Who Is at Risk?

In the 1990s, studies demonstrated the increasing discrepancy between the ideal body image portrayed in media versus the actual body size of American and Canadian women. A trend toward increasing thinness in publications such as PlayBoy and fashion models was correlated to an increase in real-life weight. According to research conducted by The National Center for Biotechnology Information,“media is a causal risk factor for the development of eating disorders and has a strong influence on a person’s body dissatisfaction, eating patterns, and poor self-concept.”

However, many people, including youth, consume media and social media, without experiencing negative consequences. Social media alone cannot be the sole villain in this narrative. There is clearly a pre-existing vulnerability among youth who develop problematic social media use or who experience negative outcomes related to their use. Overall, the etiology of eating disorders is complex, with prevalence hypothesized as a result of various biopsychosocial factors ( Box 1 ). Most eating disorders begin in adolescence. Natal females still represent the largest proportion of cases; however, there is a notable increase amongst males, athletes, those with obesity, and sexual and gender identity minorities.

This article will explore the ways in which social media can interact with the aforementioned risk factors to contribute to the development of an eating disorder. We will also highlight positive uses of social media, as well as ways in which providers can facilitate developing healthy media habits among youth.

Perception of Body Image, Health, and Wellness

The “ideal” body image continues to evolve over time informed by cultural influences and ideas about desirability. For example, fuller-figured European women in the 1500s were physical representations of their husband’s status and success, as they could afford a higher volume and quality of food. As thinner bodies became more idealized, there has also been more medical focus on weight and overall health, with various efforts to quantify potential omens for poor health and even early death, such as the body mass index (BMI). We have even created “Ideal Body Weights” and average targets for pediatric growth charts. Additionally, the media is constantly providing messages on the “best” formula for a healthy lifestyle, though this tends to be an ever changing rhetoric. With the impact of repeated exposure through social media, it is no wonder that there has been increasing focus on getting and staying “healthy” in the general population.

While social media can certainly be helpful in the spread of relevant information and guidance from reliable sources, the internet, of course, is largely unregulated, and therefore frequently inaccurate. Youth are tasked with processing available information and making decisions about the credibility and impact of the information, which is filtered through their own individual resilience and risk factors. Most of the available information is not intended to cause harm. There are ranges of applications, for example, that aim to support productive weight loss and acquiring better health, yet can exacerbate eating disordered behavior in vulnerable youth. Developing critical thinking about media is now a necessary task of adolescent development; however, it is not always modeled and taught in the context of schools, families and in provider’s offices.

Social Media and the Biology of Eating Disorder Psychopathology

Body image develops based on complex interactions between physiologic, cognitive, and sociocultural factors. This occurs in the context of the significant and dynamic physiologic changes, which occur during adolescence. ^, The repetitive opportunities in social media applications for self-comparison to images of online “ideals” can be risky for those vulnerable to developing eating disorders, and damaging to those with established, active diagnoses. However, another important question is how can we understand more about the process of cognitive distortions inherent in people with eating disorders and how they are affected by such intense visual stimuli?

Research has begun to explore the process of visual mapping in the brain, and its correlation to disordered eating. There is still only an early understanding of the underlying biology, but it is showing potential clinical importance. For example, discrepancies between the person’s receipt of body signals and their corresponding interpretation has long been hypothesized as a core characteristic of AN. There may also be potential primary dysfunctions of sensory encoding, and disrupted visual processing and parietal association networks. This can manifest as perceptual inaccuracies of their current body, as well as between their current and their ideal body. These perceptual distortions lead to both distress and subsequent eating disorder behaviors. The term “compensatory behaviors” is apt, as the person is quite literally attempting to compensate for the resulting negative emotions by changing their physical appearance. The challenge, however, is that there may never be a weight or level of thinness that provides enough emotional relief, or what feels satisfactory is so severe it results in medical complications or even death.

How this is affected by social media exposure is still poorly understood, but it is hypothesized that the repetitive exposure to visual content representing unhealthy body ideals (which is not present in other types of media the same degree) can trigger neurologic pathway abnormalities with higher frequency. Furthermore, there is a clear association between the frequency of comparing one’s physical appearance to others on social media and the potential for body dissatisfaction.

