reporting higher levels of internalization of appearance ideals in girls compared to boys, the one exception being the muscular ideal where boys scored significantly higher. Our results also align with studies seen in American adolescents [ 46 ], supporting that internalization of the western ideal and perceived appearance pressure represents a phenomenon valid across geographic regions and cultures.

In the current study, we found significant, strong positive associations between ED pathology, internalization of body ideals, and the perceived pressure from family, peers, significant others, and media in both girls and boys. These patterns of associations align with research in young adult samples, including college females [ 46 ], Turkish college females [ 51 ], and Italian males and females (18–72 years) [ 49 ]. However, associations between internalization of appearance ideals, especially the thin ideal and ED pathology were consistently stronger in girls. As for the association between ED pathology and appearance pressure, the strongest associations were found on the media subscale, both in girls and boys. Notably, the link between ED pathology and media pressure was significantly stronger in girls, indicating that girls may be more vulnerable to the adverse effects of SM on eating cognitions and behaviors. Conversely, it is plausible that girls with problematic eating behaviors are more inclined to perceive pressure from media to adhere to thin beauty standards.

Nearly all adolescents in the current study reported using SM. However, girls and boys had different patterns with regards to what SM platforms they used, and how much time they spentd on these daily. Snapchat, Instagram, TikTok, and YouTube were the most frequently used platforms, supporting previous research showing that picture and video sharing platforms are most popular in adolescents to date [ 2 ]. Moreover, nearly two thirds of the girls reported spending three or more hours on SM daily. The corresponding time spent for boys was markedly lower. Notably, a substantial proportion of girls reported that SM adversely affected their self-perception of appearance, particularly on photo and video sharing platforms like Instagram and TikTok. These findings resonate with a systematic review [ 52 ] that highlights a strong correlation between SM usage and ED pathology. The heightened exposure to appearance ideals, coupled with potential unfavourable comparisons of one’s own appearance, may contribute to body dissatisfaction and subsequently, elevated ED pathology levels. The core feature of both Instagram and TikTok is to share and view picture and video-based content, which is often edited and filtered to make it more attractive [ 53 ]. These may generate adverse social comparisons leading to body dissatisfaction and low self-esteem, well-known risk factors for the development of EDs. A recent literature review [ 54 ] suggests that highly visual SM platforms are of particular relevance for ED risk among adolescents as these may enhance upward comparison and normalize harmful eating behaviors and cognitions. In fact (pre)adolescents have been found to be particularly vulnerable for adverse outcomes of SM usage, with research showing associations between time spent on SM and the risk of developing mental health problems [ 55 ]. In a recent meta-analysis, [ 56 ] excessive time spent on various SM platforms correlated with an increase in anxiety and depression symptoms during the Covid-19 pandemic, the period during which the current study was conducted. In our study, a notable albeit weak association was observed between time spent on SM and ED symptoms in both male and female adolescents. However, we did not specifically investigate the details of SM use, e.g., the extent to which the adolescents viewed, shared, liked and/or in other ways engaged in content relevant to appearance ideals, pressure, and ED pathology. Given that studies have shown that certain activities including viewing, manipulating, uploading photos, appearance comparisons, and seeking feedback [ 14 , 23 ], may play a pivotal role in the observed association between SM use and ED pathology in adolescents [ 57 , 58 ], this represents a crucial area for future research explorations.

Both Instagram and TikTok algorithms tailor content to each user based on previous online activity. Such algorithms may function like a vicious cycle as users, once they have started using harmful content, will experience a surge of similar content. Once a SM feed becomes saturated with content focused on body image, weight, and food content, disentangling from such content becomes highly challenging. According to Thomas [ 59 ] replacing content in ones SM feed requires an active and conscious effort over time, and may help explain why many adolescents persistently engage with content that adversely affect their self-perception, self-esteem and sense of self-worth. This apparent paradox emphasizes the profound influence SM can exert on impressionable adolescents and illuminates a critical dilemma; the very features tailored to attract and retain SM users to bolster profitability and success of the entities behind these platforms, concurrently undermine the well-being of their users. The present study underscores the significance of this detrimental cycle, particularly among girls. A striking 80% of adolescent girls in our sample reported that SM adversely affects their self-perception of appearance. Concurrently, nearly a third of these girls reported dedicating four hours or more to SM daily. When considering the unprecedented rise in SM use during the Covid-19 pandemic [ 60 ] and its potential link to the increasing incidence of EDs in adolescent girls [ 34 , 61 , 62 , 63 ], this trend becomes deeply concerning.

When discussing the negative influence of visual SM platforms on ED psychopathology and appearance, it is worth noting that a substantial proportion of both girls (61.7%) and boys (49.7%) reported that SM had a positive influence on how they felt about their appearance. Content celebrating diverse appearances [ 64 ], body-positive profiles and communities [ 65 ], “SM vs. reality” images have shown to be associated with improvements in young women’s positive mood, body satisfaction and body appreciation, and have the potential to bolster women’s body satisfaction [ 66 ]. However, further research is required to evaluate potential long-term positive outcomes and to determine how best to incorporate them into targeted prevention initiatives. While considering prevention and intervention strategies for EDs in adolescents, enhancing SM literacy and addressing harmful beauty standards via cognitive dissonance methods in selective interventions appears as a paramount first step [ 67 , 68 ]. The Body Project [ 69 ] a preventive initiative designed to counteract the pervasive pursuit of the thin beauty ideal, stands as one of the most rigorously documented prevention programs globally. Currently, its efficacy is under evaluation in a randomised controlled trial in Norway [ 70 ] emphasizing the program’s potential applicability and relevance across diverse cultural and regional settings in adolescent cohorts.

Although causal inferences cannot be definitively drawn, it is likely that a bidirectional relationship exists between SM use and ED pathology. Specifically, among girls reporting negative influences from picture and video-based platforms, significantly elevated levels of ED pathology, as well as heightened internalization and pressure regarding appearance, were observed. Moreover, participants who reported that the SM platforms they were using had a negative influence on how they felt about their appearance also reported spending more time on SM daily. Further, positive associations between time spent on SM, ED pathology and appearance ideals and pressures were observed among both girls and boys. The exception for girls was the muscular ideal, and for boys, the exception was internalization of the thin/low body fat ideal. The association between SM use, appearance, and ED pathology has been illustrated in several other studies [ 36 , 40 ]. A recent review [ 54 ] reported that the strongest link between SM use and ED risk in adolescents can be found among those who are high investors in photo-based platforms. Further, highly visual SM platforms such as Instagram and TikTok have shown to be strongly associated with ED risk factors such as body image concerns and body dissatisfaction [ 71 ]. Although most existing studies are cross-sectional precluding causal inferences, a longitudinal study in adolescents [ 21 ] showed that SM use does in fact lead to body dissatisfaction, rather than those with body image concerns seeking increased SM use.

Strengths and limitations

The strengths of this study are a large adolescent sample consisting of both girls and boys, the use of validated assessment tools, and the inclusion of a wide range of SM platforms commonly used by adolescents. However, there are some limitations and methodological aspects to consider when interpreting the results. Given that data was collected during the Covid-19 pandemic, one should account for the increase in SM use during this period, which is likely to have influenced the internalization of, and perceived pressure to align with prevailing beauty standards. This, in turn, may have had an adverse effect on the onset and/or intensification of ED psychopathology in adolescents. In addition, the response options regarding the influence of SM on appearance was dichotomous (Yes/No), and the cross-sectional design hinders inferences about cause and effect. It's essential to note that our BMI calculations did not adjust for age. Additionally, the SATAQ-4R focuses on general media pressure without specifically addressing social media pressure. While the EDE-QS is developed and validated in samples that to an extent overlaps with our study's sample, it should be noted that the Gideon et al. [ 42 ] and Prjnak et al. [ 44 ] studies involve older participants and a higher proportion of females compared to our current study. Whereas prior studies [ 72 , 73 ] have suggested that a lower threshold may be required to identify clinically significant ED symptoms in males than in females, more research is needed to identify an appropriate EDE-QS cut-off in both adult and adolescent populations in the community. In addition, altering the ED pathology threshold can have produced different proportions compared to previous studies.

Implications

Our results illustrate the critical importance to keep addressing the potential risks associated with SM use among adolescents, and to maintain vigilance in monitoring how SM influence young people’s self-perception, body image, and eating behaviors. Additionally, our study highlights the need to incorporate content related to SM in ED prevention programs. Such programs should focus on promoting awareness of how an excessive emphasis on appearance on SM can contribute to body dissatisfaction and negative self-comparisons among adolescents and their peers. Such awareness can play a pivotal role in reducing the risk of developing unhealthy relationships with food, weight, and body image, thereby contributing to the prevention of eating disorders in this high-risk group. Moreover, in line with previously published recommendations [ 68 ], our results emphasize the necessity of enhancing media literacy and increasing awareness about both the positive and negative aspects of SM usage. Social media, when harnessed thoughtfully, can serve as a powerful tool in increasing ED literacy, promoting healthy eating behaviors and fostering positive body image. An inspiring example of leveraging SM for positive change is the pioneering Norwegian TikTok series “TOXIC” [ 74 ]. It effectively utilizes a platform widely used by adolescents to increase awareness about EDs in boys and encourages individuals to speak up and seek help. This initiative exemplifies the potential to counteract the negative influence of SM when used thoughtfully and constructively and could serve as a source of inspiration for researchers, clinicians and ED advocacy groups alike.

Availability of data and materials

The data that support the findings of this study are available on reasonable request from the corresponding author, [CLD]. The data are not publicly available due to containing information that could compromise the privacy of research participants.

Abbreviations

Body mass index

Eating disorder

Eating Disorder Examination Questionnaire Short Version

Sociocultural Attitudes Towards Appearance Questionnaire 4 Revised

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Acknowledgements

We gratefully acknowledge the Dam Foundation who supported this research financially, and the member organization Mental Health (Mental Helse) for their fruitful collaboration. We also acknowledge and thank study participants for their time and effort, who without this research would not be possible.

The study was funded by the Dam Foundation (Project number 353509) in collaboration with the member organization Mental Health (Mental Helse).

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CLD : Conceptualization, Methodology, Formal analysis, Investigation, Writing—Original Draft, Review and Editing, Supervision, Funding acquisition; Christine S-B: Conceptualization, Methodology, Writing—Original draft, Review and Editing; ILK: Formal analysis, Writing—Original Draft; A-LW: Investigation, Project Administration, Writing—Review; LW: Conceptualization, Methodology, Writing—Original Draft, Review and Editing.

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Dahlgren, C.L., Sundgot-Borgen, C., Kvalem, I.L. et al. Further evidence of the association between social media use, eating disorder pathology and appearance ideals and pressure: a cross-sectional study in Norwegian adolescents. J Eat Disord 12 , 34 (2024). https://doi.org/10.1186/s40337-024-00992-3

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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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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

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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 ].

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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 .

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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.

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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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• Open access
• Published: 10 September 2024

Mirror, mirror on my screen: Focus on self-presentation on social media is associated with perfectionism and disordered eating among adolescents. Results from the “LifeOnSoMe”-study

• Hilde Einarsdatter Danielsen 1 , 2 ,
• Turi Reiten Finserås 1 ,
• Amanda Iselin Olesen Andersen 1 ,
• Gunnhild Johnsen Hjetland 1 , 3 ,
• Vivian Woodfin 2 , 4 &
• Jens Christoffer Skogen 1 , 3 , 5  

BMC Public Health volume  24 , Article number:  2466 ( 2024 ) Cite this article

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Metrics details

Social media use, perfectionism, and disordered eating have all increased over the last decades. Some studies indicate that there is a relationship between self-presentation behaviors and being exposed to others’ self-presentation on social media, and disordered eating. Studies also show that the relationship between focus on self-presentation and highly visual social media is stronger than for non-visual social media, hence facilitating upward social comparison. Nevertheless, no previous studies have investigated the link between adolescents’ focus on self-presentation and upward social comparison on social media, and perfectionism and disordered eating, which is the aim of the present study.

The present study is based on a cross-sectional survey from the “LifeOnSoMe”-study ( N  = 3424), conducted in 2020 and 2021. Respondents were high school students (mean age 17.3 years, 56% females) in Bergen, Norway. Multiple regression analysis was performed, where SPAUSCIS, a measure of self-presentation and upward social comparison, was the independent variable. Perfectionism and disordered eating were dependent variables. Self-reported age, gender, and subjective socioeconomic status were used as covariates, as well as frequency and duration of social media use. Regression models were performed to compare proportions across the median split of SPAUSCIS.

The multiple regression analysis showed that increased focus on self-presentation and upward social comparison on social media were positively associated with both perfectionism (standardized coefficient 0.28) and disordered eating. A stronger association for girls than boys was found for disordered eating (standardized coefficient 0.39 for girls and 0.29 for boys). There was no gender moderation for perfectionism.

Conclusions

Findings suggest that focus on self-presentation and upward social comparison on social media is associated with perfectionism and disordered eating. We recommend promoting a healthy use of social media. This could be established by increasing adolescents’ ability to reflect on and think critically about self-presentation and upward social comparison on social media.

Peer Review reports

Introduction

Growing up today means growing up in a highly digitalized world where social media and online communication plays an important role in adolescents’ lives. Social media can be defined as “highly interactive platforms via which individuals and communities share, co-create, discuss, and modify user-generated content” [ 1 , pp. 241]. Previous studies have largely focused on the temporal aspects of social media use, and some studies indicate that social media use is associated with more mental health problems and decreased well-being [ 2 ]. For example, there are reports that more time spent on social media is associated with symptoms of depression and anxiety [ 3 , 4 ], sleep issues [ 3 , 5 ], and body dissatisfaction [ 6 ]. However, not all research confirms these associations [ 7 , 8 ], and recent studies have indicated that the observed link between time spent on social media and mental health is too small to be of practical importance [ 9 ]. A recent longitudinal study found time spent on social media to be the least important factor in relation to adolescent mental health [ 10 ]. Nevertheless, there is an ongoing and almost ubiquitous concern regarding social media’s potential negative effect on mental health. Considering this, it is increasingly recognized that it is important to investigate more than adolescents’ time spent on social media, such as their usage patterns. After all, social media offers a range of opportunities, such as seeking out like-minded others or specific topics and inspiration, for example, for food, fitness, and a healthy lifestyle. Although inspirational hashtags and pictures may be positive to many adolescents, they also frequently present a “perfect” lifestyle and some of them could even be considered unhealthy inspirations.

• Self-presentation

Self-presentation on social media has been highlighted as potentially important in connection with mental health and well-being among adolescents [e.g. 11 , 12 , 13 , 14 ]. Baumeister & Hutton [ 15 ] defined self-presentation as an individual practice related to how one presents oneself to others, motivated by a wish to make a socially desirable impression on others, and simultaneously, stay true to one’s beliefs and ideals. On social media, self-presentation may include presenting and sharing self-made content, posting of personal opinions, sharing online content of interest, and “selfies” and pictures [ 14 , 16 ]. An American report noted that adolescents are more engaged in self-presentation activities on social media than any other age group [ 17 ]. As increased independence from parents is an important developmental milestone for adolescents, external validation from others may be particularly important for this age group [ 18 ]. Feedback on social media posts through likes and comments, may therefore be an important source of external validation from peers. Considering this, it is likely that many adolescents put great importance on how they present themselves on social media. In addition, social media is a suitable arena for self-presenting activities, as it gives the adolescent control over what, when and how to present themselves on the platform of their choosing [ 12 ]. Functions such as likes, comments, followers [ 19 ], and other measures of engagement, which are implemented on many social media platforms in one form or another, give ample opportunity for immediate feedback on posted content. Hence, this provides cues of social desirability and direction to align future social media posts with how the adolescents prefer to present themselves on these platforms [ 12 ]. These features of social media, in addition to the ability to reach a large and varied audience, may serve to facilitate self-presentation [ 20 ].

Self-presentation behaviors [e.g. 13 , 14 ] on social media are closely connected to focus on self-presentatio n [ 12 , 21 , 22 ]. Focus on self-presentation consist of caring about how you present yourself on social media, e.g., retouching pictures before posting them, caring about having a nice social media feed or striving for positive feedback on your social media posts, and can be independent of how much or how often a person post something [ 12 , 21 ]. As such, focus on self-presentation differs from self-presentation behaviors, which have been more extensively researched [e.g. 13 , 14 ]. A study showed that many adolescents have a desire to focus less on their self-presentation on social media, but that they think it is hard to resist the pressure of having a good feed and receiving positive feedback such as likes, comments, and followers [ 23 ]. A higher focus on self-presentation has been linked to the use of highly visual social media platforms like Instagram, TikTok and Facebook, rather than less visual platforms [ 12 ].

Likewise, use of social media has been linked to more social comparison, and in particular upward social comparison [ 24 , 25 ]. Social comparison is the propensity to compare one’s characteristics to other people to obtain information about how we are doing relative to others [ 26 ]. Upward social comparison occurs when one compares oneself to someone perceived as better or with higher status than oneself, which may be especially prevailing on social media. One study found that social media users mostly presume that other users have better lives than themselves [ 27 ]. Moreover, following a large number of people on social media increases the reference group to which adolescents compare themselves, and may include high-status people like “influencers” and celebrities [ 28 ]. Upward social comparison has been reported to be associated with more negative feelings such as depression and lower life satisfaction [ 11 , 29 ], and more body dissatisfaction [ 30 ]. Hawes et al. [ 31 ] also found that preoccupation with appearance comparison on social media was linked to symptoms of anxiety and depression among adolescents. Thus, while self-presentation on social media may not be harmful, feedback-seeking and upward social comparison may be damaging to mental health.