The Impact of Selfies

Studies have shown that adolescent uses of selfies can be indicative of a higher risk for developing an eating disorder. In particular, the frequency and level of image manipulation prior to posting has had a measurable association with greater overvaluation of shape and weight, body dissatisfaction, and dietary restraint. Additionally, research has explored the direct psychologic impact of posting selfies, which can be negative.

For many, posting a selfie on social media has either no consequences, or there is the positive subjective experience of immediate attention and gratification. This can occur even without image editing. However, some verbalize feeling increased anxiety, less self-confidence, and lowered mood after posting untouched photos. It is important to caution against over-interpreting the impact of this effect. Even within this group, resulting negative emotions will be brief and have no longer term impact. This does represent a risk factor that can be monitored for and discussed, especially for those youth more prone to body image distortions.

The Role of Influencers

“I couldn’t stop comparing myself,” is a frequent statement from teens those who increasingly turn to social media influencers as role models and for life advice. An “influencer” is defined as someone with a social media presence and enough followers to “influence” an audience for some particular purpose. Focus areas may include lifestyle choices such as eating, exercise, and achieving certain body type goals. For certain youth followers what starts as a casual hobby can quickly devolve into an obsession. There will often be initial small dietary changes, such as eliminating sweets and adding in more fruits and vegetables. This may be followed by what seems like a reasonable amount of exercise. They likely get positive and reinforcing feedback from friends, family, coaches, and even their primary care physician.

The messages portrayed by influencers, and celebrities, can be difficult for youth to identify as potentially harmful, as they are frequently under a “health and wellness” label. For those with more developed critical thinking skills and more robust self-esteem, evaluating the merits of things like weight loss tea and appetite suppressant lollipops, may come more naturally. They may not be triggered by ‘What I Eat in a Day’ videos that show an influencer highlighting their daily meals, or exercise videos targeting a specific body part deemed a “problem area.” However, once someone begins searching and viewing particular content, most social media algorithms will work to further promote that content. More vulnerable youth can experience repeated exposure, leading to internalization of unattainable goals, such as obtaining the “perfect body,” despite the routine use of filters and editing tools by online influencers and celebrities.

Additionally, youth witness the positive reinforcement influencers get from their followers. A recent CNN article highlighted a teen’s experience with Instagram. A 14 year old athlete described wanting to excel at “clean eating” and have the “most fit body” possible. After her initial searches, her feed became automatically filled with body types that she would consider “ideal.” They were accompanied by “likes” and positive comments, which further reinforced the drive for this perfect image. At the time of the interview, she stated “I wanted to be liked and loved like they were.” She began posting her own photos, seeking similar positive online feedback; however, this was harder than she anticipated, and she often received negative comments, such as being called “fat.” Ultimately, her eating habits fully evolved into a serious eating disorder with life-threatening medical complications.

It should be emphasized that this type of effect from social media is neither universal nor guaranteed. There are certainly many youth who would either filter out negative online comments or not seek out the validation. However, identifying those who are vulnerable often happens after the fact, further supporting pre-emptive open communication with youth identifying psychologic risk factors and developing healthy online habits.

Pro-Ana/Pro-Mia

• Definitions:

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    “Pro-Ana”: Short for Pro-Anorexia

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    “Pro-Mia”: Short for Pro-Bulimia

These are slang terms, which promote restrictive eating and purging behaviors as socially acceptable ‘lifestyle choices’, rather than dangerous psychiatric illnesses. Pro-Ana websites are known for content promoting eating habits and compensatory behaviors, which support the obsession with thinness and obscure the efforts from detection. The visual aspects provide “Thinspo” or “thinspiration”, which emerged in the early 2000’s, and became known as a group of image ideals to strive for. Initially, it was primarily celebrities and models, but a selfie culture has since evolved. A documentary series, Thinspiration , came out in 2012, which further explored the Pro-Ana community’s relationship to photography and self-images. Pro-Mia websites function similarly to their Pro-Ana counterparts, with both minimizing and even outright denying the potentially devastating medical consequences of disordered eating.