• Perfectionism

In addition to being a central period for self-presentation activities, adolescence seems to be a particularly susceptible period for the development of perfectionism. Perfectionism is a personality disposition that may be defined as the tendency to set unrealistically high performance standards and striving for flawlessness [ 32 ]. Perfectionism is thought to be a disposition largely consolidated in adolescence as a part of a general identity formation [ 18 ].

Over the last 30 years, there has been an increase in perfectionistic personality traits among young adults [ 33 ]. Curran & Hill [ 33 ] hypothesize that this might be a consequence of the rise of a competitive cultural trend, and also the advent of social media in young peoples’ lives. As social media gives adolescents control over how they self-present, social media also allows them to create a (highly) specific and “ideal” image of themselves. Considering these perspectives, Curran & Hill [ 33 ] suggest that young people perceive their social context as more demanding and subsequently believe others will evaluate them more harshly. An experimental study investigating the effect of selfie taking and posting on social media on women’s mood and body image, concluded that the psychological states subsequent of posting the selfies, was related to self-consciousness and/or fear of being negatively evaluated [ 14 ]. Thus, adolescents of today may to a larger extent strive for perfectionistic self-presentation in order to secure acceptance among peers than older generations. Hewitt et al. [ 34 ] suggested the concept of perfectionistic self-presentation and argued that this is a maladaptive self-presentation style. One facet of perfectionistic self-presentation is perfectionistic self-promotion, which includes proclaiming and displaying one’s perfection [ 34 ]. Through features such as likes, comments and followers, social media may be a key arena for perfectionistic self-presentation and self-promotion, and hence a way of seeking external validation and approval in a socially acceptable way among adolescents.

A study found that perfectionistic concerns predicted longitudinal change in self-presentation and that perfectionistic self-presentation was linked to decreased well-being [ 35 ]. Hence, perfectionistic concerns indirectly affected subjective well-being through self-presentation [ 35 ]. Perfectionistic self-presentation also predicted changes in both positive and negative affect [ 35 ]. In a meta-analysis, perfectionism was found to be positively associated to different psychological disorders and symptoms, including body dissatisfaction, and eating disorders [ 36 ].

• Disordered eating

Previous research has linked disordered eating to self-presentation [ 25 ] and to perfectionism [ 36 , 37 , 38 ]. A person with disordered eating will be obsessed with food and have constant thoughts about eating, body shape, weight, and food. Symptoms of disordered eating above a certain level may constitute an eating disorder according to the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM 5th Ed.) [ 39 ] and the International Classification of Mental and Behavioral Disorders (ICD-10) [ 40 ]. A meta-analysis reported that over the last 20 years, there has been an increase in the weighted means of point eating disorder prevalence from 3.5% for the years 2000–2006 to 7.5% for the years 2013–2018 [ 41 ]. The prevalence for eating disorder was consistently higher among women compared to men regardless of timeframe (lifetime, 12-months, point prevalence). In the same meta-analysis, the authors also stressed the finding that eating disorders are highly prevalent in adolescence, with an estimated point prevalence between 6% and 8% [ 41 ].

As a great deal of content on social media promotes pictures of healthy food, diets, exercise, and appearance-focused images and idealized bodies, concerns have been raised that social media may contribute to body image concerns and disordered eating, especially among adolescents [ 42 , 43 ]. A systematic review, conducted by Holland & Tiggemann [ 43 ] showed that exposure to content on Facebook, in particular photo-based activity, was positively associated with negative body image and disordered eating behaviours in children, adolescents, and young adults. Another study found similar results; more exposure to appearance-related pictures on Facebook was associated with self-objectification, weight dissatisfaction, thin ideal internalization, and drive for thinness among girls [ 44 ].

Similarly, research indicates that exposure to others’ “perfect” self-presentations on social media may reinforce one’s own body image concerns and disordered eating [ 24 , 25 ]. Fardouly et al. [ 24 ] investigated young adult women’s appearance comparisons in different contexts in everyday life. They found that most of the appearance comparisons were made in person and on social media, and that the participants made relatively more upward appearance comparisons on social media than in person. They also found that upward appearance comparisons made on social media were associated with more body dissatisfaction than in person. In addition, upward appearance comparisons on social media yielded more thoughts about dieting than in person comparisons, but no difference in the likelihood of dieting-behaviours [ 24 ].

Furthermore, Rodgers et al. [ 25 ] found that social media use was positively correlated with higher internalization of appearance ideals, including a higher tendency to engage in appearance comparison, body dissatisfaction, muscle change behaviours and dietary restraints among both boys and girls. In addition, the internalization of social media ideals, the muscular ideals and appearance comparisons, were positively associated with body dissatisfaction, muscle change behaviours and dietary restraints. Other research has reported similar results [ 6 , 45 ]. Mclean et al. [ 45 ] found for instance, that self-presentation on social media was associated with internalization of social media ideals, and that the internalization mediated the effect of social media on appearance upward comparison and body dissatisfaction. A scoping review conducted by Dane & Bhatia [ 46 ] also reported that in cases where social media use led to eating disorder, the thin/fit body ideal internalization and social comparison often functioned as mediating pathways.

Theoretical framework, summary and the current study

The Tripartite Influence Model (TIM) may serve as a theoretical framework linking the concept of focus on self-presentation and upward social comparison on social media, with perfectionism and disordered eating [ 47 ]. The Tripartite Influence Model is a framework that can be used when exploring the relationship between social media use and body dissatisfaction. It proposes that pressures from peers, family and media makes one conform to certain appearance ideals, which can lead to internalization of body ideals, followed by physical appearance comparison with others [ 48 ]. This study’s focus on self-presentation and upward social comparison on social media, aligns with the Tripartite Influence Model’s emphasis on how media and peers (e.g. to what content that receives positive feedback from peers), may contribute to adolescents’ perception of ideal body standards. Findings indicate that higher focus on self-presentation is more strongly linked to visual social media platforms than less visual platforms [ 12 ]. This support the Tripartite Influence Model theory that media pressure, especially through highly visual social media, leads to increased body ideal internalization an upward comparison with others. Additionally, the association between social media use and disordered eating can be understood through pressure to conform to societal ideals, such as body ideals, as proposed in the Tripartite Influence Model. Perfectionism, which is linked to disordered eating [ 36 , 37 , 38 ], may be driven by similar societal pressures.

Research on adolescents’ use of social media is increasingly shifting focus away from looking merely at time spent to include potential consequences of specific aspects of adolescents’ social media usage patterns [ 2 ]. The use of social media, perfectionism, and disordered eating have all increased over the last decades [ 33 , 41 , 49 ]. Studies indicate a relationship between being exposed to how others present themselves on social media and body dissatisfaction and disordered eating [ 24 , 25 , 43 ], and some studies have also investigated the relationship between self-presentation behaviors and body dissatisfaction [ 13 , 14 , 30 ]. Moving beyond self-presentation behaviors, such as the frequency or content of social media posts, one study showed that being preoccupied with appearance on social media, was associated with increased risk for problems like appearance related anxiety and disordered eating [ 22 ]. In two previous studies, we showed that preoccupation with likes and comments, retouching photos of oneself, deleting photos with too few likes, and upward social comparison, collectively referred to as “focus on self-presentation”, was associated with more symptoms of anxiety and depression [ 12 ] and that focus on self-presentation varied significantly between adolescents [ 21 ].

Hence, the aim of the present study is to investigated the link between focus on self-presentation on social media, and perfectionism and disordered eating. Based on previous studies we hypothesize that focus on self-presentation and upward social comparison is positively associated with (i) perfectionism and (ii) disordered eating, and (iii) self-reported diagnosis of an eating disorder.

Materials and methods

Study sample.

This study is based on data from the “LifeOnSoMe” study carried out at public senior high schools in Bergen, Norway. Pupils aged 16 or older were invited to participate, giving an age range from 16 to 21 years old. Information about the survey was conveyed both by the teacher and digitally. The online web survey was conducted digitally. One school hour was set aside for carrying out the survey. The total number of eligible participants was 3,424 (mean age was 17.3 years (standard deviation 1.0)), and 56% ( n  = 1916) of the participants were girls. This study included data from two survey waves conducted in September-October 2020 and June-September 2021. For participants who responded in both waves, only their 2020 responses were used in this analysis. The response rate was 53% in 2020 and 35% in 2021. The research data was stored on secure storage facilities located at the Norwegian Institute of Public Health, which prevent the authors from providing the data as supplementary information, according to the General Data Protection Regulation (GDPR). Only researchers with approval from the Regional Ethical Committee had access. The study was approved by the Regional Ethical Committee, and is in accordance with the General Data Protection Regulation. Additional information about the study is available elsewhere [ 23 , 50 ].

Self-reported sociodemographics

The participants reported their age, gender, and subjective socioeconomic status. A small proportion of the participants did not state their age ( n  = 157). For gender, participants could choose between three options: “girl”, “boy”, and “other/non-binary”. Because too few participants (< 50) answered “other/non-binary”, these were excluded from the data set due to privacy concerns. Relative socioeconomic status was assessed by asking the participants to estimate how economically well off their families are compared to others, ranging from «very poor» (scored 0) to «very well off» (scored 10).

Amount of social media use

Two questions were included related to social media use in general: “How often do you use social media?” and “On the days that you use social media, approximately how much time do you spend on social media?”, giving an estimate of the frequency and duration of their usage, respectively. For frequency, the response alternatives were “almost never”, “several times a month, but rarer than once a week”, “1–2 times per week”, “3–4 times per week”, “5–6 times per week”, “every day”, “several times each day”, and “almost constantly”. In the present study, we differentiated between “daily or less”, “many times a day”, and “almost constantly”. For duration, seven response alternatives ranging from “less than 30 min” to “more than 5 h” were available. In the present study, we differentiate between “<2 h”, “2–4 h”, “>4–5 h”, and “>5 h”.

Independent variable: Self-Presentation and Upward Social Comparison Inclination Scale (SPAUSCIS)

The items used to assess upward social comparison and aspects of self-presentation were developed based on focus group interviews with senior high school pupils [ 23 ], and have been shown to have adequate psychometric properties in both this sample [ 21 ] and elsewhere [ 12 ]. Cronbach’s \(\alpha\) was 0.87, indicating a very good internal consistency. The results of an exploratory factor analysis (EFA) and a confirmatory factor analysis (CFA) for the SPAUSCIS have been reported in a previous publication based on the “LifeOnSoMe”-data [ 21 ]. Also, EFA and CFA was investigated in another, smaller sample of senior high school students [ 12 ]. The results from both studies strongly suggested a unidimensional scale and the fit indices from CFA were all considered good. Examples of items included in SPAUSCIS are “I retouch images of myself to look better before I post them on social media”, “I use a lot of time and energy on the content I post on social media”, and “The response I get for what I post (images/status updates/stories) impacts how I feel”. The response categories were “not at all”, “very little”, “sometimes/partly true”, “a lot”, and “very much”, coded 1–5. The mean summed score thus ranges from 1 to 5, with higher scores indicating a higher focus on self-presentation and upward social comparison on social media.

Dependent variables: Perfectionism and disordered eating

Perfectionism (edi-p).

Perfectionism was assessed by the 6-item perfectionism scale in the Eating Disorders Inventory (EDI) for children and adolescents [ 51 ]. The perfectionism items (EDI-P) are usually rated on a 6-point Likert scale. In the present study, however, the response options were “not true” (scored 0) “sometimes true” (scored 1), and “true” (scored 2) in accordance with the version employed in the youth@hordaland survey [ 52 ]. This yields a potential score of 0–12 when the items are summed. Previous research has found that the EDI [ 53 ] and EDI-P [ 54 ] have satisfactory psychometric properties in similar populations. Cronbach’s \(\alpha\) was 0.72 in the present study, indicating acceptable internal consistency.

Eating Disturbance Scale (EDS-5)

Symptoms of disordered eating was assessed using the Eating Disturbance Scale (EDS-5) [ 55 ]. EDS-5 consists of five questions specifically related to eating, such as comfort eating (item 2) and strict dieting in order to control ones eating habits (item 4). The response options are “not true” (scored 0) “sometimes true” (scored 1), and “true” (scored 2), and the summed scored ranges between 0 and 10. The questionnaire have shown adequate psychometric properties and convergent validity in previous research [ 55 , 56 ]. Cronbach’s \(\alpha\) was 0.78 in the present study, indicating an acceptable internal consistency.

Operationalization of EDI-P and EDS-5

For the purposes of the present study, both EDI-P and EDS-5 were used as continuous measures, as well as dichotomous variables, differentiating between low and high scores based on the 90th percentile. The chosen cut-off point is informed by previous research which suggest this to be an adequate delineation for mental health problems [ 52 , 57 ].

Diagnosis of eating disorder

For the participants participating in the study in 2020, self-reported psychiatric diagnoses were available ( n  = 1978) using a pre-defined list adapted to fit this age-group. Initially, the participants had to answer “yes” or “no” to the question “Have you ever received a diagnosis for a mental health problem?”, followed up by a list of 11 possible different diagnoses for those who endorsed the initial question. The list was based on a similar operationalization used in a large population-based studies [ 58 , 59 ]. The list contained no definition of the included disorders or conditions. For this study, the participants who chose “Eating disorder” ( n  = 36; 1.8%) from the list were identified as having been diagnosed with the condition, and all others were designated as not having received the diagnosis.

Statistical procedure

First, summary statistics of the included variables for the whole sample were estimated across the median-split of SPAUSCIS and presented in Table  1 . For categorical variables, the number and proportions were estimated, and the mean and standard deviation (SD) was estimated for continuous variables. Comparisons across the median-split of SPAUSCIS was done using Pearson’s chi-squared tests for categorical variables, and Wilcoxon rank sum tests were used for continuous variables. Then, two simple linear regression models were estimated using SPAUSCIS as an independent variable and (a) score on perfectionism (EDI-P) and (b) score on disordered eating (EDS-5) as dependent variables, respectively. The scores of the dependent variables were standardized (Z-scored) to ease interpretation of the resulting coefficients. Potential gender-moderation was investigated by entering genderxSPAUSCIS in both models as an interaction term into the model. The interaction term was considered statistically significant with a p-value of < 0.05, and if significant, results from the linear regression model were then presented separately for girls and boys. Linearity of the association between SPAUSCIS and the dependent variables were investigated using restricted cubic splines with four knots. Next, two gender-specific multiple logistic regression models were estimated using the median-split of SPAUSCIS as the main independent variable, and the 90th percentile score on (a) perfectionism (EDI-P) and (b) disordered eating (EDS-5) as dependent variables, respectively. Both models were adjusted for usual amount of social media use and socioeconomic status, and the results are presented as odds ratios with corresponding 95% confidence intervals. The median-split of SPAUSCIS were used in these models for simplicity and ease of interpretability. In post-hoc analyses, we did however, investigate the association between SPAUSCIS as a continuous measure and the 90th percentile score (a) perfectionism (EDI-P) and (b) disordered eating (EDS-5) as dependent variables, respectively. This was done using logistic regression analyses with restricted cubic splines to test for non-linearity. Both these models were adjusted for usual amount of social media use and socioeconomic status, and the results are presented in-text as odds ratios for trends with corresponding 95% confidence intervals. Finally, we investigated the association between the median-split of SPAUSCIS and self-reported eating disorder using simple logistic regression. No adjustments or investigation of potential gender-moderation was included for the latter analyses as the number reporting eating disorder ( n  = 36) limited the statistical precision. Missing data ranged from n  = 2 (0.1%) to n  = 55 (1.6%) across analyses, and pairwise deletion was applied to ensure the highest number of observations in each analysis.

Descriptive statistics of the included variables are presented across the median split of score on SPAUSCIS in Table  1 . For all of the included variables, there were significant differences between the SPAUSCIS-groups (all p-values < 0.001). The group with median or above scores on SPAUSCIS were more likely to be girls, more likely to use social media more often and for a longer duration but reported a slightly lower subjective socioeconomic status. Furthermore, they were more likely to report higher scores on perfectionism (EDI-P) and disordered eating (EDS-5).

Results from gender-specific multiple logistic regression models with median-split of SPAUSCIS as dependent variable, and the 90th percentile score on (a) perfectionism (EDI-P) and (b) disordered eating (EDS-5) as dependent variables is presented in Table  2 . For boys and girls, scoring on or above the median on SPAUSCIS was associated with increased odds for both dependent variables. For both perfectionism and disordered eating, the models are adjusted for social media use and socioeconomic status. In the post-hoc analyses using SPAUSCIS as continuous variable, the odds ratios (OR) in relation to perfectionism were 1.88 (95% CI 1.43–2.47, p  < 0.001) and 1.77 (95% CI 1.44–2.17, p  < 0.001) for boys and girls, respectively. For disordered eating, the corresponding ORs were 1.94 (95% CI 1.40–2.68, p  < 0.001) for boys and 2.00 (95% CI 1.72–2.32, p  < 0.001) for girls. Using restricted cubic splines, we did not find evidence for non-linearity in the post-hoc analyses.

There was a significantly higher odds of reporting being diagnosed with an eating disorder among those scoring median or above on SPAUSCIS (crude OR 3.32; 95% CI 1.58–7.84; p  = 0.003).