Just like other forms of social media, the danger does not just lie with the passive existence of these sites. The goal is to attract new users and keep people engaged in what has become a very strong belief system, which is frequently hostile to outsiders. According to recent media reports, approaches are quite persuasive and interactive, with high utilization of videos, social networking, and organized tactics to promote the Pro-Ana lifestyle. A 2015 article highlighted how some sites require “proof” that you are dedicated enough to your eating disorder to be part of their group. Anorexia was written to have been called the “Goddess of Emaciation,” an externalized entity requiring capitulation from group members.

Positive and negative feedback is given based on one’s success following rigid, low calorie meal plans, engaging in compensatory behaviors, and even feeling the physiologic effects of starvation. Developmentally, for vulnerable youth craving social acceptance, identity formation, and validation, these sites can be particularly dangerous. Research studies demonstrate similar risks, showing that online discussion of behaviors, outcomes, and perceived benefits is highly influential. ^, They also emphasize the importance of broad education to schools, parents, providers, and so forth of monitoring youth use of social media and recognition of potentially problematic online behaviors in all settings.

Parental Monitoring and Controls

It is strongly recommended that the adults in a family system have an active awareness of how a child is using social media. There can often be a more limited focus on how much time is being spent online, but, in fact, the content consumption on social media is as, if not more, important. There are a wide variety of tools to support developmentally appropriate monitoring, though concurrent discussions about healthy habits and safe use is also required. Any use of parental social media controls may also provide an opportunity for teaching about self-acceptance, self-regulation, and critical thinking about content. Helping youth determine valid health-promoting information versus misinformation and disinformation is a crucial skill to develop. Additionally, it is worth noting that social media does not have to be considered “problematic” for these conversations to be beneficial, and in fact may be even more effective when considered a routine part of growing up and part of ongoing discussions. Resources exist to support families in getting quality information about social media platforms and available monitoring options, as well as facilitating family discussion-

• Common Sense: Parents Ultimate Guide to Parental Controls

• Google Family Link

• Apple Parental Controls

• AAP Family Media Plan

The Preventative Impact of Teaching Media Literacy Skills

As stated earlier, critical thinking about media is not necessarily an inherent ability for youth, and is best assumed as a skill to be learned. The generally accepted definition of “media literacy” is the promotion of said independent critical thinking when consuming media. There has been a general interest in eating disorder prevention programs, including exploration of improved media literacy for those at risk for developing eating disorders. Originally, research targeted print and screen media, which remains the primary body of research, requiring extrapolation of results for similar effects with social media use. More recently, studies have begun to explore social media literacy, with results reassuringly demonstrating comparable benefits. ^,

It is widely accepted that the cognitive distortions and health-compromising behaviors associated with eating disorders deeply involve body image dissatisfaction, internalization of societal beauty standards, and drives for thinness, all of which media can exacerbate. Media literacy typically aims to support challenging published visual ideals and reducing eating disorder perceptions and symptoms. Interventions may include highlighting image manipulation that is frequently implemented in visual media.

Regarding the efficacy of such prevention programs, there have been several meta-analyses, all reporting positive benefit. A more detailed exploration however, did show that effect sizes were influenced by the prevention approach. Those that focused only on the internalization of body image from media, versus also including media literacy, were less effective. Additionally, dissonance-based prevention programs, as well as those targeting selective interventions were more beneficial. Regardless of the approach, no prevention programs displayed negative consequences.

The Positives of Social Media and Eating Disorders

There are certainly ways in which social media can play a positive role in the treatment and recovery from eating disorders. For example, the National Association of Anorexia and Associated Eating Disorders provide access to online support groups and informational blogs. Additionally, “Pro-Recovery” communities have become more prevalent on mainstream social media platforms. Emerging literature highlights that though these online communities can also become a place of visual self-comparison, there can be more opportunities for this to be a beneficial experience. Unlike other groups that are specific to certain eating disorders, such as AN, general recovery groups, house a variety of body types, and may also include a wider range of genders and ages. Additionally, there are opportunities for positive role models, as groups may include those more established in their recovery journey. It has been hypothesized that in the right online space, social media can serve to reduce the stigma of eating disorders, by encouraging open dialogue about personal struggles.