Association between focus on self-presentation and perfectionism and disordered eating. Linear regressions with restricted cubic splines. Note: Figure 1: SPAUSCIS: Self-Presentation and Upward Social Comparison Inclination Scale; EDI-P: Eating Disorders Inventory-Perfectionism; EDS-5: Eating Disturbance Scale-5

Figure 1 presents findings from linear regression models with mean score on SPAUSCIS as the independent variable and the standardized (Z-scored) score on (a) perfectionism (EDI-P) and (b) disordered eating (EDS-5) as dependent variables. For both dependent variables, a potential gender moderation of the association with SPAUSCIS was investigated, and potential non-linearity was investigated using restricted cubic splines with four knots. For disordered eating, a significant gender moderation was found, and the association was stronger for girls than boys. For perfectionism, no evidence for a gender moderation was found. For both dependent variables there was a significant linear association with self-presentation equal to a low-to-moderate effect size.

Overall findings

In the present study we investigated the potential association between focus on self-presentation and upward social comparison on social media, and perfectionism and disordered eating. As hypothesized, we found evidence for consistent positive associations. Increased focus on self-presentation and upward social comparison was associated with increased levels of both perfectionism and disordered eating with a small-to-medium effect size. For perfectionism, the associations were similar for both boys and girls, while we found evidence of a gender moderation for disordered eating. Specifically, the association with disordered eating was somewhat stronger for girls compared to boys. For self-reported eating disorder, we also found a positive association with focus on self-presentation and upward social comparison. Focusing on how the adolescents relate to self-presentation on social media, the study gives new insight into important aspects of usage patterns of social media. It also provides new insight into potential gender differences in focus on self-presentation and upward social comparison on social media, and social media´s potential role in development of disordered eating. These findings are pertinent in a public health perspective and may help to inform efforts to mitigate these potential negative effects.

Relation to previous perspectives and findings

Our findings are consistent with the Tripartite Influence Model, as our study revealed positive associations between focus on self-presentation and upward social comparison on social media, and both perfectionism and disordered eating. Individuals who focus on self-presentation and upward social comparison may be more susceptible to sociocultural pressures which may lead to a strive for perfection and conforming to unhealthy body ideals. Our findings underscore the potential role of sociocultural pressures in shaping body image dissatisfaction and disordered eating behaviors. Specifically, the positive association between focus on self-presentation on social media and perfectionism may have several explanations. Curran & Hill [ 33 ] argue that the increase in perfectionistic traits among young adults may be due to a response to cultural changes towards a more individualistic and competitive culture in Western societies. As social media is an important part of adolescents’ and young peoples’ lives, it is likely that the perfectionistic tendencies will affect self-presentation on these platforms as well. Curran & Hill [ 33 ] also suggest that the increase in perfectionism among young adults may be due to their perception of increased demands from the social environment. Self-presenting in a socially desirable way in general, and on social media specifically, may be a way to ensure social acceptance from peers. They further hypothesize that the fear of losing acceptance may increase perfectionistic traits [ 33 ]. Hence, increased perfectionism may be the reason for stronger focus on self-presentation on social media. However, since we cannot interpret the direction of the association from this study, focus on self-presentation may also increase adolescents’ perfectionistic tendency. As perfectionism is a personality trait that largely establishes during adolescence, it may be that the increased opportunity to self-present on social media, and thus focus on self-presentation, makes adolescents more susceptible for developing perfectionistic traits.

There is a lack of research on the relationship between focus on self-presentation on social media and disordered eating. Most of the research investigating this relationship have looked at being exposed to appearance-related self-presentation on social media and body dissatisfaction and disordered eating [ 24 , 25 , 43 ], in addition to self-presentation behavior [ 13 , 14 , 45 ], not the relationship between a person’s focus on self-presentation on social media and disordered eating. Our results indicate a positive relationship between focus on self-presentation on social media and disordered eating. Highly visual social media platforms that expose adolescents to “perfect” bodies through others’ self-presentation may constitute an important source of such exposure. Previous findings support that being exposed to body ideals, may lead to internalization of these ideals among adolescents [ 25 , 45 , 46 ]. Other findings also report that upward social comparison may be a potential consequence of the exposure to others’ “perfect” appearance related self-presentation [ 24 , 31 , 60 ], leading to body dissatisfaction [ 30 ]. Subsequently, some adolescents may be more preoccupied with eating, weight, body shape, and muscularity. This preoccupation could serve as a mitigation strategy to reduce the discrepancy between the adolescent’s perceived appearance and the ideal body and appearance of the reference person. Thereby reducing the negative body image and negative feelings produced from the upward social comparison.

Another explanation may be that adolescents with disordered eating already are more preoccupied than other adolescents with how they appear to others. Social media is an apt arena to self-present in an appearance-related and desired way, and could elicit wanted feedback from others through likes and comments. This may further reinforce the focus on self-presentation. A third potential explanation for this relationship is perfectionism as a conceivable mediating factor. As perfectionistic self-presentation can be understood as a maladaptive self-presentation style [ 34 ], perfectionism may lead to a strict view of what constitute a good-enough self-presentation. This may as well include the adolescent’s expectations and demands to their own body as thin or muscular, hence increasing the standards of flawlessness in their own appearance-related self-presentation on social media. If these expectations are too rigid, it might for some adolescents be a contributing cause in the development of disordered eating.

In relation to the association between focus on self-presentation on social media and disordered eating we found a stronger association for girls than boys. Hjetland et al. [ 61 ] found significant gender differences in how adolescents related to self-presentation on social media. Girls reported that they invested more time and energy on the content of their own social media posts. They used more filters to look better at least sometimes and reported feeling less satisfied with themselves because of other peoples’ social media posts. Girls also tended to ascribe more importance to the feedback they got on social media than boys. In general, the report showed that social media played a bigger part in the girls’ lives than the boys’, and that the girls placed more importance on what is happening on social media [ 61 ]. Hence, more importance placed on self-presentation on social media among girls, and social media playing a more important role in girls’ lives, may increase the focus on self-presenting in an ideal way, in addition to being stronger underlying causes in development of eating disorders for girls than for boys.

There may as well be other explanations for the gender difference we found. The objectification theory [ 62 ], suggests that women’s bodies are more often looked at, evaluated and potentially sexually objectified. Fredrickson & Roberts [ 62 ] further argue that these views make women internalize the observer’s perspective of themselves, and to some degree also socialize women to treat themselves as objects for the pleasure of others. The emphasis put on girls’ and women’s physical appearance, in particular, is well established in our culture [ 60 ]. Through social media’s feedback mechanisms, girls may be more encouraged than boys to self-present in an objectifying way.

Social comparison theory [ 26 ], and especially upward social comparison, is another possible explanation for the gender difference between focus on self-presentation on social media and disordered eating. Strahan et al. [ 60 ] found that when describing their physical appearance, women used significantly more upward social comparisons than downward social comparisons. Men, on the other hand, made more downward comparisons than upward. This tendency was not seen when women and men described other personal characteristics like social skills. For women, they also found that the more upward social comparison they made, the more negative statements they made about their body [ 60 ]. They proposed that ubiquitous appearance norms, mostly applying to women, disrupted strong self-enhancement behaviors [ 60 ]. Fardouly et al. [ 24 ] also found that women relied on upward social comparisons when comparing their appearances, and that doing this on social media was associated with more body dissatisfaction than in person. A proposed explanation for this is that women may experience a stronger discrepancy between themselves and women they see on social media compared to women they see in person [ 24 ].

Previous research on self-presentation behaviors has primarily focused on appearance-related self-presentation and upward social comparison [e.g. 24 ] and associated risk among girls, such as body dissatisfaction [ 13 , 14 , 30 ], thin ideal internalization and disordered eating behavior [ 25 , 44 ]. However, it is important to recognize that boys may also be affected by these issues, and a study showed that body dissatisfaction affected boys’ risk of engaging in disordered eating behaviors [ 63 ]. The current body ideals for boys emphasize muscularity [ 64 ], and Eisenberg et al. [ 65 ] found that muscle-enhancing behaviors are common among American adolescents, including both boys and girls. This were behaviors like dieting, exercising, and taking protein supplements or steroids, with the aim of increasing muscle size or tone. However, most of the behaviors measured were significantly more common among boys [ 65 ], and Compte et al.’s [ 64 ] investigation of muscle dysmorphia among young adult men indicated a prevalence of almost 7%. Hence, another explanation for the gender difference we found, may be that the EDS-5-questionnaire does not identify symptoms of drive for muscularity or muscle dysmorphia. In fact, muscle dysmorphia seems to be more of a concern than thinness and weight loss among boys [ 64 ]. The EDS-5 measures of symptoms of disordered eating are linked to preoccupation about weight loss, body shape and drive for thinness [ 55 ], and may therefore not fully capture the range of body image concerns among boys.

Implications

The present results demonstrate the need to address focus on self-presentation and upward social comparison on social media as potentially important factors for adolescents’ mental health. As such, promoting a healthy use of social media could be established through a focus on increasing adolescents’ ability to reflect on and think critically about self-presentation and upward social comparison on social media. Our results indicate a need for targeted interventions to promote healthy social media use and enhance adolescents’ critical thinking about self-presentation and underscores the urgency of public health initiatives. One public health approach would be to equip adolescents with critical thinking skills to navigate social media mindfully. In relation to appearance-related ideals, educational programs should address the unrealistic standards perpetuated online, while fostering resilience and promoting positive self-image. Educational programs and social media literacy programs in school have been suggested to increase adolescents’ reflections about their own and others social media use [ 42 , 66 , 67 ]. Gordon et al. [ 42 , 67 ] introduced a four-lesson social media literacy program in a junior high school that aimed to decrease body dissatisfaction, dietary restraints and focus on increased muscles among young adolescents. They found only a small effect of the intervention. The intervention did not focus on self-presentation and based on results from this study and previous research [e.g. 12 , 27 ], this would be an important topic to address for future interventions. Also, previous results suggest that interventions led by individuals who already have an established relationship with the adolescents and are familiar with their needs help facilitate discussions among the adolescents [ 42 ], and improve intervention outcomes. Teachers could therefore be considered effective social media educators, especially if social media literacy could be integrated in existing school subjects.

A study of university students showed that women who had a higher internalization of the thin-ideal, were more vulnerable to disordered body image and hence to appearance exposure in media [ 68 ]. They also found that body appreciation protected women from negative effects of the exposure [ 68 ]. Thus, developing social media literacy programs specifically focusing on the effects of self-presentation and upward social comparison could be an important target for interventions, and possibly reduce focus on self-presentation. Research [ 69 ] also suggest that increasing self-compassion is a useful strategy to prevent perfectionistic self-presentation on social media. As perfectionistic self-presentation is related to lower subjective well-being [ 35 ], this may also be a topic to address in an intervention aiming to reduce focus on self-presentation and upward social comparison on social media.

While our study adds to the knowledge base, future research should investigate the concept of self-presentation on social media more closely. It will be important to examine if different ways of self-presentation vary from each other. Previous research has investigated how people self-present, especially through the use of selfies [e.g. 70 , 71 ], and further research should investigate if taking pictures of oneself and posting them is dissimilar from other ways of self-presentation on social media when considering its association to mental health among adolescents. SPAUSCIS consist of only one item asking about specific ways of self-presenting (“I retouch images of myself to look better before I post them on social media”), thus future research on other ways of self-presenting behaviors should include self-presentation for example through pictures of other aspect of the adolescents’ life, like friends or hobbies, or through text only. Investigating focus on self-presentation on social media, perfectionism and disordered eating among younger adolescents than we included in our study will be important as the use of social media starts early and as disordered eating often emerges in adolescence [ 72 ]. Understanding at what age focus on self-presentation becomes more prominent for adolescents’ and potential gender differences regarding this, may also be important to pinpoint intervention opportunities.

Strengths and limitations

A major strength of the present study is that it is the first study to investigate the relationship between focus on self-presentation on social media, perfectionism and disordered eating. So far, the research on this has focused on self-presentation behaviors [e.g. 13 , 14 , 30 , 45 ] in addition to being exposed to others ’ (perfect) self-presentations and the prevailing body ideals [e.g. 24 , 25 , 43 ]. To our knowledge no previous study has examined the association between focus on self-presentation and perfectionism and disordered eating. In addition, the scales used in this study are well-established [ 55 , 54 , 56 ]. Also, the items of SPAUSCIS were derived from focus-group interviews with adolescents [ 23 ], which make them relevant for adolescents’ experiences related to self-presentation and social comparison on social media. Some limitations are also worth mentioning. The study is cross-sectional, thus we cannot determine causality between the investigated factors and mental health. Despite the sample being large, it is limited to high schools in Bergen, Norway. Consequently, the results may not be generalizable to other countries or cultures. Also, the participation rate was moderate (53% and 35%), which may impact the validity of our findings. However, associations are less vulnerable to bias caused by low participation rates than prevalence estimates [ 73 ]. Another limitation is that SPAUSCIS in this study does not differentiate between various methods of self-presentation. Consequently, we cannot conclude from this study whether specific types of self-presentation, such as taking selfies versus posting pictures of hobbies, have the same impact on perfectionism, eating disorders or disordered eating. Also, the use of self-reported amount of social media use has been shown to be biased in previous research and is not likely to be an accurate measure of actual use [ 74 ]. This may have impacted our ability to effectively account for the confounding effect of social media use. And finally, although EDS-5 is a well-established and validated measurement, the questionnaire does not cover specific symptoms of drive for muscularity and muscle dysmorphia.

While previous studies have focused on self-presentation behaviors, this study found that focus on self-presentation and upward social comparison on social media is positively associated with both perfectionism and disordered eating, as well as self-reported eating disorders among adolescents. As such, promoting a healthy use of social media could be established through increasing adolescents’ ability to reflect on and think critically about self-presentation and upward social comparison on social media. Our results underscore the importance of targeted public health interventions to promote awareness and healthy social media use among adolescents, emphasizing the need for educational programs that address focus on self-presentation, unrealistic appearance-related ideals and foster resilience and positive self-image.

Data availability

Explicit consent from the participant is required by the Norwegian Health research legislation and the Norwegian Ethics committees in order to transfer health research data outside of Norway. Ethics approval for this was also dependent on storing the research data on secure storage facilities located at the Norwegian Institute of Public Health, which prevent the authors from providing the data as supplementary information. Request to access these datasets should be directed to [email protected].

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Acknowledgements

We are grateful to Bergen municipality and Vestland County Council for their collaboration on this study. The present study is linked to a larger innovation-project lead by Bergen municipality in Western Norway related to the use of social media and mental health and well-being. The innovation-project is funded by a program initiated by the Norwegian Directorate of Health and aims to explore social media as platforms for health promotion among adolescents. Above all, we are very thankful for the pupils who participated in this study.

The work of GJH was supported by Dam Foundation (grant number 2021/FO347287) while the work of JCS, AIOA, and TRF was supported by The Research Council of Norway (grant number 319845).

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Hilde Einarsdatter Danielsen, Turi Reiten Finserås, Amanda Iselin Olesen Andersen, Gunnhild Johnsen Hjetland & Jens Christoffer Skogen

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JCS analyzed the participants’ data regarding the LifeOnSoMe-study. All authors contributed to interpretation of the results. HED and JCS wrote the first draft of the manuscript. Additional contributions and revisions to the manuscript were made by TRF, AIOA, GJH, VW, JCS, and HED. All authors read and approved the final manuscript.

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Danielsen, H.E., Finserås, T.R., Andersen, A.I.O. et al. Mirror, mirror on my screen: Focus on self-presentation on social media is associated with perfectionism and disordered eating among adolescents. Results from the “LifeOnSoMe”-study. BMC Public Health 24 , 2466 (2024). https://doi.org/10.1186/s12889-024-19317-9

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Social media use, disordered eating, and body image in adolescent females: a systematic review of the literature.

Alara Ozpolat Follow

Adolescent females are especially at risk of developing eating disorders due to expectations surrounding body image, social pressures, and influence from peers. With the significant role of social media in daily life, the average adolescent currently spends several hours a day engaging with content on social media. The overall aim of this review was to better understand the impact of social media consumption on disordered eating and body image among female adolescents. The primary research questions explored within this systematic review were as follows: Is there a relationship between social media use, body image concerns, and/or eating disorder symptoms in adolescent girls? What social media platforms and forms of engagement on social media are related to body image concerns and disordered eating? What is the age, race/ethnicity, and socioeconomic status of adolescent females endorsing body dissatisfaction and/or eating disorder symptoms? Seven studies that met the inclusion criteria were examined and their findings were synthesized narratively. Results of this review help identify gaps in the literature to guide eating disorder prevention, treatment, and research.

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Mass media and teenage girls; Eating disorders in adolescence; Body image in adolescence

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Judy Ho Gavazza

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Ozpolat, Alara, "Social media use, disordered eating, and body image in adolescent females: a systematic review of the literature" (2022). Theses and Dissertations . 1289. https://digitalcommons.pepperdine.edu/etd/1289

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Screen time and social media use linked to eating disorder symptoms in young adolescents

by University of Toronto

As adolescents continue to spend more time on screens and social media, a new study finds that among 9–14-year-olds, excessive time online is associated with a higher risk of having eating disorder symptoms.

These symptoms include worrying about gaining weight, tying one's self-worth to weight, compensatory behaviors to prevent weight gain , binge eating , and experiencing distress over binge eating.

The study is published in the journal Eating and Weight Disorders—Studies on Anorexia, Bulimia and Obesity .

"Social media promotes constant comparisons to peers and exposure to unattainable body ideals," says senior author Jason M. Nagata, MD, an associate professor of pediatrics at the University of California, San Francisco. "This can contribute to dissatisfaction with one's own body, reduced self-esteem , and unhealthy attempts to control weight, all of which increase the risk of developing eating disorders and other mental health issues."

Problematic social media and mobile phone use , characterized by dependence that impairs daily life, are also associated with eating disorder symptoms. Social media overconsumption may not only increase exposure to body ideals and comparisons, but may also intensify impulsive behaviors, reinforce binge eating, and contribute to addictive tendencies.

"Adolescents should limit social media that encourages eating disorders and appearance comparisons. Parents can play an important role by developing Family Media Use Plans and holding open conversations about problematic screen use and disordered eating concerns," says Nagata.

The study builds on existing knowledge surrounding eating disorders in adolescents, which have among the highest mortality rate of any psychiatric disorder. The study uses data from the nationwide Adolescent Brain Cognitive Development (ABCD) study, the largest long-term study of brain development in the United States. The study collected data for 11,875 children aged 9–14 years old. Study participants provided information about their typical screen habits, as well as whether they had experienced eating disorder symptoms.

"This study underscores the need for more research on the relationship between social media , problematic screen use, and mental well-being in early adolescence ," says co-author Kyle T. Ganson, Ph.D., assistant professor at the University of Toronto's Factor-Inwentash Faculty of Social Work. "Future research should focus on identifying specific types of content that pose the greatest risk for young people developing eating disorder symptoms."

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Factors associated with eating disorders in adolescents: a systematic review

Candy laurine suarez-albor.

1 Faculty of Nursing, Universidad Popular del Cesar, Valledupar, Colombia

Maura Galletta

2 Department of Medical Sciences and Public Health, University of Cagliari, Monserrato, Italy

Edna Margarita Gómez-Bustamante

3 Faculty of Nursing, University of Cartagena, Cartagena de Indias, Colombia

Background and aim:

The World Health Organization has placed eating disorders among the priority mental illnesses for children and adolescents given the risk they imply for their health. Recognizing the risk factors associated with this problem can serve as the basis for the design of timely and effective interventions. The objective of the study was to identify the factors associated with eating behavior in adolescents through a systematic review.

Systematic review. Search of the literature in the bibliographic sources CINAHL, CUIDEN, Pubmed, Dialnet, SCIELO and Science Direct. The search was conducted in October and November 2020. The search terms were Eating Disorders, Food Intake, and Adolescents. The evaluation of the methodological quality was carried out using a specific guide for observational epidemiological studies. A narrative synthesis of the findings was made. Additionally, the vote counting and sign test technique was applied.

25 studies were selected. The associated factors were body dissatisfaction, female gender, depression, low self-esteem, higher BMI that increases the risk of eating disorders.

Conclusions:

a high impact of psychological factors was observed. These should be considered in the design of effective interventions to prevent this disease, although the search needs to be broadened to identify larger and more complex studies that allow for a more comprehensive review. ( www.actabiomedica.it )

Introduction

Eating disorders (EDs) are complex and multifactorial pathologies that affect physical and mental health and are life threatening. They are characterized by an excessive preoccupation with the weight and shape of the body or a frank deviation of the body image, accompanied by voluntary restriction of the intake or the presence of episodes of binge eating that cause great suffering, impairment of health and quality of life ( 1 ). The prevalence of eating disorders is variable; in the last two decades several studies have been carried out, especially by the National Institute of Mental Health of the United States, which has compiled cases even from European countries. The countries with the highest cases are Switzerland 12%, Chile 8.3% and Spain 6.2% ( 2 ); Colombia is followed by 4.5% ( 3 ), the United Kingdom 3.7% ( 2 ) and Portugal 3.06% ( 2 ). Countries such as the United States, Italy, Costa Rica, Mexico, Honduras, Venezuela, have numbers between 0.5% -1.5% ( 4 , 5 ). Most of these disorders are more common in women and begin in adolescence, a stage of change where body image is consolidated. This in turn generates numerous crises of identity, physical appearance, friendly or sexual requirements and a struggle for autonomy, traits of perfectionism and self-demand that can lead to low self-esteem, dependence on the environment, difficulty in expressing emotions or expressing aggressiveness ( 6 , 7 ).

The World Health Organization (WHO) has placed eating disorders among the priority mental illnesses for children and adolescents given the risk they imply for their health and the great psychiatric comorbidity ( 8 ). Among the most frequent, depressive disorders 23.3%, anxiety disorders 10%, adaptive disorders 3.3% and negative perception of family relationships 43.3%, which aggravate the problem and cause important complications in the state of health ( 7 , 9 ). For this reason, EDs have become more relevant for the interest in the clinic, research and epidemiology ( 9 ). Various factors intervene in the occurrence of eating disorders and show a higher attributable risk such as biological, psychological, family and sociocultural ( 2 - 7 ). Thus, scientific evidence is abundant when addressing various aspects of eating disorders, however the state of the art revealed that in the last five years no literature review have been published on the subject, which is relevant to design or guide effective interventions that allow professionals to prevent these events. In this sense, the aim of this work was to carry out an exhaustive review of the published evidence about the factors associated with eating behaviour in adolescents.

A systematic review was carried out according to the guidelines of the PRISMA ( 10 ) statement, in the bibliographic sources LILACS, CUIDEN, Pubmed, Dialnet, SCIELO and Science Direct and MEDES. The search was carried out in October and November 2020. The search terms to be used were consulted in the DECS and MESH libraries, to guarantee their standardization, in English and Spanish, they were conjugated in search equations with the Boolean operators AND and OR thus: AND factors (Eating Disorders OR Food Intake OR Eating Behavior) AND adolescent.

Inclusion and exclusion criteria

Articles were selected from cohort, cross-sectional, and case control studies about factors associated with EDs in adolescents. The inclusion criteria were (a) free access articles in full text, (b) primary studies published between 2009 and 2020 to ensure that as many necessary and relevant studies as possible have been included in the review, (c) studies with a sample of adolescents aged from 10 to 19 years, according to the classification provided by the WHO ( 9 ). Dissertation, meta-analysis, review, experimental, intervention, or treatment studies were excluded, as well as studies with a mixed sample (children, adolescents, adults), and investigations without statistical information of association.

Article selection and evaluation of methodological quality

The selection of the articles was carried out in 4 phases. First, title and abstract were read to determine the suitability of the study and elimination of duplicates. Second, full text was read and the inclusion and exclusion criteria were applied. Third, a reverse and forward search was performed on the included studies to locate as many documents as possible. Fourth, the risk of bias was assessed through critical reading based on the Critical Reading Guide for Observational Studies in Epidemiology ( 11 , 12 ). A guide to assess cross-sectional studies was used ( 11 ). This instrument included 31 items that allow for minimizing biases and the confounding effect of internal validity. It was evaluated qualitatively using MB: very good, B: good, A: regular, and NI: does not report. A second guide was used to assess cohort studies and case-control studies ( 12 ). The instrument included 21 items and evaluated qualitatively the followings aspects: selection of subjects, validation of question, evaluation of the final outcomes, confounding factors, statistical analysis, general evaluation of the study, and description of the study, using A: adequately, B: partially, C: improperly, and D: I don’t know. This process was carried out by the first author and was audited by the other authors.

Data extraction

The data were consolidated through a structured booklet in Excel based on two types of information: (i) information about articles’ characteristics such as study sample, main author, year of publication, language, country, design; (ii) information about eating disorder risk factors such as biological, psychological, sociocultural, and family factors.

Data analysis

The information was treated qualitatively and analysed in a narrative way. The results were organized in tables and figures according to the PRISMA statement. Additionally, the found results exceeded the number of 20 articles, so the vote counting technique was applied. Such a technique consisted in granting a positive vote for studies with a statistically significant relationship between a risk factor and EDs, and a negative vote when there was no significant association. Subsequently, the sign test ( 13 , 14 ) was applied to determine if the difference in the number of positive studies was significantly greater than the opposite result. A significance value was established to be less than 0.05. It is important to notice that these techniques are limited but they can help to guide the results of the review in the absence of meta-analysis ( 14 ).

General diagram of the study

Methodological quality assessment

About the cross-sectional studies, 54.5% (n = 12) obtained high methodological quality, 27.2% (n = 7) medium quality, and 4.6% (n = 1) low methodological quality. This study was excluded by the revision. With regard to the cohort studies, it was assumed that studies with adequate rating in 23-26 items were considered to be of high methodological level; medium level was attributed to studies with adequate rating in 19-22 items, and low methodological level was attributed to studies with adequate rating in 18 items or less. In this sense, 100% (n = 3) of the cohort studies obtained a medium methodological quality ( Tab. 1 and Tab. 2 ).

Critical reading and assessment of methodological quality for cross-sectional studies.

Note . Internal validity. It defines whether the study design allows minimizing biases and the confounding effect ( 12 ).

The Items used were:

2. The inclusion and exclusion criteria of participants are indicated, as well as the sources and selection methods.

3. The selection criteria are adequate to answer the question or the objective of the study.

4. The study population, defined by the selection criteria, contains an adequate spectrum of the population of interest.

5. An estimate was made of the size, the level of confidence or the statistical power of the sample to estimate the measures of frequency or association that the study intended to obtain.

6. The number of potentially eligible people is reported, those initially selected, those who accept and those who finally participate or respond; fifteen. Statistical analysis was determined from the beginning of the study.

16. The statistical tests used are specified and appropriate

17. Participant losses, lost data or others were correctly treated

18. The main possible confounding elements were taken into account in the design and in the analysis.

Assessment: MB=very good; B=good; R=regular; NA=not applicable; NI=no information.

Critical reading and assessment of methodological quality for cohort studies.

Note . Cohort studies allow a direct determination of relative risk and allow calculation of the interval between exposure or risk factor and overall study disease ( 12 ). It was scored according to the validity of the question, selection of subjects, evaluation, confounding factors, statistical analysis, general assessment and description of the study. Rating: according to the author, the items were rated as follows: A: adequately; B: partially; C: improperly; D: I don’t know. For the purposes of this review, it was assumed that studies with adequate rating in 23-26 items were considered to be of high methodological level; medium level was attributed to studies with adequate rating in 19-22 items, and low methodological level was attributed to studies with adequate rating in 18 items or less.

Characteristics of the studies

Among the selected studies, 86.4% (n = 19) were cross-sectional design (15─33), 13.6% (n = 3) were cohort studies (34─36). Fifty-percent (n = 11) of the studies were conducted in Latin America (18, 20─22, 24─27, 31─33), 31.8% (n = 7) in Europe (15, 19, 23, 29, 30, 33, 34), 9% (n = 2) in Asia ( 16 , 34 ) 4.6% (n = 1) in Africa ( 17 ), and 4,6% (n = 1) in North America ( 28 ) ( Tab. 3 ).

Synthesis of the studies included in the review.

Factors associated with eating disorders

Different instruments were used to measure the factors associated with eating disorders. In 14.2% (n = 7) of the analysed studies, authors used the Eating Attitude Test (EAT-26) ( 17 , 18 , 20 , 21 , 25 , 30 , 31 ), 11% (n = 5) the Body Shape Questionnaire (BSQ) ( 21 , 25 , 27 , 29 , 31 ), and 9.5% (n = 4) the Sociocultural Attitudes Questionnaire towards appearance-3 (SATAQ-3) ( 20 , 28 , 32 , 36 ). About 93% (n = 14) of the studies analysed risk factors and about 7% (n = 1) analysed correct self-image and hours of practiced sport as protective factors (B = 0.11; p = 0.047) ( 30 ). Regarding the risk factors, psychological risks were the most frequently analysed by the studies (71%). They included dissatisfaction with body image, low self-esteem, high depression, high perfectionism, stress, impulsivity, personal and interpersonal insecurity, emotional dysregulation, and ineffectiveness. About 14% of the studies analysed sociocultural factors such as alcohol use-related problematics, internalization of the thinness ideal, influence of media, ridicule related to weight, and being an immigrant adolescent. Also, 7.1% of the studies analysed family factors such as authoritarian family style, family functioning, poor communication, and family care. Lastly, 7.1% of the studies analysed biological factors such as being female. The complete description of the factors is summarized in Tab. 3 .

Analysis of vote counting and sign test

It was found that there was a greater number of studies that reported statistically significant relationships between factors such as body dissatisfaction, female gender, depression, low self-esteem, and higher body mass index (BMI) with eating disorders ( Tab. 4 ). In this sense, adolescents with those risk factors are more likely developing eating disorders.

Analysis by vote counting and sign test.

In the present review, the results show that the main factors associated with eating disorders were psychological-type with a prevalence of the factor inherent the dissatisfaction with body image ( 16 ─ 18 , 21 , 25 , 27 , 29 , 31 , 32 , 35 ). Literature refers that dissatisfaction with body image increases significantly in adolescence due to environmental pressures like media (e.g., television, social networks, virtual and written press) ( 20 , 28 ). They represent channels of transmission of the current body aesthetic model and have a positive or negative impact on an adolescent’s body image. This is more common in women, as it was the biological factor reported in this review. However, the findings are consistent with other studies where dissatisfaction with body image occurs more frequently in females and is positively associated with BMI as a predictor of eating disorders. ( 37 , 38 ). Similarly, BMI appears directly related to dissatisfaction with one’s own body, namely the higher the BMI, the higher the body dissatisfaction ( 25 , 31 ─ 33 , 36 ). This association is more recurrent in female gender ( 17 , 22 , 26 , 28 , 30 ) as girls generally show greater instability of self-image, lower self-esteem and general dissatisfaction with their body, if compared to boys. In most studies, the sample studied was female ( 29 , 33 , 34 , 36 ). Other psychological factors were emerged from the review. They were: appearance orientation ( 28 ), high level of perfectionism ( 23 , 29 ), low self-esteem ( 18 , 29 , 33 , 34 , 36 ), impulsivity ( 22 ), stress, suicidal idea and depression ( 22 , 26 , 27 , 29 , 34 ), eat in the absence of hunger ( 28 ), concern about being overweight, submission ( 24 ), personal and interpersonal insecurity ( 29 , 36 ), and emotional dysregulation ( 33 ). A teenager with low self-esteem shows a negative attitude and evaluation towards himself. In fact, low self-esteem has been repeatedly considered as a relevant factor of vulnerability for the development of EDs. This evidence is supported by a previous review ( 39 ). It is also important to identify depressive and anxiety manifestations that have an impact on food restriction and concerns about figure and weight. The number of studies that supported the relationship between psychological factors and eating disorders was statistically significant according to the sign test.

Socio-cultural factors were analysed in 14.2% of the selected studies ( 15 , 16 , 20 , 24 , 26 , 32 , 36 ). The most frequently revealed were the internalization of the thin ideal followed by the influence of media, weight-related bullying , and immigrant adolescents. These sociocultural factors and the desire to conform to body aesthetic models promoted by media and advertising have a greater likelihood to developing perceptions of body dissatisfaction. Moreno ( 40 ) showed a very high relationship between the influence of the media and the presence of eating disorders in the adolescent population. This is a cultural problem that comes from long ago where the idea that a perfect body is thin and that this it is accepted by society. The media are very important agents in the transmission of messages about the desire for thinness that is constantly present in eating disorders; the media channel social pressure to be thin is obviously stronger on females than males ( 40 ).

A few studies analysed the relationship between family factors and eating disorders ( 19 , 21 , 34 ). However, family functioning, poor communication, family care, and authoritarian styles are factors described in the literature as predisposing to eating disorders by impacting the way adolescents worry about the amount of calories in food and obsessed with food and weight gain. In this sense, parents can play a protective role, but they can also represent a risk factor for their children’s eating behaviour, as adolescents regulate their behaviour according to their parental model from early childhood ( 40 , 41 ).

In this review, we found only one research that addressed protective factors related to physical exercise and correct ideas about body image. This could be due to the fact that research in the last two decades has focused on mitigating or controlling risk factors as the sole basis for interventions to prevent eating disorders in adolescents. However, protective factors make adolescents less vulnerable to the development of eating disorders and facilitate the achievement of physical and mental health, the quality of life of adolescents, the development of healthy habits and social welfare. Protective factors are susceptible to being modified and intensified and do not necessarily occur spontaneously or at random. In this sense, interventions focused on strengthening those factors could be effective to prevent eating disorders behaviours. This requires the development of research that identifies and analyses the protective factors that can be strengthened in adolescents ( 42 ─ 44 ).

Most of the studies included in this systematic review are cross-sectional and in a lower percentage are cohort studies. Spain is the country that has done the most research on the factors associated with eating disorders in adolescents, thus showing a particular interest in this topic. However, this review has shown that there is a plurality of studies in the scientific community from different sociocultural contexts. This can explain why there is variability of risk factors for eating behaviour, although body dissatisfaction is the most common factor emerged from the revision.

The limitations of the review reflect the heterogeneity of the study that does not allow to carry out a meta-analysis and statistic associations between factors. Although the vote count and the sign test allow giving an additional value to the narrative synthesis of the results, they are limited procedures to establish reliable statistical associations with data. In this sense, reviews around the subject with quantitative analysis procedures would be necessary.

Conclusions

Psychological factors were found to be the main risk factors directly related to eating disorders in adolescents. The most common were: dissatisfaction with body image, depression, low self-esteem and higher BMI. Being a woman was also identified as the most reported biological factor associated with eating disorders. These risk factors become relevant when guiding the creation of mental health promotion programs for adolescents and the prevention and early detection of the eating disorders in adolescents.

Conflict of Interest:

Each author declares that he or she has no commercial associations (e.g. consultancies, stock ownership, equity interest, patent/licensing arrangement etc.) that might pose a conflict of interest in connection with the submitted article.

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